WHCC 2008 just wrapped up with a final keynote from Secretary Leavitt. Leavitt’s keynote was a progress report on the four cornerstones that have driven HHS under his leadership.
Cornerstone One: Standard Quality Measures
There has been a lot of quality metrics established, but agreement on the standards by which these will be measured is still a big challenge. Leavitt believes we are moving too slow. Currently, HHS is doing an inventory of the quality measurements they are currently using throughout HHS. They have identified 100 of them and will be going public with these measures this year.
Cornerstone Two: Standards for Cost of Care
Leavitt came down hard on healthcare costs and billing structure stating:
Our billing system in healthcare is insane.
He went on to draw an analogy between a consumer buying a car and a consumer buying knee replacement surgery going on to say we need to challenge the assumption that buying healthcare services is any different from other industries. Leavitt believes that current efforts striving for the perfect solution will never move us forward - he again stated we are moving to slow. We need to strive for good, not perfection. CMS is currently aggregating its cost for common procedures data and will make that publicly available to push the cost transparency issue forward. Getting back to that knee/car analogy, CMS covered the costs for 250.000 knee surgeries in 2007, the costs for those procedures will be made public this year.
Cornerstone Three: Interoperable EMR
Sees HHS steadily marching forward on interoperability. Quite proud of the establishment of CCHIT and the certification process used to insure EMR software is in compliance to interoperability standards. HHS, via it National Health Information Network (NHIN), will test flow of data among several systems by end of this year. Next year, he foresees this moving beyond test data to the flow of real data and scale-up.
While Leavitt recognizes the challenge of a broader NHIN and interoperability with fewer than 10% of small practices having an EMR system, he gave little concrete guidance on how to overcome this issue. They are looking to change the economic equation to promote adoption. What that equation will be remains to be seen, but I’d look to CMS as the prime leverage point.
One of his chief objectives this year is to see further adoption of eRx practices, which he will promote strongly. Currently looking to attach eRx requirements with physician reimbursement payment rule of he CMS bill before Congress.
Cornerstone Four: Incentives to Seek Value
He saved the fuzziest statements for this last cornerstone. Again, Leavitt promoted the need to establish standards for value metrics and incentives. Also emphasized the need for trust among all stakeholders to get this to work. The biggest challenge that HHS has uncovered here is that value and incentives are driven locally. Therefore, HHS’s role will be to establish the standards, and let the local community drive incentives. Chartered Value Exchanges, of which 14 have been awarded/funded to date, will be the mechanism to drive value and incentives at the local level. Goal is to have 50 opertational by 2010.
Leavitt closed his presentation by stating he sees the unbridled rise in healthcare costs as the biggest threat to our nation’s national economic security. Solving the healthcare puzzle is this generation’s challenge.
Analysis:
Yes, movement on Cornerstones One and Two has been glacial. Too many vested interests have very strong financial reasons to stall any progress on cost and quality transparency. While it appears that HHS will look to further leverage the clout of CMS, seems too little too late, unless of course the next administration picks up where Leavitt left off and pushes even harder to make this happen. In full agreement with Leavitt that we should strive for good enough and not perfection. Advocates for perfection are the ones truly stalling the process.
For Cornerstone Three, do believe that for all the complaining I have heard, all-in-all, CCHIT is moving the interoperability ball forward and EMR companies are structuring their solutions to comply. Now we just need to educate the physician. Here, HHS has fallen far short of the mark. For all the talk about wanting to drive adoption among physicians, adoption is still horribly low. Coupled with strong incentives to encourage adoption (CMS payment structure?) HHS could do more in educating physicians on what’s in it for them. The EMR market is still surprisingly fragmented, and even for me, an HIT analyst who covers this market for a living has a difficult time keeping up with all of them. Maybe CCHIT can provide some guidance here as well.
Corenerstone Four is my least favorite and was where Leavitt made the least clear statements. Defining value and structuring incentives around value is an extremely hard thing to do. The Chartered Value Exchange sounds like a re-branding of the failed RHIO concept and I don’t give these new exchanges any more chance of surviving than its predecessor. Secretary Leavitt, with all due respect, throw this one in the can and go with a three legged stool, afterall, a three legged stool is more stable anyway.
CIGNA & WellPoint to Make PHRs Portable in 2008
You heard it here first folks, CIGNA and WellPoint will make member data portable by end of 2008, following the lead of Aetna and UnitedHealth.
Sat in on the session, Critical Health IT, which had representatives of WellPoint and CIGNA talk about their consumer and broader health IT initiatives. During Q&A got a chance to ask both why have they not come forward with a public statement that they support the portability of a member’s PHR. (Note, during their own prepared remarks they gave somewhat dismal views of PHRs stating adoption has been a challenge). Both stated that they have every intent of making a member’s data portable. WellPoint and CIGNA are currently deploying the CCR standard internally to insure that the data will be portable and enable a member to populate a PHR of their choosing outside of their health plan. They also went on to state that this will be completed in 2008.
Towards the end of our exchange on this question, the WellPoint representative went on to state that they still have issues regarding privacy and releasing such data to a non-covered entity. GIGNA nodded in agreement. What a load of bull, particularly after WellPoint has had a few privacy/security breaches of their own.
Hey WellPoint, its my data, let me choose whether or not I wish to take the risk and stop being so damn paternal. Or is it, you just don’t want anyone between you and me? Watch out, you are about to be dis-intermediated.
And finally, thank you to the WHCC 2008 team for inviting me to attend what has been an excellent event. Your ability to bring together many of the leaders in the healthcare industry is to be commended. I have learned much in these two and a half days, so thanks again for the opportunity to participate.
John Moore is Managing Director of Industry Analyst firm, Chilmark Research
The WHCC conference sessions on transparency in healthcare are demonstrating that this movement is way more than a passing fad. As all stakeholders in the healthcare system — private institutions, government agencies, health plans, employers, group practices, research organizations, online service companies — are all getting in the mode of how to open up the black boxes in healthcare to consumers and payers of all stripes.
What’s fascinating is is to witness not just the measures, programs and politics unfold, but also the evolution of the questions that are being asked. Reed V. Tuckson, MD, UnitedHealth Group observes, for example, that the question of what is the best hospital is morphing into the question of what is the best hospital for me and my particular medical condition.
Robin Downey, a Senor Vice President with Aetna argues that once consumers ‘get it’ about the usefulness of healthcare information, they just want more and more. With her health plan, the black box they are opening, is “what is it going to cost me to be a covered by Aetna?” This is not just about co-pays, and premiums, but also about what Aetna is paying to their contracted doctors and hospitals. So they are starting to disclose Aetna’s actual negotiated rates with their provider network. And people are surprised wondering if they are giving away their bread and butter, that is, proprietary information that they have spent considerable money to develop.
The bar for transparency is rising, and the market place is responding. Hang on.
Anyone interested in a new payment model for health care needs to keep
an eye on the High Value Health Care Project under way at Mayo Clinic.
Its goal: Support a new national model for high value care delivery.
Robert Nesse, MD, president and CEO, Franciscan Skemp Healthcare, Mayo Health System, reported on this important initiative at a breakout session this morning.
Mayo, using its 54,000 employees, retirees and dependents as a study cohort, launched the project about six months ago in conjunction with Dartmouth Institute of Health Policy and Clinical Practice and the Institute for Health Care Research at Intermountain Health Care. That’s a formidable team.
As you probably know, the Dartmouth Atlas of Health Care identifies Intermountain and Mayo as the benchmarks that everyone else should be chasing. And Peter Orzsag, director of the Congressional Budget Office, has his eye on benchmarking as a key to solving America’s health care cost crisis–which means this project is likely to inform analysis that is presented to Congress.
In the first phase of the project, five conditions are under the
microscope: congestive heart failure, diabetes, heart disease, low back
pain and depression.
The project seeks to understand high value care for these chronic illnesses:
Document the quality and cost over time (not well understood by providers today) of best practice for selected patients with chronic illnesses
Implement evidence-based best practice and patient shared decision-making for high cost, high prevalence chronic diseases
Study new reimbursement models that support high value care for patients with chronic illness
I missed the press conference at which the book was unveiled this morning, but attendees received advance copies at home and copies of the book are on every table at this conference. Its authors are keen on getting wide attention to their ideas so I share their summary of the health initiatives needed to put the house in order, Schultz-Shoven style:
Private system
Encourage national, rather than state, markets in health insurance, thereby promoting competition, putting downward pressure on costs, and providing reasonable choices of covered services.
Promote enhanced consumer information about health service prices and quality. Medicare records on the quality of hospitals and health service providers and the effectiveness of alternative treatments should be made public while the privacy of individuals is protected.
Strengthen the incentives for company-sponored HSAs and accompanying catastrophic insurance by making them portable across employers and permitting tax-deductible health spending for those who have fully participated in an HSA program.
Make tax-advantaged HSAs and relative low-cost catastrophic insurance available to all those who do not have employer-sponsored plans.
Medicare
Offer consumer choice among plans (Kaiser-style HMO plans, high-deductible catastrophic insurance plus HSAs, and traditional Blue Cross-type plans.)
Use smart means testing: Value of vouchers would depend on lifetime labor earnings.
Ensure gradual transition: Existing Medicare participants would be allowed to stay with traditional coverage.
Finance with dedicated taxes, thereby promoting cost effectiveness.
Medicaid
Provide risk-adjusted vouchers.
Continue to allow states to experiment with structure.
Offer consumers choices, including HSAs with catastrophic insurance.
Provide increased coverage: Replace eligibility notch with phased reduction of the value of vouchers.
Finance federal support with dedicated taxes, thereby promoting cost-effectiveness.
I did have a chance to read his book before coming to the conference and look forward to see what he has to say about health care reform. For Shultz the story of reforming health care and social security begins with the stability and growth of the US economy. In order to respond effectively to the coming cost catastrophe the economic pie has to growth. Any reforms have to be designed to pass Shultz’s “pie test.” Simply put, proposals that weaken the the GDP fail the test. So making use of the competitive market to discipline costs, raising labor force participation, recognizing labor mobility, growing personal savings, forcing government to confront the cost of over-promised entitlements, increasing taxes only as a last resort — these are some of the dynamics that should be examined when looking at the impact of healthcare reform measures.
Thus the “Shultz-Shoven health care initiative” includes, but is not limited to, the following:
Encouraging national rather than state health insurance markets
Making health insurance benefits portable
Enhancing consumer access to healthcare price and quality information
Risk-adjusted vouchers for Medicare and Medicaid
Offer Medicare and Medicaid beneficiaries choice of private health plans
Fund government programs dedicated taxes rather than general fund to promote cost effectiveness
Replace Medicaid’s eligibility “notch” with phased reduction in the value of vouchers as income increases
Shultz’s ideas are not new but they do enjoy an economic logic that cannot be denied or ignored.
He sums up his proposals in the following way:
. . . we seek to modernize and significantly reform Medicare and Medicaid, improve employer-sponsored health plans, and ensure that those who do not have access to such plans will still be able to obtain affordable major health insurance. We advocate that all Americans have access to strengthened Health Savings Accounts and a more competitive health insurance environment.
The question will be whether in today’s healthcare debate these conservative, market-oriented ideas will seem somewhat tepid in the face of corporate conspiracies and single payer fantasies.
In a soon-to-be-published article, Ruth Gardiner argues,
we are seeing a shift from the ‘informed patient’ which has resulted from improved access to healthcare information, primarily from the Web, to the ‘participative patient’ as we move into Web 2.0 territory.
This is a “major turning point” according to Gardiner, “that could present greater challenges for healthcare professionals, organizations and the patient or client.” How will providers adapt? What impact will Google et al. have in their attempts to “own” the health care consumer? And how will even newer information technologies — such as digital video change the healthcare landscape, she asks.
The distinction Gardiner makes is an important one. The first notion is almost universally perfunctory now: the ‘informed patient’ is either the product of the patient’s own initiative, or a point in the patient care process where he or she gets to sign the consent and waiver form. In short, a tolerated but necessary legal exercise.
But the second notion implies that attention to the patient’s awareness of the relevant information and risks at the proper time is an essential and critical component of the total care experience; a mindfulness and respect for the patient exhibited at every point, by every care provider.
Gardiner puts to question the impact of information technologies on this aspect of medical care. And to a certain extent she is right to ask, since, in many ways, the push of information technology has brought us to a place where it is now possible to serve the “participant patient” in ways that could not have been conceived only a few decades ago.
Just returned from a presentation by Dr. Elliott Fisher, Professor of Medicine at Dartmouth Medical School, on “Spending, Quality and the Paradox of Plenty”, where he addresses the problem of rising health care costs, poor quality and declining access to healthcare. His research and association with the Dartmouth Atlas of Health Care Project focuses on examining the differences in spending and medical practice patterns across regions in the U.S..
Not surprising, but always interesting are findings that are counterintuitive to those outside of the healthcare industry. For example, that higher spending regions in the country generally suffer from worse technical quality of care, slightly higher mortality, lower patient satisfaction with hospital care, and patient perceptions of worse access to primary care. Physicians in these regions also perceive greater difficulty in ensuring both the quality and continuity of healthcare.
Fisher argues that “higher spending across regions and physician groups is largely do to overuse of supply-sensitive services — hospital and ICU stays, MD visits, specialists consults; and — at the margin — more is worse.” He also thinks that “overuse is largely a consequence of reasonable differences in clinical judgment that emerges in response to local organizational attributes (capacity, clinical culture) and a national policy and culture that promotes growth and more care.”
Underlying causes include, according to Fisher:
A lack of accountability for key local determinants of quality, costs and health outcomes
An assumption that more is better, thus equating less care with rationing
A payment system that rewards more care, increased capacity, high margin treatments and entrepreneurial behavior
The challenge of “improving health and reducing suffering” requires organizational accountability for quality, costs and capacity, comprehensive performance measures and new approaches to payment, says Fisher.
Despite the continuing pressure on physicians to invest in electronic medical records, only about one-quarter have done so, and usually in large medical groups. There are numerous quality and efficiency of care reasons for making the investment, but these often fail to persuade physicians, who tend to feel that others gain most of the benefits while they suffer all of the costs.
Recently, BlueCross Blue Shield of Massachusetts came out on the physicans’ side on this issue, indicating its belief that the return on investment to physicians would not justify the expense, based on its current bonus program. Its own analysis indicated that physicians gain only 11% of the money saved through EMRs, and that isn’t enough to cover costs what physicians in that state gain under its bonus program. Henceforth, it will not require physicians to have EMRs in order to qualify for bonuses. [PL Dolan “Insurer Finds EMRs Won’t Pay Off for Its Doctors” amednews.com, Mar 10, 2008]
In many, probably most small physician practices, available bonuses and financial/efficiency gains from EMR investments tend to be far greater per patient served than is the case for larger groups. And there simply is no current way to recover the investment costs, even if physicians could afford to spend or borrow the money required. But there may be a way to do so through the growing movement toward “medical homes” and proactive health management (PHM), at least for primary specialty physicians and secondary specialties that are willing to move into PHM for their chronic disease patients.
One of the elements of PHM as practiced by physicians is the need for frequent contact with patients, through individual or group visits, phone consultations, outbound e-mails and other methods used for monitoring and motivating patient adherence to medications and lifestyle change “prescriptions”. Moreover, while EMRs are used mainly as background information in sickness care, they are close to essential for patients and physicians to monitor and make adjustments on an ongoing basis for PHM goals and processes.
EMRs become “personal health records” routinely and easily accessible to both patient and physician, as well as to other practice staff involved in patients’ PHM efforts. They can be the basis for reminding patients when regular measures of their behavior change commitments, when it is time to make a measurement of progress in losing weight, blood pressure/sugar/cholesterol levels, calorie intake, physical activity, etc. They also serve by providing objective data, often including graphic displays, of patients’ overall progress, and can be used by patients involved in employer-based PHM efforts to validate their eligibility for incentive payments.
The MDVIP organization, with over 200 physician practices in 19 states, for example, offers EMRs and patient web pages that are used to track and record patient progress toward whatever personal health goals each is working on. The records, themselves, serve as a reminder of how far each patient has come since initiating each’s health improvement effort, as well as how far each has left to go. They also serve to remind physicians to consider congratulating patients on progress, or adjusting the patient’s support program if progress is slow or non-existent.
MDVIP patients also receive a mini-CD that they can use in their own computers or carry with them when they go to physicians or other providers that are not in the MDVIP system. They have their own web page for their records and MDVIP’s electronic access to health information they might be looking for. In spite of the fact that MDVIP physicians have no more than 600 patients each, this is enough to make having EMRs worthwhile for their PHM-focused practices.
Given the significant value of sharable EMRs in PHM, together with the greater simplicity of the records and applications required therein, before primary physicians make decisions on EMR investments, it might be wise for them to confer with peers who have adopted truly PHM-focused medical home models, such as MDVIP physicians, to get a more complete idea of the advantages vs. costs involved. The investment may not be justified under traditional payment systems, but may be sensible, necessary, and affordable in PHM-focused practice.
In a cover story in TIME magazine, an interesting if dubious list of “Ten Ideas that Are Changing the World” was described. Included were predictions such as “#8 “The New Austerity” – People will start living within their means”; #4 “Reverse Radicalism” – Talking to retired terrorists will show us how to end terrorism” and #3 “The End of Customer Service” – Sales clerks are being replaced by technology. But of particular interest to readers of this blog might be #9 “Mandatory Health” – Companies are going to make employees lead healthy lives. [D. Wolfe “10 Ideas That Are Really Changing the World” Ageless Marketing Mar 19, 2008]
There are clear indications that some employers, at least, are pushing the idea of a “consumer-based solution” to their already unaffordable and ceaselessly burgeoning healthcare costs. As most already realize, employee health status and behaviors create costs or lost productivity and performance that can be two to five times as much as their impact on healthcare costs, already unbearable. And many favor a common “management” solution to this problem: make healthy behavior and status a requirement, i.e. a condition of employment.
I still recall the time a hospital system CEO for whom I worked at the time included among “company policies” a statement that we expected employees to be loyal to the organization in everything they did. My suggestion that we reword the statement to read that it was our intention to earn employee loyalty, rather than expect it, fell on deaf ears. This was, to me, a position reflecting the attitude of employers during the Depression, when employers felt that they deserved loyalty of their employees for the “favor” of granting them a livelihood, rather than modern realities that employees are valuable, usually essential assets, that need to be attracted, developed, and retained in much the same way that we “manage” our customer assets.
It is understandable, if unfortunate, that it is probably natural that managers who make decisions about employee health feel that managing it is the best strategy, compared, say to marketing it. Many managers still aim to manage customers, for example, and “customer management” technologies, strategies, white papers, and methods continue to sell well, though how well they work is open to question.
But employee health, being something that, in most cases, is “co-managed” when it is managed at all, by employees (dependents and retirees, where applicable) and their chosen health advisers and counselors, with employers well behind in relative influence. Health behaviors, risks conditions, existing acute and chronic diseases and injuries require 24-hour, or at least every-waking-hour attention by employees, and frequent attention by health professionals, while in reality, employers can do relatively little,
Moreover, while employers can enable, encourage, and empower employees, and to far less extent dependents and retirees, via incentives and support devices that may add to their motivation, capabilities and awareness of healthier behavior options, they cannot truly manage such behaviors. When employers have attempted to require a few behaviors as a condition of employment, such as abstinence from tobacco, abuse of alcohol or illicit drugs, they have had limited success, given the difficulties of authenticating compliance with such requirements, to say nothing of federal and state laws plus union agreements limiting such requirements.
Moreover, when they employers restrict their employee hiring to prospects who are already healthy or healthy behaviors, they risk both violation of ERISA, ADA and HIPAA regulations, but missing out on increasingly valuable and scarce talent. One employer might get away with such a strategy, but the fallacy of composition would soon catch up to all if all attempted it. The bright side, of course, is that through employee health empowerment, development, or similar employee-benefit-focused philosophies and interventions, employers have already shown that dramatic savings can be gained with enabling employees to maintain healthy behaviors, reform unhealthy ones, and self-manage their own chronic conditions.
Many employees may be motivated to improve their health, risk behaviors and conditions, and self-management of their chronic conditions. Employer support and recognition of self-motivated efforts need cost little, compared to incentives and rewards (“bribes”) for doing the same. Employees may adopt the “betting” approach to their own health goals, putting up their own money as a self-imposed penalty they agree to pay, but only if they fail to reach goals they set for themselves in an agreed-upon time frame. Such an approach takes advantage of the tendency for people to work harder to avoid losing money than they will to gain some. [R. McKenzie “Dieting for Dollars” Wall Street Journal, Jan 4, 2008.
Any approach to employee health that creates an adversarial relationship between employer and employee is almost sure to end up costing more than it is worth, in one way or another. Taking a partnership approach, such as by investing in worksite support, work environment modification, and ensuring that executives and managers model healthy behaviors and enthusiastic, visible participation in health initiatives, has almost always proven far more effective. Empowerment, per se, delivers the added benefit to employees of enhancing their personal control over their lives and autonomy with respect to their employer. Such added benefit may, by itself, help employers retain the talent they need to survive and succeed, while increasing their productivity and performance at the same time.
Bill Hsiao, a respected Harvard China healthcare scholar, along with co-author Winnie Yip, also at Harvard, have in this most recent issue of Health Affairs describe the challenges China faces in healthcare reform very succinctly:
China is at a loss as to how to transform its new money into efficient and effective health care. To tackle the root cause of unaffordable health care—rapid cost inflation caused by an irrational and wasteful health care delivery system, the very same issue confronting the United States—China needs to decide how to reform its health care delivery and payment systems; otherwise, most of the new money is likely to be captured by providers as higher income and profits.
By injecting substantial government funding to provide basic health care universally, China has taken giant steps forward to address its problems of unaffordable access and medical impoverishment. But these initiatives are silent on how China intends to tackle a fundamental cause of its problems: rapid cost inflation and inefficiencies of the delivery system.
The decisions that China needs to make are complex, and there is no silver-bullet solution. In light of the potential scale and magnitude of their impacts, it would be advisable for China to take a step-by-step approach, guided by pilot experimentation and objective, evidence-based evaluation.
As I have argued before, the expansion of coverage without paying serious attention to the outcomes of that care, will be a very expensive and troubling experience for China.
Matthew Holt interviews Jonathan Cohn, a senior editor with The New Republic whose book - "Sick: The Untold Story of America’s Health Care Crisis — and the People Who Pay the Price” - was recently published.
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