November 23rd, 2009

The medical home is reform without objections, so far

Posted by Dana Blankenhorn @ 10:13 am

Categories: Aging, Ethics, Finance, General, Government, Home Health Care, Hospital IT, IT Management, Internet, Medical IT, Medical Office IT, Medical Records, Wellness

Tags: Team, Patient, Health Care, Home, Doctors, Team Management, Management, Dana Blankenhorn

There is one type of health reform that, so far, has received little publicity and no political objections.

It’s called the medical home. (Picture from the American Academy of Family Physicians.)

Physicians have been talking up the concept since the 1960s, and at its heart it is pretty simple. Charge for wellness and create a team, headed by a physician, that can deliver it.

When people like Larry Green, who heads the American Board of Family Medicine, talk about moving toward a “blended payment” model he’s advocating for this team approach to care.

Many doctors’ groups support the medical home, but getting from here to there is not easy. Doctors are basically being asked to create a new business, with a new set of employees, and to do this they need start-up capital.

The AAFP magazine Family Practice Management published an article last month with 10 suggested steps for getting that capital.

These start with using existing medical codes to generate more revenue from each patient visit, hiring more nurses and medical assistants, then using these people to increase the number of patients you “see” each day. Wash, rinse, repeat.

If this sounds like gaming the system to generate revenue, it reads like this to me, too. But this revenue has a purpose. The article suggests that capital go into an Electronic Health Record (EHR) system, a “patient portal” through which customers access health data, and links to other helpful electronic resources.

One idea of the $19.2 billion HITECH stimulus cash is that it helps doctors pay for these computer resources so they don’t need to game the system to get the money. But they still have to build scaled businesses.

Only after doctors have their office and systems right should they focus on high-cost patients, the article continues. A lot of alligators need to be slain before you drain this swamp.

From the patient point of view, you’re going to be given a lot more control over your care, you’re going to have a lot more appointments with people other than the doctor, but you’re going to get more face time with people trained to help you.

It’s that face time that can end disputes like the present one over pap smears and other tests. You will have people you can discuss these issues with, people who have access to your medical records, people who will have the time to listen to you as well as talk.

Now that you know the good news, here is the bad news:

1. The financial success of a medical home is based on nagging. You get the data, you get access to the people, but money is only saved when you take the advice.
2. It takes money and business transformation to get from here to there. Running a team takes money and organization. Either doctors become businessmen or go to work for people who are. Either they buy and build systems they need or they associate with others who have them.

A health policy based on the medical home is going to be a lot more intrusive than the present fee-for-service model. The team will know if you smoke, how much you drink, what you eat, even what you’re likely to die of, based on a whole lot of data.

If the medical home is to save money, and lives, that team will need power to enforce what’s good for you. It could come from an adjusted insurance rating, based on your observed lifestyle, with the higher fee going to your medical home.

Or the medical home needs the power to force you out for non-compliance.

The medical home, in the end, offers the promise of lower costs and personal attention, in exchange for your willingness to be bound by your doctor’s advice on what’s good for you.

Do you still like the medical home?

November 23rd, 2009

Who wants tea with their turkey?

Posted by Dana Blankenhorn @ 8:59 am

Categories: Finance, General, Government, U.S.

Tags: Sen., Tea, Republican, Vertical Industries, Benefits, Healthcare, Human Resources, Dana Blankenhorn

Whenever I had Thanksgiving dinner with my in-laws in Texas, there was always tea at the table.

Usually sweet tea. (Still from an anti-reform video by the Tax Tea Party.)

There’s going to be a lot of unsweet tea at a lot of American tables this Thanksgiving, as Republicans and other health reform opponents launch an all-out media blitz to keep the Senate from getting 60 votes to end debate on S. 3590, on which debate has officially begun.

The Republican ads are targeting moderates like Louisiana Sen. Mary Landrieu (above), whose deals for supporting debate are being called “back-room” bribe agreements reached “in the dead of night.”

Maybe they were, although the vote to start debate was at 8 PM on Saturday.

The problem is the condemnation won’t end for these Senators no matter how they vote. Republicans successfully targeted both Democratic supporters and opponents of health reform in 1994.

The threats would have more meaning if Republican voters were willing to embrace party-switchers, like Sen. Joe Lieberman. (They accepted several in 1994 and one, Sen. Richard Shelby, remains in the Senate.)

But polls show grassroots Republicans think little of such converts. As a Republican Lieberman might even lose a primary to Cliff Clavin (played on Cheers by John Ratzenberger, left.)

One thing Republicans can do in the coming debate is support conservative amendments, in which case the magic number becomes 11. Any amendment getting solid Republican support and 11 Democrats goes into the bill that must then get 60 votes to come up for a final vote.

Democratic leaders will spend the holiday negotiating to see what amendments might win the support of people like Sen. Landrieu on final passage without antagonizing the liberal majority. Republicans will try to win 11 Democrats to amendments liberals will detest enough to turn against their own bill.

Good thing, then, that the football games this weekend are going to be lousy. Take Green Bay, Dallas, New York, and Harry Reid. Give the points.

November 18th, 2009

Why electronic health records have far to go

Posted by Dana Blankenhorn @ 7:30 am

Categories: Finance, General, Government, Hospital IT, IT Management, Internet, Medical IT, Medical Office IT, Medical Records, Physician Information, U.S.

Tags: Electronic Health Record, Training, Health Internet, Moore, E-health, Healthcare, Dana Blankenhorn

It’s easy to seize on word that electronic health records (EHR) are not yet saving money and call everything the Obama Administration is doing in health care bogus.

That would be unfair to the technology.

Ashish Jha of the Harvard School of Public Health offered the report this week as a scene-setter for the school’s Public Health and Technology (PHAT) conference, whose speakers’ list is a who’s who of EHR advocates. (Picture from Dr. Ashish Jah’s home page at Harvard.)

Rather than being a hit piece at the current Administration’s aims, the report focuses on the best practices of groups like Kaiser Permanente and the Cleveland Clinic, which have spent years adapting their work to the technology. Do these things and you can make things work, as proven in areas like heart care, he writes.

Rather than focusing on paying for the computers and software, he says, emphasis should be placed on training people, and adapting practices to take advantage of what the data can do. As in any business a failure to adapt means you’re wasting money.

Dr. Jha made this point in the School of Public Health’s in-house publication last month. Speaking at a University-sponsored public forum in September, he said this:

The money in the stimulus bill is going to help a lot in terms of getting systems adopted. You’re going to see this entire field change dramatically in the next several years. You’re going to see new vendors getting into this field who haven’t been there before. I’m hopeful this will mean better products that will require less training. There’s no doubt in my mind that five years from now, we are going to have far more widespread use of electronic health records.

Whether we are going to get to 90% as President Obama has said he wants, I’m not sure. But the bottom line is that this train has left the station. We’re moving towards electronic records. The only question is whether we can do it well. The big challenge for us is to make sure we adopt these systems effectively, that we remember the prize is not electronic records; the prize is higher quality at lower cost. And that’s only going to happen if we really think through how to adopt these systems in a more organized and effective way.

Those are the words of an EHR enthusiast, not a skeptic, and certainly not a cynic.

Fact is the EHR revolution has barely begun. The Health Internet is still being implemented. Barely one hospital in 10 has a functioning EHR system. Moore’s Law of Training (there is no Moore’s Law of Training, we learn as fast as we learn) has barely kicked in.

The health IT revolution will not happen like the turning on of a light switch, as people in every other industry that has been touched by computers, including journalism, will tell you.

It’s a long-term process.

November 16th, 2009

Niacin best for raising good cholesterol

Posted by Dana Blankenhorn @ 5:42 am

Categories: Aging, Consumer Information, Drugs, Finance, General, Home Health Care, Medical Equipment, Research, Wellness

Tags: Cholesterol, Dana Blankenhorn

Want more of that good HDL cholesterol?

(Picture from Costco.com.)

Try a timed-release niacin, and be skeptical if your doctor gives the sales pitch for Zetia or Vytorin.

The authority for this is a study dubbed ARBITER-6, which was stopped suddenly this summer, with the study’s authors insisting safety had nothing to do with it.

It was a question of efficacy.

The results, described in the New England Journal of Medicine, make clear that niacin does better at the main job, keeping arteries open.

“The use of extended-release niacin causes a significant regression of carotid intima–media thickness when combined with a statin and that niacin is superior to ezetimibe.”

Ezetimibe is the generic name for the active ingredient in Zetia, while Vytorin combines the same drug with a generic statin, simvastatin.

This does not mean ezetimibe is worthless. It works. It just doesn’t work as well as niacin.

This has important implications for anyone who, like me, has a family history of hypertension and high cholesterol. But if you want to save some serious money, look further.

The ARBITER-6 study compared ezetimibe with Niaspan, a drug form of timed-release niacin. But you can get similar dosages, for a lot less, with a supplement containing the same stuff. I use something called Slo-Niacin.

On most insurance plans you’ll pay $10/month for a generic statin and $30/month for Niaspan, or $30 for Zetia, “saving” $10 by using Vytorin (which contains the statin).

But Costco offers 150 Slo-Niacins for about $10, so even if you double your dosage to 1 gram (as many doctors recommend, taking one in the morning and one at night to prevent flushing), that’s $14/month for simvastatin and niacin, or $30/month for Vytorin.

Last time I got checked out, my combination of simvastatin and 1 gram of SloNiacin per day was working like a champ. Total cholesterol under 150 and a ratio of bad to good that had my doctor putting exclamation marks on my chart.

The paragraphs above, combined with the results of ARBITER-6, represent the heart of comparative effectiveness, and the way we old-timers can interpret those results to stay healthy for less.

As health IT begins collecting hundreds of millions of health records over the next several years studies like this will become easier to do, and they will be more accurate, given the larger number of records being studied.

But this is bad news for drug-makers. You not only have to prove safety, not only prove that your drug does what it claims, not only prove you’re better than a placebo, but you now have to prove you’re better than alternatives before you’re going to get the big money.

Bad for drug companies, good for patients. That’s what comparative effectiveness studies are all about.

November 6th, 2009

Canadians get a taste of American medical system with IMS Health buy

Posted by Dana Blankenhorn @ 7:28 am

Categories: Finance, General, Government, Medical Office IT, Payment Processing, Research, SaaS

Tags: IMS Health Inc., IBM IMS, CPP, CPP Investment, Sales Strategy, Sales Force Management, Personal Finance, Benefits, Payroll Solutions, Sales

You have likely never heard of IMS Health, but they’re a big deal in the current IT environment of American medicine.

IMS buys prescription records in bulk from big pharmacies, strips out the patient names but identifies the doctors, then tells drug companies of the doctors’ prescribing habits. This lets the drug companies target their sales efforts.

The picture at the right, taken from IMS’ current home page, illustrates the firm’s view of it. The little blue ball represents sales, and the nice lady has IMS knowledge to shoot it accurately.

Critics have their own view. New Hampshire sought successfully to stop IMS data collection in court, and the American Medical Association (AMA) runs a program through which doctors can opt-out.

Regardless of your view, it’s a data processing company that makes money. IMS earned $311 million on sales of $2.3 billion last year. This made it attractive, and a leveraged buy-out of the company was announced yesterday.

Which is where the Canadians come into the story. The main player here is TPG Capital, run by the renowned financier David Bonderman, but his partner in this deal is the CPP Investment Board.

CPP is the investment arm of the Canada Pension Plan, which you might compare with a privately-run Social Security system. CPP Investment seeks a return on the pension contributions of Canadians. The CPP collects the fees and pays the pensions.

Out of the CPP’s $116.6 billion in assets, private investments like this represent “just” $18.4 billion. But that’s enough money, and the law offers CPP Investment enough leeway, for it to get into some very interesting deals.

Like this one.

All of which means that Canadian pensions may be riding on the success of an American company performing computing feats that would be incomprehensible in their own country, which is a single-payer system run through the nation’s provinces.

November 6th, 2009

House due for its health reform vote tomorrow

Posted by Dana Blankenhorn @ 5:54 am

Categories: Curioisities, Finance, General, Government, U.S.

Tags: Protest, Democrat, Republican, Health Care, U.S. Senate, Vertical Industries, Benefits, Healthcare, Human Resources, Dana Blankenhorn

Defying a Republican Day of Rage on the Capitol steps, House Democrats said they will vote through a health reform bill, with a public option, on Saturday.

For history buffs, the protest came a little over 40 years after the left’s infamous Days of Rage, a series of protests against the Vietnam War that turned violent and tarred all liberals for a generation.

Yesterday’s event featured most of the House Republican leadership and signs comparing reform to Naziism, Maoism, and the Joker as played by the late Heath Ledger.

There was no violence, just a star turn by Minnesota Rep. Michele Bachmann (right, naturally), the tea party’s Janis Joplin, who performed a medley of her greatest rhetorical hits and basked in the love.

Keith Olbermann called the protest “an orgy of veiled threat,” but perhaps getting him riled was part of the point. (Snarks might say Bachmann took another little piece of Keith’s heart now, ba-bee.)

As the vote neared President Obama became more visible, appearing at the White House briefing room to tout endorsements of the House plan by the American Association of Retired Persons (AARP) and the American Medical Association (AMA).

For the bill to become a law, it must be merged with a yet to-be-passed Senate bill, then go through both Houses again. Opponents of reform in the Senate may have to depend on Sen. Joe Lieberman (CFL-Conn.), who as noted last week has said he would support a filibuster aimed at killing any proposal with a public option.

After a decade of Democrats watching Lieberman as Droopy Dog playing Hamlet (will he, won’t he, he din-nit) now Republicans can enjoy that thrill. Starting Monday he will have become their Obi-Wan Kenobi, their only hope.

Here is the smart takeaway on all this (as opposed to the smart-aleck takeaways above). Once whatever passes passes (or doesn’t) employers know the environment into which they’re putting a major portion of their budgets, and can firm decisions on whether to hire, or how much, next year.

The show has been fun, but it needs to close.

UPDATE: Maybe not tomorrow, maybe later. Like some old rock concerts I don’t remember.

November 3rd, 2009

GOP will present a health care bill

Posted by Dana Blankenhorn @ 8:37 am

Categories: Finance, General, Government, U.S.

Tags: GOP, Republican, Health Care, Proposal, Hill, Quality, Vertical Industries, Business Operations, Dana Blankenhorn

It’s still not in final legislative language, but House Republicans say they will have a health reform bill available for the body’s final debate.

Rather than dealing with calls for increased access to care, the Republican bill is all about cutting costs.

That means moving toward nationalizing medical malpractice standards to limit awards, and toward nationalizing the market so customers can buy across state lines, along with statewide “pools” of high-risk patients with pre-existing conditions.

Right now insurance is a state market, based only on state laws, meaning there are 50 different regulatory standards and 50 different legal standards. The Republican plan would move toward changing this. To that extent, the proposal is a reversal of the party’s own call for state and local control.

The Wall Street Journal reports the proposal still lets insurers deny sick people coverage, and they could cancel coverage if people become seriously ill.

Democrats pounced on that lack of “guaranteed issuance,” but Republicans insist that cost, not coverage, is the issue.

The Hill writes that, after spending months criticizing Democrats for writing a lengthy bill, the Republican proposal will come to 2,000 pages. The party plans an online conference starting at 1 PM Thursday to discuss the measure with their activists.

Regardless of how the proposal is graded, it does represent a concession to Democratic demands that Republicans offer their own bill.

The Republican proposal is guaranteed to be rejected, but now they have something they can offer on the campaign trail next year when voters complain about whatever does pass.

The proposal offers another advantage. It clearly sets terms for future debate. Is it about coverage, or costs? Should the present system be tweaked, or fundamentally changed?

Today may be an off-year Election Day but it does remind us that, in the end, voters will decide which side is right.

November 2nd, 2009

Don't cry for me Joe Lieberman

Posted by Dana Blankenhorn @ 7:09 am

Categories: Curioisities, Finance, General, Government, U.S.

Tags: Democrat, Lieberman Software Corp, Joe Lieberman, Option, Liberals, Leadership, Vertical Industries, Benefits, Healthcare, Healthcare Reform

The good news on health care reform today is the movie is nearly over.

Democrats are facing up to the choice that faced them from the start of the debate. They can either tell their grassroots to suck on this and pass a bill moderates within both parties will accept, one without a public option, or they can roll their opponents in a parliamentary floor fight.

The question was put by Sen. Joe Lieberman, who now says he will vote with Republicans to filibuster any bill with a public option in it. The leadership bill includes a public option, but Lieberman plus a united Republican caucus mean that bill can’t come up for a vote.

No reform is better than a public option, he told CBS’ Face the Nation.

House Democrats, meanwhile, are pushing ahead with a bill that includes the public option, plus new regulatory authority for the Federal Trade Commission over health insurers. This despite the fact the public option they have crafted would only get a 2% market share, according to the Congressional Budget Office.

Liberals are calling for Lieberman’s political head on a platter. Matt Osborne of The Huffington Post says including the public option makes the leadership bill a budget measure eligible for reconciliation, so a filibuster would be out of order. Markos “Kos” Moulitsas notes Lieberman was for ending filibusters as a freshman Senator.

Of course tossing aside Lieberman might leave moderates in both camps without a party at all. Could we have an American version of England’s Liberal Democrats come out of this?

Stay tuned. I think a dance number is coming up.

October 28th, 2009

The fight for medical cost transparency is coming online

Posted by Dana Blankenhorn @ 9:11 am

Categories: Consumer Information, Finance, General, Government, Insurance IT, Internet, state government

Tags: Ingenix Inc., Health Care, Vertical Industries, Benefits, Healthcare, Insurance, Human Resources, Business Operations, Corporate Insurance, Dana Blankenhorn

When conservatives criticize health reform one of the first things they suggest might work is greater transparency in health care costs.

Sites like Healthcarebluebook.com and Changehealthcare.com have been trying to offer this service for some time.

Procedures like MRIs, CT scans, colonoscopies, minor orthopedic surgeries and mammograms can all be shopped with these resources. You can also compare drug prices and learn what to do if a medical claim is denied.

Increased deductibles are giving more families a reason to consult these resources. But they are only a partial answer. Insurers control most costs through their repayment schedules.

This is where government action has proven necessary. But not national government action.

After Ingenix, a unit of UnitedHealthCare, was caught manipulating its repayment rates, New York Attorney General Andrew Cuomo won a settlement that includes a third-party estimate of what insurers should be paying.

That national database, to be called FAIR Health, will debut in about a year under a contract signed recently with Syracuse University and other state universities. The database will calculate “reasonable and customary” charges, based on location, eventually replacing Ingenix.

While Ingenix was used only within the industry, FAIR Health will be available to the public, so you can compare your own doctor’s charges to the market.

Reform and cost controls are a big problem with a lot of moving parts. Most experts agree broadly on what needs to be done. Comparative effectiveness is one tool. Price transparency is another. These are moving ahead regardless of what happens in Washington.

October 28th, 2009

Insurer research arm pushes comparative effectiveness

Posted by Dana Blankenhorn @ 6:03 am

Categories: Finance, General, Government, Insurance IT, Research, U.S.

Tags: Health Care, Lewin Group, Vertical Industries, Benefits, Healthcare, Insurance, Human Resources, Business Operations, Corporate Insurance, Dana Blankenhorn

The Lewin Group, the research arm of UnitedHealthcare, is pushing for greater use of comparative effectiveness in personalized healthcare,  programs tied to patients’ genetic makeup.

Attacking comparative effectiveness as “getting between you and your doctor” was a big feature of the political attack on health care reform this spring and summer, where it was called “rationing.”

But this was never the view of the insurance industry, which will control the health care market in the absence of regulation. Lewin maintains its own site on comparative effectiveness research, and delivered its latest report at a conference hosted by the drug industry.

In an online summit on comparative effectiveness hosted by The National Journal last spring, Lewin Group actuary John Sheils noted that guidelines produced by the research are adhered to barely half the time, suggesting that they be enforced with higher patient co-pays or government refusal to pay for care outside the guidelines.

These are precisely the actions anti-reform activists focused on in their attack on reform.

It’s certainly not necessary for people on the same side of the issue to have different views. But the views that will control in this case are those of The Lewin Group. Failure to pass health reform will have no impact on the move toward rationing care based on guidelines or using your genetic code to decide what is to be done with you.

If you want to fight that, take your tea party to UnitedHealth Group. Need someone to draw you a map?