Health Wonk Review #25

Welcome to the Silver Edition of Health Wonk Review, celebrating HWR’s 25th bi-weekly installment.  No need to wait for the 50th installment to celebrate; in the words of the immortal bard, "All that glitters is not gold." 

To quote another poet:

All that is gold does not glitter,
Not all those who wander are lost;
The old that is strong does not wither,
Deep roots are not reached by the frost.
From the ashes a fire shall be woken,
A light from the shadows shall spring;
Renewed shall be blade that was broken,
The crownless again shall be king.

Those of you who are J.R.R. Tolkien fans will recognize these lines and appreciate them in their original context; others may wish to read into these lines some echoes of their own thoughts on the current national political scene.  I’ll leave my own thoughts unspoken; feel free to divine what they may be — but please, no wagering.

On to the task at hand.

This past fortnight could have been dominated by posts concerning the President’s health plan unveiled in the State of the Union address.  Instead, I would say that the plan has served as a trigger for broader debate.

There were, of course, posts on the plan.  I think Matthew Holt at The Health Care Blog wins the prize for most comments on a post regarding the Bush plan.  Michael Cannon at Cato @ Liberty stakes out a position that the plan is not a tax hike for some high wage earners.  At Managed Care Matters, Joe Paduda says that the plan will not help the often disenfranchised folks with pre-existing conditions.

Jane Hiebert-White at the Health Affairs Blog notes that health care reform has not lost its luster, and that the interest in health care reform has emboldened the early participants in Decision 2008 to touch this "third rail" and offers links to further discussions of some candidates’ views (Clinton and Obama). A Healthy Blog highlights Edwards’ plan and sees a Massachusetts influence.

While not one of our usual suspects, Mark Thoma, at Economist’s View, brings together a couple of articles about the decoupling of health insurance from employment, including coverage of the winners of this week’s strange bedfellows award, Wal-Mart and SEIU. There’s some lively discussion in the comments.

Interest in how other countries manage their health care and health insurance systems seems to wax and wane over time; these days, interest seems to be on the rise.  Living through the Massachusetts experience in wrestling with the question of what is an affordable health insurance plan (under the Massachusetts universal health care law) made me think that the intended beneficiaries might have to hock the family silver, if they had any, in order to afford the plans proposed by the HMO’s.  A Healthy Blog’s post on the subject garnered a lot of comments about European models, their (lower) costs, and whether they were worth discussing.  Here at HealthBlawg, I posted a link to the recent Commonwealth Fund report comparing the rate of growth in costs in the U.S. vs. certain European countries over the past 25 years (and offering prescriptions for slowing the rate of growth here).  InsureBlog‘s Henry Stern reacts to talk of nationalized health care systems by arguing that the grass isn’t always greener.

At The Antidote: Counterspin for Health Care and Health News, Emily DeVoto delves into the American College of Physicians’ proposed health plan which, she observes, goes beyond coverage and into prevention and holistic care, in an interview with the College’s government affairs VP.

The policy debate extends beyond the issue of coverage.  However, without coverage — and sometimes without the "right" coverage — there is no access to timely and adequate health care services.  Jason Shafrin, at Healthcare Economist, has a post up about two studies highlighting the gap between access to emergency services (which is near-universal, thanks to EMTALA) and access to follow-up care (good to dismal, depending on source of payment).

Many states are hard at work on various forms of universal health care plans.  Meanwhile, the Lone Star State is forging ahead with a single-disease prevention effort.  Beth Newell offers her Health Care Musings on HPV, Rationing and Health Ethics.

While I’ve seen a ton of commentary on the Texas initiative, Roy Poses at Health Care Renewal chews on the dearth of ink (and bytes) on the anechoic story of HRDI.  (Great adjective, Roy.)  In brief, HRDI was a for-profit corporation created, owned and operated by the CEOs of 30-odd prominent U.S. health care systems and hospitals.  The main purpose of this organization seemed to be to sell memberships to select corporations which sell products and services to hospitals, in exchange for face-time with the hospital and health system CEOs.  It was shut down by the Connecticut AG. 

You’re probably wondering: What about EHRs?  Well, Micky Tripathi at the MA eHealth Collaborative Blog recently wrote about a malpractice insurance credit now available to Massachusetts docs with EHRs, noting that malpractice insurers would otherwise remain free riders, benefiting from the investments of others in EHR systems thro

ugh improved care and reduced claims activity.

You also must be wondering: How will the U.S. Energy Policy Act of 2005 affect HIT?  Hint: The Act shifts Daylight Savings Time from an April-November affair to a March-October one.  Well, Shahid Shah, The Healthcare IT Guy, explains everything one might need to attend to in order to ensure that HIT systems are not bolloxed up by the Act’s monkeying with our clocks.  Shahid says it’s not Y2K (well, neither was Y2K . . .), but forewarned is forearmed.

Despite the thrill of the national health care policy debate, some Americans were preoccupied with football this past week; Jon Coppelman at Workers’ Comp Insider is no exception. He contemplates the sad case of former New England Patriots linebacker Ted Johnson and the lessons for sports medicine and workers’ compensation return to work programs.

Thanks for dropping by, and be sure to check out the next edition of Health Wonk Review, to be hosted by Julie Ferguson at Workers’ Comp Insider on February 22.

— David Harlow

Commonwealth Fund report on strategies for slowing health expenditure growth

There was a brief flurry of debate over the past couple weeks concerning the Bush health plan, though that seems to have died down for the moment.  For a taste of the debate, check out the comment marathon following Matthew Holt’s post on the Bush health care "plan" in the State of the Union address over at The Health Care Blog.

Whenever issues of health care cost and affordability come up, someone always notes that European countries provide better care at lower cost, and someone else always says, so what, that’s not relevant, and maybe not even true. 

Well, I’ll jump into the fray, but not alone — The Commonwealth Fund’s Commission for a High-Performance Health Care System released a report last month entitled Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?  The report led with a look at growth in health care costs over the past 25 years in the U.S. and in Europe — guess who’s ahead.  (Check out the graphic — click to enlarge.) 

The summary of the report reads as follows:

The U.S. is an outlier in the level of health care spending, with far higher spending on health care per capita than other countries. There is ample evidence that the U.S. does not obtain value for money spent, and that there are wide variations in health care spending across the U.S. that do not contribute to better health outcomes.

Substantial net gains in quality at lower costs are potentially achievable from realigning payment incentives to reward efficient and high-quality care, reshaping market incentives to reward value-driven health care, improving administrative efficiency, and redesigning care delivery systems to enhance primary care. Such reforms would be founded on enhanced information about the quality and cost-effectiveness of care and appropriate deployment of modern information technology. Fragmented policies that focus on one aspect of care or shift expenditures from one payer source to another, or from one sector to another, will not result in transformation of the health care system to yield high performance.

There is a compelling need for a coherent public and private sector strategy, with all parties working in concert toward agreed-upon health system aims. Such a strategy should place high priority on policies and practices that have the potential to move our nation toward benchmark levels of performance on access, quality, and efficiency, so that the U.S. health system could achieve commensurate value for the significant resources it commands.

The report lays out some background and a framework for thinking about how to slow the growth in costs, and is worth reading.

It is human nature to like to hear from folks who agree with us — and so I’ll close by plucking out one bit of this report that I liked reading:

Again and again, studies have found that high cost-sharing, including deductibles, leads patients—particularly those with low or modest incomes—to forgo both essential and more discretionary care.

So we need a new way of thinking about this problem.  The flavor of the month seems to be value-based, or value-driven health benefit design.  Check out the discussion in the report.

— David Harlow

Reminder: Health Wonk Review #25 in this space soon

Submissions of posts for Health Wonk Review #25 are welcome.  Please submit your own or others’ wonkiest posts dated Jan. 24 – Feb. 7, by 9 a.m. on Feb. 7, through one of these channels:

Through Blog Carnival;

Through Trusted MD Network; or

Via email (with HWR in the subject line, please).

See you back here Feb. 8 for HWR #25.

— David Harlow

GAO says HHS is on the road to a coordinated privacy policy, but not there yet

GAO testimony before a Senate subcommittee yesterday provides a concise overview of the past few years’ developments in the realms of privacy and interoperability as they relate to HIT — both in terms of regulations and the superstructure necessary to implement them.

HHS believes that it is further down the road to developing an integrated approach to ensuring the protection of privacy of patient information than does GAO. 

It has certainly cooked up another big batch of alphabet soup — ONCHIT, NHIN, NCVHS, etc.  But per the GAO,

HHS is in the early stages of its efforts and has therefore not yet defined an overall approach for integrating its various privacy-related initiatives and addressing key privacy principles, nor has it defined milestones for integrating the results of these activities. GAO identified key challenges associated with protecting electronic personal health information in four areas (see table).

Update 2/5/07:  All of the testimony from the hearing is up on the subcommittee’s website.  Pay special attention to Mark Rothstein’s statement.  He chairs the privacy and confidentiality subcommittee of the National Committee on Vital and Health Statistics (NCVHS), and is rightfully steamed over HHS’s sitting on his recommendations for six months.  He began:

In my testimony today, I want to make only two points. First, HHS has made very little meaningful progress in developing and implementing measures to protect the privacy of health information in electronic health networks. Second, time is of the essence. HHS must begin to act immediately on the key privacy issues, and Congress needs to hold HHS accountable.

Here’s hoping that the regulatory structure can catch up with the realities of the marketplace.

— David Harlow

Value-driven health care: Premier HQID demonstration yields improved performance, HSAs may as well — but there's a limit to these things

CMS recently released year-end results from its "groundbreaking" CMS – Premier Hospital Quality Improvement Demonstration.

Participants in the Premier Hospital Quality Improvement Demonstration reported significant improvement in quality of care across five clinical focus areas measured by more than 30 nationally standardized and widely accepted quality indicators.

The average improvement in the project’s second year was 6.7 percentage points, for total gains of 11.8 percentage points over the project’s first two years.

There’s more detail in the rest of the press release and on the Premier website.

CMS and others seem to be going ga-ga over the results, but the question needs to be asked:  Are value-based P4P initiatives really going to lead to improved health care quality across the board?  In the zero-sum game of health care financing (and it might have to be less than zero — see earlier post on this topic), if the top two deciles in the HQID got some extra bucks, then lower-performing deciles and other provider types missed out on $8 million of CMS funding.  Does this incentivize the low performers?  Maybe.  Is enough money at stake in the aggregate to harm the low performers and drive their performance even lower?  Not yet.  Are the health care quality gains, including those occasioned by preventive care, significant enough to warrant these P4P payments?  Probably.  What happens when all deciles bunch up at the top?  That’s a good thing, that’s what we want to incentivize, but then the distinctions between deciles are what law professors like to call "a distinction without a difference." 

Value-driven choices include HSAs as well.  A tip of the hat to Jane Hiebert-White over at the Health Affairs Blog for posting on this issue.  She wrote yesterday:

Gaining greater clarity in exposing costs and value of health care treatments is at the heart of a new approach [2 week free access] published yesterday in Health Affairs by Harvard professor Michael Chernew and Allison Rosen and Mark Fendrick of the University of Michigan. The aim of this “value-based insurance design” is to “help patients spend their health dollar wisely.”

Another voice in favor of promoting HSA flexibility is David Gratzer of the Manhattan Institute, whose Wall Street Journal piece this week bemoaned their underutilization.

In theory, I do not doubt that HSAs can help some well-informed individual consumers save health care dollars.  I also do not doubt that, in theory, value-based insurance design may have some benefits.  However, I think we have a long row to hoe before these experiments could pay off for the population at large (in terms of both cost savings and health status improvement). 

Value-based insurance design means, largely, tiered financial obligations for consumers based on insurers’ decisions about safety and/or efficacy of particular treatments or providers.  Well, tiered provider panels — on the agenda again in the Massachusetts universal health care law; see my summary here) have never gotten off the ground in my neck of the woods (everyone wants to go to the Harvard teaching hospitals, sometimes even for the proverbial hangnail).  And moving consumers to act in their enlightened self-interest may require bigger out-of-pocket expenditures than many folks are willing to stomach (triggering a failure to access preventive health care services and thus leading to higher total costs), and a significant departure from the cost-is-no-object mindset that has pervaded the consumption of health care services.  (See this week’s Washington Post op-ed piece on this subject, also cited by Jane in the same Health Affairs Blog post.)

— David Harlow

EHR: cost or benefit?

Today’s edition of Modern Healthcare’s Health IT Strategist reports: 

Two influential economists yesterday told federal lawmakers that the widespread implementation of e-prescribing tools and electronic health records may only have a marginal effect on savings — and could conversely result in increased costs.

Robert Reischauer, president of the Urban Institute, and Eugene Steuerle, a senior fellow also from the institute, both challenged industry estimates that adoption of health information technology could trim billions of dollars from ever-rocketing healthcare costs.

Reischauer and Steuerle’s views run counter to the widely held belief that adoption of EHRs and other high-tech gear would produce almost immediate savings across hospitals and physician offices alike.

Further detail (including a two-hour streaming video of the hearing for the true insomniacs out there) is available on the Senate Budget Committee’s website. (Navigate to 1/30/07.)

Whether or not you believe that EHR implementation will increase the efficiency and efficacy of care, a well-executed EHR roll-out may now entitle some lucky physicians to a better deal on malpractice insurance.  Exhibit A: Micky Tripathi, at the MA eHealth Collaborative, announced a new insurance plan offering credits to physicians with qualifying deployments of EHR systems.  Check out his post on the subject from earlier this week, excerpted below, at the MAeHC Blog:

Malpractice insurers stand to be among the biggest winners in the move to digital health records. Some of the greatest sources of liability risk for physicians — messy documentation, inconsistent collection of family histories, poor tracking of patients — are addressable by EHRs and HIEs, as long as they’re implemented correctly and properly used.

Of course, there could be some increases in risk as we move to modern electronic systems. Breaches of confidentiality, and increased errors while physicians and medical staff become familiar with the new systems come immediately to mind. However, we can work on reducing these types of risks; for example, the [CT Medical Insurance Co.] program will require that physicians demonstrate long-term commitment to the EHR and to effective risk management. Implementing EHRs and HIEs within a program framework, such as MAeHC’s, dramatically increases the odds of effective implementations and significant net risk reduction. Of course, risk reduction means fewer medical errors, so patients will be the biggest beneficiaries at the end of the day.

Cognitive dissonance?  Not necessarily.  Reischauer and Steurle are looking at the health care system and opining that EHRs will not reduce the amount of money spent within the health care system.  Tripathi is looking at individual physician practice costs and telling us that malpractice insurers have signed on to the notion that EHRs can improve physician performance (from a quality perspective), thus lowering physician’s risk profiles, and thus qualifying for malpractice premium credits.  If Reischauer and Steurle are right, then EHR implementation may just be the latest high-tech boondoggle from a cost perspective: good for patients, good for physicians (if they can recoup some of the cost through premium credits), but adding another layer of cost to an already-burdened system.

— David Harlow