Category Archives: Health Policy

Air Travel and Healthcare, Amended

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The video below, “If Air Travel Worked Like Health Care” has been making the rounds of the healthcare blogosphere. I spotted it first over at Running a Hospital, and it’s based on Jeffrey Rauch’s column from the National Journal.

But wait, there’s more! After seeing the video, a physician friend pointed out that it was missing a critical point of disfunction. He then sent me this, which I begged him to allow me to post:

Booking Agent: Hello, NationalAir. How can I help you?

Customer: Yes, I’d like a flight from Boston to DC on February 3rd with Joseph Smith as the pilot.

Booking Agent: I’m sorry. Pilot Joe Smith is completely booked for the next 6 months. How about Pilot Jane Wallace?

Customer: I don’t know, my previous regional pilot recommended Pilot Joe Smith directly. Maybe you know my previous Pilot, Pilot Jeffery Jones? He and Pilot Smith trained together in Denver. Apparently, Pilot Smith is phenomenal on the Boston DC run. Be honest, is Jane Wallace a good pilot?

Booking Agent: Yes, Jane is great! She’s new to our airline, but she comes highly recommended. She graduated from the Air Force Academy with honors. She’s written several books on combat flight techniques and has studied passenger usage of air sick bags during high G evasive maneuvers induced by terrorist surface to air attacks.

Customer: Okay……great. What is her track record on the Boston to DC flight?

Booking Agent: I’m sorry, we don’t release that information.

Customer: Okay, how about stats of NationalAir flying from Boston to DC?

Booking Agent: We’re having discussions about that internally. I will tell you that 6 out of 10 NationalAir frequent fliers choose NationalAir when flying on the East Coast on Tuesday between 8pm-12am in December (p<.001). We also have great customer satisfaction for our inflight movie selection on transcontinental flights. That work was actually recently published in the International Journal of Travel Pilots. We also have more Air Force Academy trained pilots than any other airline on the East Coast. We're very proud of that.

Customer: Okay….that’s helpful. NationalAir certainly has a great reputation…I’m sure Pilot Wallace is more than capable of flying from Boston to DC. Book me for her please.

Booking Agent: Great, you won’t be disappointed. She has an opening in late April……

A Final Word on Breach Notification

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The new data breach notification rules for covered entities and PCHR Platform providers go into effect on September 23 (for covered entities) and September 24 (PCHR Platforms and providers). There’s a nice wrap-up here.

One big change from the prior environment is that the business associates of a HIPAA covered entity are now directly covered by the rule. Previously, protections were extended by contract with the original CE. Practically, I don’t think this makes a huge difference, since the Covered Entities would have just gone back and renegotiated the existing agreements to share the notification burden. Extending those requirements through regulation probably even saves some money and lawyer time, since there’s now no need to go and revisit all of those agreements.

The final rule does, however, have a pretty substantial loophole. Notification is required only when there is a chance of substantial harm to the person whose data was released. And that determination is made by the covered entity. Obviously, there is a huge opportunity for things to go wrong here. But the opposite extreme – mandating disclosure at all times – would be overly burdensome and would also have the very negative side effect of scaring consumers who receive breach notifications for trivial things – their city and phone number were accidentally released to a contractor, who then had a laptop stolen while on vacation in Guatemala. Odds of harm to the patient are pretty close to zero, and putting the burden on them to worry about sophisticated identity thieves is not particularly fair.

So I don’t think they got this one entirely right. A public audit process might be the solution – all breaches need to be disclosed, and outside groups can choose to make a stink about situations where individual notifications should have occurred but didn’t. I suspect this would get behavior into line pretty quickly.

Cost Savings and Retail Clinics

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I’ve been interested in retail clinics for years. It’s a wonderfully simple idea: there are a range of conditions for which a doctor just isn’t the right tool for the job, any more than you need a trained engineer to change a light-bulb.  If someone has inflamed tonsils (pharyngitis), a urinary tract infection or an ear infection (otitis media – you’ll need the vocab for the next section) sending them to a physician or an emergency room makes no sense – you have an expensive provider delivering by-the-book care. And in the event that the patient has something serious masquerading as something common? They’ll almost certainly get the basic care anyway and end up coming back in later.

Retail clinics, such as CVS’ MinuteClinic chain, are intended to provide an alternative. Rather than going to the Emergency Room, you go to your local drug store, get checked out in a few minutes and are handed the prescription. If your condition goes off-script, they send you to a doctor or to the ER. The clinics are manned by nurse practioners or physician assistants, depending on the state, and supervised by a physician who may be off site.

Until recently we haven’t had much insight into the effectiveness of retail clinics. That’s beginning to change. In the current issue of the Annals of Internal Medicine, Ateev Mehrotra and colleagues analyze the long-term costs of care in retail clinics in Minnesota for the three conditions I listed above. You can read the abstract of the article here.  Here’s the summary:

Overall costs of care for episodes initiated at retail clinics
were substantially lower than those of matched episodes initiated at
physician offices, urgent care centers, and emergency departments
($110 vs. $166, $156, and $570, respectively; P < 0.001 for each
comparison). Prescription costs were similar in retail clinics, physician
offices, and urgent care centers ($21, $21, and $22), as were
aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient’s
receipt of preventive care (14.5%, 14.2%, and 13.7%) (P < 0.05
vs. retail clinics). In emergency departments, average prescription
costs were higher and aggregate quality scores were significantly
lower than in other settings.

In other words – if a patient goes to the retail clinic rather than ER, the insurance company saves $460, and the patient gets care faster and suffers less discomfort.  The quality scores show that retail clinic customers do not suffer in terms of other healthcare services (such as scheduled preventive procedures) compared to those who seek initial care in a physician office.

As we like to say in healthcare economics, this is only an initial study. It’s biggest weakness is an inability to control for severity of the underlying condition – it’s conceivable that only healthier patients took a chance on the retail clinics, leaving the physician offices and emergency rooms to handle a much sicker group. I don’t think this is likely, however. With these three conditions it is difficult for the patient to judge severity when the disease presents itself. Minnesota is particularly well seved by retail clinics – it’s MinuteClinic’s home turf – so access issues are also unlikely to play a role.

In general, I think these are promising results, and they should help encourage insurance providers to reimburse for care delivered in the retail clinic setting. That should help with adoption – the market has not exploded, and MinuteClinic has even resorted to running some clinics seasonally.

Oh, and for those looking for an informatics connection: retail clinics tend to be pretty good at operating electronically and making patient data available to the patient upon request. MinuteClinic, again, was one of the early Google Health partners, and they’ve long seen electronic health information exchange as a key component of their integration with local health systems.

Future of Google Health

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John Moore at Chilmark Research asks today if Google Health is irrelevant. I’m re-blogging it because I agree with him. Microsoft is easily the leading player in broad audience Personal Health Record platforms. That doesn’t mean their product is ideal – it’s certainly not – but they’ve been improving it steadily and have integrated it with a very cohesive strategy aimed at engaging with the healthcare industry as a whole. Google hasn’t done that.

One take-away I had from the Microsoft Health Solutions Group conference in June (besides one heck of an airplane-acquired infection) was how tightly Microsoft is linking Amalga UIS – its hospital intelligence/data warehousing offering – with HealthVault. Amalga is the back-door – hospitals will make the data integration investments because of bottom-line and quality improvement benefits that are realized by UIS. But once that work is done, integrating with HealthVault is just flipping a switch. Microsoft has allocated its R&D money accordingly.

Google, on the other hand, still strikes me as simply dallying in healthcare. They’ve done some good work in focused healthcare search, but that’s pretty much where it ends. I completely agree with John’s statement that Google has gotten disproportionate attention simply because it’s Google. I’m not really inclined to start trying to take down the myth of Google here, but it’s safe to say that the company isn’t omnicompetent. From very personal experience, it was quite difficult to get projects in PHR off the ground during the six months after Google Health leaked but before it launched. There was a huge chilling effect – everybody wanted to wait and see what Google would do.

Chrome OS has nothing to do with PHRs

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I usually don’t bother picking on other people’s editorials. But this one, from FierceHealth IT (which I usually like, incidentally – it’s a nice roundup of daily HIT stories) just struck me as trying to fill space:

Google’s Chrome OS may heat up PHR competition with Microsoft – FierceHealthIT.

Google’s Chrome OS has nothing to do with healthcare. This is not a signal of the shift to cloud computing – that signal flare went up several years ago. Google won’t “tightly couple” Google Health to Chrome OS. HealthVault is just as web based and interactive as Google Health (admittedly, a little more complex to use, but you get more out of it).  Both systems have all kinds of big, enterprise-class integrations behind them.  Chrome OS is about Netbooks – they’ll ship a few million units on cheap hardware, and it will be easier for us to sit in front of the TV at night checking email. I won’t say it will never be a competitive desktop operating system, but that would be many years and several paradigm shifts down the road. A new version of Google Calendar would be more significant – at least you could integrate that with appointment reminders somehow.

The last sentence kind of sums it up:

I don’t pretend to have any kind of crystal ball here. But I do think it’s hard to argue that the PHR world is a lot more interesting with the Chrome OS in it.

That’s verbatim. And I agree – it is VERY hard to argue the proposition that Chrome OS makes any kind of difference whatsoever.

Android, by the way, is a different story – while it’s also too early to say, Google’s OTHER OS project, intended at the moment for cell phones, could enable a range of interesting healthcare applications. Since it doesn’t require always-on connectivity, Android could form the base of a handheld computing ecosystem in healthcare. Apple’s iPhone OS could do the same thing, and if Apple brings out a tablet, as they’re now expected to, I’d look for a wave of innovation coming off that platform. Local storage coupled with intuitive interfaces and great performance? That matters.

EHR Challenges in the Netherlands

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My friend FJ, who blogs at TechSocioTech, sent me a link to a news article from a Dutch newspaper, covering the results of a survey of 1800 patients by the Dutch Patient Consumer Federation. Since my Dutch is poor, he kindly provided me with a quick translation (probably not intended for blog publication, but it’s a lot cleaner than Google translate!). It speaks for itself:

AMSTERDAM – Medical records are often full of errors and incomplete. Almost 60 percent of the people who responded to a campaign to notify the Dutch Patient Consumer Federation (NPCF) had to correct or supply missing information to caregivers because insufficient information was available.
Moreover, participants regularly noted egregious mistakes.Therefore a large majority has a negative attitude towards digital medical records. The case files of one in five patients were even lost at one point or another, a spokesperson said.
Most people who are already worried about the medical data are therefore also skeptical about the safety of the SPD. While they worried, two thirds believe that digital exchange of patient data is helpful in case of emergency,  medication, and clinical insights. 1800 people took part in the campaign of NPCF. (ANP)

I’ve been trying to find an English copy of the press release, but no success so far. Do we have an entire country of ePatient Daves? This reinforces a simple observation about EHRs in general – they probably won’t be widely accepted until the data quality reaches a sufficiently high level, and that just hasn’t happened yet. Right now consumers expect that EHR data is both more widely available than it actually is, and over higher quality. What happens when they find out?

Porter on Healthcare Reform

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In the current issue of the New England Journal of Medicine, Michael Porter, the Strategy Czar from Harvard Business School, has a very interesting manifesto on how to fix the healthcare system. Since it’s a Perspective, the NEJM is letting you read the whole thing for free.  For what it’s worth, I’m pretty much in agreement with Porter’s vision on the end-state of healthcare reform. We need to fix payment by bringing everyone into the system (and yes, that more or less means universal coverage, whether by government administration or simple mandate) and we need to restructure the delivery system in a way that creates powerful incentives for care coordination and health maintenance.

Porter suggests we have to start all these changes at the same time, because they’re self-reinforcing. And as I think about it, I have to – perhaps a bit reluctantly – agree. Anybody who has been seriously interested in healthcare reform for any amount of time has invested quite a bit of thought into “process patches” on the existing healthcare system. Personal Health Records are one such, but as promising as it is, consumer controlled healthcare information isn’t going to do more than create some small efficiencies. That may still add up to billion dollar sums, but against a $2 trillion backdrop even the odd billion doesn’t go as far as it used to. There just aren’t enough little fixes to add up to one big fix.

Since this is nominally an informatics blog, I’ll call out Porter’s very sound observation on the role of EHRs:

Sixth, electronic medical records will enable value improvement, but only if they support integrated care and outcome measurement. Simply automating current delivery practices will be a hugely expensive exercise in futility. Among our highest near-term priorities is to finalize and then continuously update health information technology (HIT) standards that include precise data definitions (for diagnoses and treatments, for example), an architecture for aggregating data for each patient over time and across providers, and protocols for seamless communication among systems.

Aggregating data across time and providers may sound scary to anyone concerned with patient privacy, and Porter doesn’t mention that part of the equation at all.  If there is going to be systematic reform, the average citizen is going to wonder about its implications for medical confidentiality. One nice thing about universal coverage is that it dramatically reduces “breach consequences” for medical privacy. It doesn’t eliminate them – there will always be conditions that create social awkwardness or worse – but the big threat, loss of health coverage, no longer applies.  I’m surprised that isn’t pointed out more often.

The Tories and HealthVault

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The Google froth turned up an interesting op-ed from the Guardian newspaper in London. Apparently the Conservative party has started agitating for use of systems like HealthVault and Google Health to replace the large, centralized National Health Services databases.  Certainly fits the small-government agenda, but as the article correctly points out there’s a lot more in a real EHR than you’re going to find in HealthVault. Patients do need their records – but so do physicians.

The Guardian: Don’t ask the public to care for its data.

To be fair, the proposal only came from a think tank, and they weren’t really focusing on healthcare per-se; they were focusing on large government programs. But still, I’ve heard the same question come up from very educated sources outside the health and health IT areas.

Simulations and Public Access

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Andrew Yates over at Think Gene has an interesting post suggesting  A Force Fix for Healthcare. The idea is a simple one – all third party healthcare payers (insurance companies) must expose a web service that allows the public to simulate any insurance coverage decision. You put in all the inputs, and you get out a yes or no answer.  He argues that since the decisions are being made by computers and algorithms anyway, there’s no reason that this couldn’t work.

I like the idea in principle – in general, I’m in favor of exposing decision making processes to consumers whenever possible, and enabling smart, motivated people to build tools that streamline complex systems for everyday users. Physicians would love it, too  – much less revenue at risk.

That being said, there are a couple of practical issues. I’m not sure I’d go as far as calling these problems, since they’re surmountable and wouldn’t kill the idea outright.  The core issue is that coverage decisions are not isolated. Take a doctor’s visit as an example. Most insurance companies, including Medicare, won’t cover more than one primary care office visit (for a routine checkup) within a certain time period.  So to simulate the coverage decision accurately for a particular patient, we need to know when their last reimbursed office visit was. With Medicare that information may not be available in real time, and I suspect other insurance systems face similiar problems. You can still simulate, but you have to provide a set of assumptions that will vary on a bill by bill basis.  Doing better may well require a rip-and-replace for Medicare’s systems.

The other issue is that coverage decisions aren’t deterministic, and there often is some medical thought that goes into it. Genetic testing is an excellent example. A few months ago I got to spend a day shadowing one of the attending physicians in the adult genetics clinic at one of the major Harvard hospitals. We spent a lot of time talking about the challenge of getting insurance companies to reimburse for some of these tests. It’s clear that, right now, there aren’t a lot of simple rules that can applied to reimbursement decisions at the cutting edge of medicine. Appropriateness of testing (and it’s expensive testing) is going to depend on a lot of factors, including the makeup of the patient’s extended family.  While I doubt the insurance companies are this sophisticated, a test might be appropriate for a 50 year old woman with three children, but not for a 50 year old with no children. For the former, the test could create intervention opportunities for the kids. For the latter, it may just be informational.

The bottom line: it’s an interesting idea, but I’m not sure if it can really be applied to all coverage decisions, and at a reasonable cost.

Microsoft Connected Health Conference

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I spent all day yesterday at the Microsoft Connected Health Conference in Bellevue, Washington. I had to miss todays’ wrap-up sessions in order to attend a few other meetings, and was generally crippled through the whole event thanks to an airplane-acquired something-or-other, but it was still a very interesting day. One of the great things (if not the only great thing) about a sore throat is that it gives you an excuse to listen to other people.

The conference opened with a very nice panel, featuring Peter Neupert, Microsoft’s Corporate VP for the Health Solutions Group, Uwe Reinhardt of Princeton University, former Secretary of Health and Human Services Michael Leavitt, and David Kibbe of the AAFP. The topic was one that we’ve all rehashed dozens of times – how do we fix the US healthcare system, what role can Information Technology play, and if IT is valuable in the long term, what do we have to do to get it into place?

That’s an important distinction, by the way, that many events miss. Health IT adoption is not a goal in and of itself. The fact that my physician types rather than uses a pen is of no intrinsic value to me. The value comes in faster, more accurate, safer, cheaper and more effective healthcare.  That’s the goal – investments in Health IT are just one of several non-exclusive paths to a more functional healthcare system.

In the end, the panel concluded that it all comes down to Congress. When I was at HHS myself, we had all kinds of things we wanted to try, but we generally couldn’t – not enough money, or not enough Congressional authorization.  A great example of this phenomenon (which Leavitt mentioned in his remarks) was a recent program to require bidding for Medicare Durable Medical Equipment contracts. Congress actually authorized the program, which went into effect on July 1, 2008, and was projected to save the government about a billion dollars (and that from just ten products in ten regions). The DME industry went to Congress, and on July 17th the program was shut down. At CMS and on the AHIC Chronic Care workgroup we looked at trying to do a demonstration program for electronic patient visits, but were blocked because the Medicare telemedicine statutory restrictions are very, very tight.

Another point of (at least apparent) consensus on the panel was that while the Medicare reimbursement system was fundamentally flawed, its status as the 800 pound gorilla of the US healthcare system means that every hospital and small practice has to set themselves up around the Medicare fee for service model.  Fee for service payments are not good at aligning incentives between participants in a market. So what happens if (as some propose) we extend Medicare to the entire population? Will centralized ownership of risk lead to the kinds of preventive medicine programs and support for (appropriate) technology investment that will ultimately take cost out of the system? Or will the system ossify under Congressional supervision?

I offer no answers, of course. I’ll post some other thoughts on the conference later (paticularly around HealthVault and Amalga), but for now, I leave you with a great, if slightly paraphrased,  Leavitt quote from the keynote panel: “The problem isn’t a lack of political will. It’s an overabundance of political will. Whenever we get close to actually making a change people start unholstering their political will on each other.”