What do tomorrow’s physicians think about trends in health care?

4 questions for: Megan Gray, MD/MPH Candidate 2011

1-What do you think is driving up health care costs so much?

1) Insurance companies- the very nature of inserting a middleman creates often unnecessary jobs, time, and paperwork. compare the example of Ontario’s 900-bed general hospital with Mass Gen’s 900-bed hospital… Ontario has 3 people in the billing department, while Mass Gen has 300… so really it’s a bunch of kind of false jobs created that are taking up resources.  For-profit insurance companies also drive up health care costs, as well as pharma companies that claim to increase costs to pay for R&D, but really spend too much on marketing/pushing drugs to doctors.

And if you want to get philosophical, Americans aren’t used to a patriarchal healthcare system… but this seems to work well in other developed nations.  Americans would probably do better with less choice for insurance plans… although Germans have 240 “sickness funds” to choose from.

2-Dr. David Brailer, former national coordinator for health information technology in the Bush administration, in evaluating Wal-Mart’s upcoming Electronic Health Records plan, states that “If Wal-Mart is successful, this could be a game-changer” (see http://healthcareinformaticsblog.wordpress.com/2009/03/11/wal-marts-electronic-health-record-plan-could-be-a-game-changer/) Do you agree?

Wal-Mart would absolutely be a game changer- I noticed how freaked out physicians got over losing some autonomy to Wal-Mart’s hugely successful in-store clinics when they started, run mostly by nurse practitioners… a lot of the recent TMA (ed. note: refers to Texas Medical Association) discussions have been about limiting these types of clinics… Wal-Mart is enormously savvy in the healthcare sector and in that respect, proved they knew their clients… so with the EHR endeavor, they’re again proving they know their clients- just about every small town has access to a Wal-Mart, so small town/suburban doctors can easily access the system from a source/name they trust, with a store presence in case they need assistance… rather than a traveling IT salesperson coming into their office and then retreating to headquarters back in Dallas or New York… so yes, Wal-Mart plays a huge role in the industry.

3-When all the smoke is cleared from the policy battles over the level of access the insurance industry will have to patient EHR/EMR, do you think there will be more, not less, successful denial of coverage for policyholders by the insurance companies, based on data-mining for evidence of patient pre-existing conditions? Is the HIPAA Privacy Rule adequate to protect patient privacy?

I would think less since the nature of EHR allows for more standardization of practices/commonalities across patient cases, and a better electronic trail to document just why a claim was denied.

Another point: insurance companies might be wary of too much data mining, in case of a public backlash and an industry shift to phase them out so as not to worry of data mining at all… if we expanded a national system like Medicare to cover everybody, pre-existing conditions would cease to exist at all…as a greater risk pool would decrease the cost to insure any one member.

4-Where are the low-hanging fruit in the healthcare system that could keep costs from rising further, if any?

I really think that moving to an EHR system would help us contain costs better… not exactly low-hanging, but inevitable… and all the medical students I talk to can’t imagine using paper records in their careers, after having grown up with info so readily accessible online.  Hopefully in the next few years it will take to implement such a system, the 60-65 year old bracket of old school anti-EHR docs will be on their way out…

A lso, practicing defensive medicine grossly exaggerates our use of labs/tests… for example, in Britain, doctors come up with the most likely diagnosis and begin to treat that… if there is no resolution, they move on to what’s next most likely on their differential diagnosis list. here in the U.S., docs are so fearful of litigation that they must order CTs and MRIs and extra labs from the outset just for the rule/out… for it’s better to spend a couple hundred extra now than risk thousands of dollars if you don’t seek out extra problems.

Also, pharma drugs- I wish there could be some type of legislation to limit the amount of marketing $ each company could spend… a national healthcare plan could also negotiate better bulk rates on drugs, similar to the dirt-cheap rate the VA gets now… I know lots of people who get prescriptions from Canada because the exact same drugs are literally 1/2 the price…

(in the interests of full disclosure, the repsondent is a family member)

Ephraim Schwartz: Financial and technology issues make Obama’s EHR push not so easy to execute

from www.infoworld.com/article/09/03/11/10FE-electronic-medical-records_1.html

Up until now, the benefits of electronic medical records that have occurred accrue to just about everybody — patients, employers, state and federal governments, and medical insurers — but the actual health care providers. Doctors get the least benefits, especially in small practice groups (those with fewer than five physicians) that make up most medical practices.

But even those who might benefit from electronic health records don’t, says Homer Chin, associate medical director for clinical information systems at Kaiser Permanente Northwest. Why? Because there is little incentive to share information, the core of an electronic health record (EHR; also called an EMR for “electronic medical record”). For example, hospitals make money by doing tests. But once EHRs are up and running, a doctor ordering a test electronically might immediately receive an alert saying the test was unnecessary because the patient had the same test or procedure at another location. “There is not much revenue and profitability in putting in an EHR. There is little financial incentive,” Chin says.

An ironic consequence of EHRs is that, by helping raise the quality of health care, they penalize doctors and other medical providers for success, says Wes Rischel, a vice president at Gartner. The bottom line: Doctors will see fewer patients.

Beyond the income factor, the high cost of EHR systems today — not only the systems, but the setup and training — also dissuades adoption by doctors, especially those in small groups. Physicians have been unwilling to invest anywhere from $20,000 to $50,000 in an EHR system where the economic benefits tend to go to someone else. Today’s EHR systems are not as easy to use as they could be, so there is a large learning curve required, Chin says: “There is something intuitive about paper chart and prescription pad.”

Recognizing these factors, the stimulus package tackles these financial challenges head on by offering money to health care providers. Hospitals submitting via EHR systems to Medicare and Medicaid will receive up to $6 million a year in additional payments for sending data electronically. This incentive will remove much of the adoption inertia seen so far, says Richard Archer, a principal in the health care IT advisory practice a KPMG.

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But now Microsoft, Google, and AOL founder Steve Case’s Revolution Health are looking at entering the health care information exchange market. All three offer individuals a personal health record, which puts the patient in control of his medical information. But the business aspect is in giving health care providers access to a person’s complete health record from a single site.

There are two major questions around the reliance on health records from these providers, say industry analysts. One is whether users will trust a for-profit organization to care for the most personal kind of information. The second is whether each of us can be trusted to manage and keep such a life-and-death record up to date or if it’s safer to leave that responsibility to organizations whose only job it is to keep the health data updated.

The prognosis for EHRs
EHR providers are, not surprisingly, bullish on the future of EHR efforts. Greg Mancusi-Ungaro, a senior director at Exigen Systems, says deploying an EHR system is just like implementing any big enterprise application, only the enterprise in this case is bigger and the stakes are higher. “The technology exists today and despite the fact that we lack some core standards, we are enabling the development of a flexible infrastructure to stay in tune with requirements. I can visualize a successful national system,” he says.

As Kaiser’s Chin points out, there is a convergence occurring around health care technology regarding how to share it and use it to assist delivery of services and treatment. But the challenge of orchestrating and satisfying so many stakeholders remains. Plus, even if the solutions are mandated rather than eventually negotiated, the task of gathering the many pieces that are still in flux, then integrating them remains a complex technical and process task.

Over time, both industry representatives and analysts expect that every U.S. citizen will have an EHR available nationwide. But to make it happen will require a great deal of cooperation, innovation, and an investment in health-oriented IT. This shift will likely start at a less ambitious level than the political rhetoric suggests, with local practitioners sharing patient information in a local health care ecosystem.

Lobbying War Ensues Over Digital Health Data

from www.washingtonpost.com/wp-dyn/content/article/2009/02/09/AR2009020903263.html

The effort to speed adoption of health information technology has become the focus of an intense lobbying battle fueled by health-care and drug-industry interests that have spent hundreds of millions of dollars on lobbying and tens of millions more on campaign contributions over the past two years, much of it shifting to the Democrats since they took control of Congress.

At the heart of the debate is how to strike a balance between protecting patient privacy and expanding the health industry’s access to vast and growing databases of information on the health status and medical care of every American. Insurers and providers say the House’s proposed protections would hobble efforts to improve the quality and efficiency of health care, but privacy advocates fear that the industry would use the personal data to discriminate against patients in employment and health care as well as to market the information, often through third parties, to generate profits.

Resolving these competing visions will be the task of House and Senate negotiators. The outcome could determine, for example:

· whether a hospital or doctor can make a profit by selling people’s medical data, without their consent, to pharmaceutical companies for research;

· whether a hospital or other provider must obtain patient consent before sending them fundraising letters.

Neither version is perfect, both business and consumer groups say. But where the House bill expands a patient’s right to know who has been given access to his health information, the Senate would defer that issue to the Health and Human Services secretary. And an effort in the Senate to require health-care providers to notify patients if their records were unintentionally disclosed has been blocked.

Harvard law prof: HIPAA “dismantled the longstanding moral and legal tradition of patient confidentiality”

from  www.accessmylibrary.com/coms2/summary_0286-35587036_ITM

“The HIPAA paradox: the privacy rule that’s not.

HIPAA is often described as a privacy rule. It is not. In fact, HIPAA is a disclosure regulation, and it has effectively dismantled the longstanding moral and legal tradition of patient confidentiality. By permitting broad and easy dissemination of patients’ medical information, with no audit trails for most disclosures, it has undermined both medical ethics and the effectiveness of medical care.

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Most physicians, patients, policy analysts, and journalists believe that the HIPAA “privacy rule” protects medical confidentiality. They are mostly incorrect. The Health Insurance Portability and Accountability Act creates medical records rules that tighten internal practices, like hiding computer screens and not talking in elevators, and these protections are an improvement over previous practice, but they are limited. (1) Perhaps because the enabling legislation called for a “standard for privacy of individually identifiable health information” and the original final rule in 2000 required patient informational consent, there is a belief that the Department of Health and Human Services rules provide strong privacy protections for medical information. Unfortunately, that belief is a misconception. (2) In fact, the amended final HIPAA rule (for simplicity, hereafter referred to as “HIPAA,” or “the HIPAA rule”) provides much less privacy than the term “privacy rule” suggests.”

Will the Obama EHR/EMR plan enable government surveillance?

from  www.amconmag.com/article/2009/mar/09/00009/

“At this point, fewer than 20 percent of the nation’s physicians have gone full-speed on computerization. Obama’s plan offers between $44,000 and $64,000 to doctors who computerize patient records and up to $11 million per hospital. “On the stick side of the equation,” the Wall Street Journal reported, “the measure includes Medicare payment penalties for physicians and hospitals that are not using electronic health records by 2014.” If records are digitized on the federal dime, it will be far easier for politicians to claim the resulting information.

But the feds have no technological silver bullet to distribute to docs across the land. David Kibbe, a top technology adviser to the American Academy of Family Physicians, warned Obama in an open letter late last year that existing medical software is often poorly designed and does a miserable job of exchanging information. Kibbe declared, “If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists.”

Marc Roberts, a Harvard professor of political economy and health policy, notes, “Many healthcare systems are now intentionally building medical record systems that are nonstandardized and noncompatible so they can own and control the data.”

In the same way that George W. Bush bragged about the percentage increase in homeownership, President Obama will be able to boast about the increase in doctors’ offices using electronic records. It didn’t seem to matter to Bush that many of the new federally subsidized homeowners went bankrupt, and it may not matter to Obama that the federally controlled health-record system is bound to be a trainwreck.”