Wednesday, August 29, 2007

Dr. Roxane Townsend

This week, Dr. Katherine Baineaux Blanco appointed Dr. Roxane Townsend as secretary of the Louisiana Department of Health and Hospitals. The appointment of this great leader comes on the two-year anniversary of Hurricanes Katrina and Rita. This writer had the opportunity to meet Dr. Townsend and work with her in the week after Katrina.

Few individual demonstrated more leadership and compassion than Dr. Townsend. Her temperament, skills, and passion for improving the health of the citizens of Louisiana has made her a national example of what we as a nation should expect from health care leaders.

The Government Technology Web site characterizes Dr. Townsend as a "health IT advocate." She clearly champions health IT, but in this writer's experience, she is an advocate viewing health IT as a means to an end. Never has this observer seen Dr. Townsend take her eye of the primary mission - improving health care for the citizens of her state - and through her other collaborations - for the Nation.

Bravo and congratulations, Dr. Townsend.

Sunday, August 19, 2007

CMS, DRGs, and Hospital-acquired complications

The Federal Register (Vol. 72, No. 85) of Thursday, May 3, 2007 has a 457-page listing of proposed changes to the hospital inpatient prospective payment system for the 2008 fiscal yer. These proposals affect 42 CFR Parts 411, 412, 413, and 489.

This is essential reading. The posting of these proposed changes is a watershed event with implications that may extend far beyond the altruistic intentions of CMS.
Page 24716, Section F begins a lengthy discussion of how CMS proposes to reimburse hospital-acquired conditions, including infections. The changes are revolutionary and will have a tremendous impact on how hospitals - and other organizations - manage health information.

CMS has proposed some target conditions. At least to this writer's limited understanding, if one of these conditions is developed during a hospitalization, CMS would not reimburse for any higher DRG rates but instead would reimburse for the DRG that is not associated with the complication. Proposed conditions include:
  • Catheter-associated urinary tract infections.
  • Pressure ulcers
  • Air emboli resulting from injection
  • Stephylococcus septicemia
  • Erroneous transfusion with the wrong blood type
  • Ventilator-associated pneumonia.
  • Infections relating from intra-vascular infection
  • Clostridium difficile-associated gastrointestinal infections
  • Drug-resistant staphyloccocus infection
  • Surgical site infections.
  • Wrong surgery.
  • Falls

The legislative authority is clear. Quoting from the Federal Register:

Section 5001(c) of Pub. L. 109–171 requires the Secretary to select, by October 1, 2007, at least two conditions that are
(a) high cost or high volume or both,
(b) result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and
(c) could reasonably have been prevented through the application of evidence-based guidelines.
For discharges occurring on or after October 1, 2008, hospitals will not receive additional payment for cases in which one of the selected conditions was not present on admission. That is, the case will be paid as though the secondary diagnosis was not present. Section 5001(c) provides that we can revise the list of conditions from time to time, as long as the list contains at least two conditions. Section 5001(c) also requires hospitals to submit the secondary diagnoses that are present at admission when reporting payment information for discharges on or after October 1, 2007.
The mere targeting of this vital issue may transform both the means by which data are collected in the hospital and the means by which the status of a patient must be determined prior to hospitalization (the "present on admission"indicator becomes crucial). It will lead to better health care, greater systemic application of best practices, greater complexity, higher administrative costs, and perhaps add additional weight to the arguments made by proponents of global capitation or a single-payer health care system.

Aside: What is the Present on Admision indicator? Maybe this quote from the Register can help - or at least demonstrate again how health care is mired in the complexity business.

The current electronic format used by hospitals to obtain this information (ASC X12N 837, Version 4010) does not provide a field to obtain the POA information. We are in the process of issuing instructions to require acute care IPPS hospitals to submit the POA indicator for all diagnosis codes effective October 1, 2007. The instructions will specify how hospitals under the IPPS will submit this information in segment K3 in the 2300 loop, data element K301 on the ASC X12N 837, Version 4010 claim.

Now, isn't that clear?

The intent of these regulations is laudable. Who, after all, should be responsible for the costs incurred when the wrong limb is amputated, when a sponge is left in a body, when the wrong type of blood is transfured, or when a catheter is left too long unattended and leads to septicemia? That said, some of the areas are far more problematic. Complications - including septicemia, C. difficile happen under the best of practices. Where decubitus ulcers are concerned, determining the onset of these conditions is problematic - particularly in the case of patients who are bedridden or largely sedentary prior to admission.

In addition to the obvious coding and IT implications, these regulations may have other implications:

  • A far more extensive investigation for pre-existing conditions at the time of admission - expect every patient to have a more extensive set of tests and perhaps photographic documentation of state of skin care. Expect a tension between those who "up code" at admissions and those who suspect fraudulent behavior.
  • An escalation of the "blame game" between long-term care facilities and hospitals
  • A significant financial impact on hospitals as the same regulations are adopted by commercial health plans
  • A new basis for malpractice claims
There are other, perhaps unlikely long-term implications. As our system becomes more and more complex and as more and more dollars go towards coding and assigning blame rather than treating, at the same time providers will be adopting health care guidelines with greater enthusiasm, payers will be revolting over the escalation in costs associated with documentation rather than care. Proponents of single-payer systems - long arguing that the administrative costs of health care in America are prohibitive - will have a new and powerful arrow in their quiver.

Sunday, August 12, 2007

The Best Health Care System in the World - Sometimes

An August 12 Editorial in the New York Times reviews the findings from a recent Commonwealth Fund report on the relative performance of the U.S. health care system when compared with other countries.
Let's start with the good news. According to the report and the editorial, our Nation ranks very high in following certain guidelines for preventive care. The Times states that three-fourths of Americans "rate their medical care as excellent or good, so it could be hard to motivate these people for the wholesale change thought by the disaffected." The Commonwealth Fund polls, the editorial states, rate U.S. opinions as very negative stating that a third of the "adults surveyed called for rebuilding the entire [health care] system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada."

In the "Dark Ages"

The editorial emphasizes what we already know: "despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines." Admittedly, these claims must be considered in light of the correlation between payer complexity and automation and the reports of dissatisfaction and information technology snafus in the U.K. and elswhere, but it does seem unconscionable for a sector controlling this much of the GDP to have allowed such neglect in our infrastructure.

Other issues

The editorial adds to a long list of factors that we as citizens ought to weigh when we consider the state of our health care in the present and for our Nation's children and grandchildren. These include:
  • Access. Try to find care on a weekend. The editorial and report point out we as a nation are les likely to have a long-te3rm doctor, less able to see a doctor on the day when sick, and less apt to get our questions answered.
  • Disparities. Try to find care on a weekend if you have no insurance
  • Insurance coverage. It is difficult to say anything new here.
  • Life and death. We score high in some critical areas
  • Healthy lives. We have a shameful infant mortality rate, but we seem to neglect our own care as well as that of our infants; we rank very low in healthy life expectancy at age 60.
  • Quality. The report mentions our inability to coordinate the care of our chronically ill, emphasizing again that our "system" of care arguably forces silos of care to compete - to the disadvantage of our own care. This writer believes such coordination can only be realized if we address the information technology infrastructure in the right way.
Everyone reads what they believe in such reports. Some may focus on the higher out-of-pocket expenses Americans pay for health care. This claim should be placed in context with the higher out-0f-pocket expenses the middle and upper classes incur for plasma TVs, automobiles, and consumer debt.

No answers or even firm opinions are offered here, but one should ask the broader question - what is the total cost for our social safety net if we include employer tax deductions and other hidden "taxes" we as citizens pay. Perhaps the challenge is to make the true cost of this sincere but faulty system more transparent. The challenge, perhaps, is to lay out the facts in a way that makes the real decisions more apparent. It may be that we are reaching a point where we cannot make any decisions other than painful ones (much as the Romans, no doubt, did not "decide" to let the Goths invade their failing empire.)

For this reason, the issue is not a partisan one but more one of first creating a spirit of true "transparency" in our health care system - something Secretary Leavitt strongly supports. With a more transparent system based on useful data, we can debate our different views on equity, self-reliance, and role of both government and the individual.

The system is broken. Some make the analogy with a trauma patient on life support who will not recover from a their injuries. Some would argue we should work even harder at saving this life as it is currently organized. Others would argue it is time to let this soul go and to start thinking about how to harvest organs. A crude choice, perhaps, but in the end the editorial is not just about ideas, it is about the savage reality of life and death.

Thursday, August 2, 2007

Following Intel's CEO

What follows is a compendium of postings from my other sites concerning Intel's visionary CEO. This observer heard his September 2006 address and thought his remarks put our health care delivery crisis in the right context. Enclosed as well are subsequent postings and links.

Barrett, September, 2006

On September 26 at 8:30 am, Intel CEO Craig Barrett spoke at the eHealth Initiative Health Information Technology Summit. He preceded Secretary of HHS Michael Leavitt.

He prefaced his remarks by emphasizing both his support for the political process but also his frustration with the pace of change and leadership "around the margins." He mentioned in a positive sense his participation in the American Health Information Community.

But Barrett's words were strong and, in the view of this observer, dead on.

Among his comments:

  • U.S. jobs will continue to move offshore at a rapid pace unless corporate America exerts its power to force the health care industry to adopt systems that will cut costs and improve efficiency. "Every job that can be moved out of the United States will be moved out ... Because of health care costs," which on the average were in excess of $6,300 per person in 2004.
  • "The system is out of control, it's unstable, it's basically bankrupt, it gets worse each year and all we do is tinker around the edges when what we need are major fixes"
  • Asking "who should pay for it" is the wrong question. No one can pay for it.
    Even if one makes a massive, one-time change in the chronic care disease management, unless the trend is toward continual improvement, the costs will inexorably climb.
  • "Every other industry has adopted this technology and (the health care) industry continues to sit here and debate"
  • Why does the health care industry expect subsidies to pay for health care technology? Every other industry makes these investments as a matter of survivability?
  • Employers should demand that hospitals select standardized record systems to lower costs or take their company's business elsewhere
  • Companies should only do business with health care providers who meet certain standards, including fully electronic patient records and published "best practices" for patient treatment
  • Price transparency is critical to employer and consumer engagement. How many other industries can't tell you what a service will cost or explain their charges in a simple way?
  • Hospital networks could and should be transformed into "competitive centers for excellence" that are paid to keep employees healthy.

Wal-Mart Stores Inc. Executive VP Linda Dillman joined Barrett on the stage and spoke of Wal-Mart's costs as an employer and their innovative approach to providing health care in pilot settings.

  • Barrett said the health care industry could learn from the efficiency of Wal-Mart.
  • He claimed Wal-Mart was an information technology company that sells what it tracks and excels by its ability to employ IT in conjunction with effective business models and great customer service

Barrett (November, 2006)

In a September 29 posting to this site, this writer quoted from a presentation given by the CEO of Intel to the eHealth Initiative meeting. Warning of the crisis in health care delivery, he assured the public that large employers will take action.

In a November 29 article in the Wall Street Journal by Gary McWilliams, Barret's "jolt to the health care system" is describe in greater detail. mcWilliams states that in the coming week, Intel, Wal-Mart, British Petroleum, and others will disclose a plan to provide digital health records to their employees "and store them in a multimillion-dollar-data warehouse" linking hospitals, doctors, and pharmacies. (This writer believes the actual technology will be an exchange with strong privacy protections and not a giant data warehouse; a clarification will assuage public concern).

Craig R. Barrett, Intel's chairman, calls this effort part of a "building-block to modify the U.S. health industry" and he doubts that "the industry is capable of modifying itself."

The costs projected for the project seem low; the article claims a contribution of 1.5 million each from 10 employers. The model appears to let "consumers and insurers...evaluate price and performance data from millions of employees." Eliminating duplicate tests and erroneous or lost information would also slash administrative overhead, accounting, according to the article, for up to 40% of medical costs. An appeal to reduction of adverse drug events is also made.

Functionality includes an ability for doctors to "measure which treatments worked best for chronically ill groups of patients" and the ability to prescribe electronically.

The article raises some points that will draw concern. Quoting:

"Coalition members believe that giving consumers control over their own records would help get around the technical and cost issues. But the idea of portable medical records and a massive repository still faces hurdles. Privacy advocates worry that digital records will be misused by employers and insurers to deny jobs or health-care coverage. The watchdog group Patient Privacy Rights Foundation urges employees to shun the approach until there are adequate protections. 'The system is leaking information,' says Chairwoman Deborah C. Peel, a practicing psychiatrist. 'Once out there, it's like a Paris Hilton sex video. It's [there] for the millennium.' "

Other features:

  • The employers will insist that health-care providers adopt electronic records and prescribing as a condition of future business.
  • Wal-Mart will apply its purchasing power to get bar codes on products intended for hospitals and clinics.
  • Employers will expect employees to pick doctors willing to use and update their records, though employee compliance is voluntary.
  • The "records will be the property of the employees, and the data will be mined by insurers and others only after the patients' identity is stripped off."

Linda Dillman, who was on the stage with Barrett at the eHealth Initiative meeting in September, states that they are "trying to bring all the right people to the table and show them what can be done."

The article also elaborates on some sobering costs, claiming that "Intel figures its health-care spending will be as much as a fifth of its research and development costs by 2009. Wal-Mart says the costs for its 1.3 million U.S. employees, if unchecked, will climb $1 billion annually for the next five years."

The final feature - patient "ownership" will be an interesting driver. Quoting from the article:

The Intel-Wal-Mart plan to offer employees medical records and automatically update those records with hospital, doctor and pharmacy detail "is very ambitious," says Dr. Greenfield, an adviser to Care Focused Procurement LLC., a nonprofit putting together an HMO claims database. "We love the patient as the agent."
"It has always seemed unusual to me that the medical record is seen as the property of the medical system," adds Donald Berwick, chief executive of the Institute for Health Care Improvement, Cambridge, Mass. Tests are duplicated and information lost in the handoff between physicians or clinics. "The best integrator in the end is the patient," Dr. Berwick says.

One expects reaction to be rather diffuse until more clarification is obtained. The "disruptive" element of this plan is note employer drive for digital health as much as, this writer suggests, it will lead to alternative care delivery models. Something that our Nation dearly needs.

Follow-up stories and links

Barrett (July 2007)