Saturday, December 15, 2007

The Budget

On December 13, 2007, CBO director Richard Orszag testified before the Committee on Budget of the United States House of Representatives.
Quoting directly from the Director's introductory comments:

Significant uncertainty surrounds long-term fiscal projections, but under any plausible scenario, the federal budget is on an unsustainable path—that is, federal debt will grow much faster than the economy over the long run. In the absence of significant changes in policy, rising costs for health care and the aging of the U.S. population will cause federal spending to grow rapidly. If federal revenues as a share of gross domestic product (GDP) remain at their current level, that rise in spending will eventually cause future budget deficits to become unsustainable. To prevent deficits from growing to levels that could impose substantial costs on the economy, revenues must rise as a share of GDP, or projected spending must fall—or some combination of the two outcomes must be achieved.

For decades, spending on Medicare and Medicaid—the federal government’s major health care programs—has been growing faster than the economy, as has health spending in the private sector. The rate at which health care costs grow relative to national income—rather than the aging of the population—will be the most important determinant of future federal spending. The Congressional Budget Office (CBO) projects that under current law, federal spending on Medicare and Medicaid measured as a share of GDP will rise from 4 percent today to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today.

This report and testimony are not as "dry" as one would expect. In some respects, the CBO projections lag behind the analyses of many state governments. State governments are even more constrained in terms of debt creation and revenue generation. State governments and communities bear an increasing burden of health care costs relative to federal expenditures for health (particularly through Medicaid, uninsured, and taxes to business). State government leaders are canaries in a mine that appears to have few escape routes.

The Federal "fiscal gap" analysis (difference between federal revenues and outlays as a percent of the GDP adjusted to 2007 dollars) "represents the extent to which the government would need to immediately and permanently either raise tax revenues or cut spending—or do both, to some degree—to make the government’s debt the same size (in relation to the economy) at the end of that period as it was at the beginning."

What are the implications?

Testimony states: "growing budget deficits and the resulting increases in federal debt could lead to slower economic growth. The risking federal debt (particularly under an alternative scenario that includes many expected legislative actions including indexing the alternative minimum tax to inflation and indexes physician payments to Medicare inflation "would affect the capital stock (businesses’ equipment and structures as well as housing). In CBO’s estimation, debt would reduce the capital stock—compared with what it would be if deficits were held to their share of the economy in 2007—by 40 percent in 2050 and would lower real gross national product (GNP) by 25 percent. (GNP rather than GDP is used for this calculation "because rising deficits can increase borrowing from foreigners.")

What is the reader interested in health information technology to conclude?

Setting aside the revenue issues (corporate taxes, AMT, excise, etc.) economic security of our nation seems to depend on an evolutionary but radical approach to managing health care costs. These costs can be managed only if the following conditions are met:
  • The public - both as individuals and as a collective - must understand how their behavior impacts costs both out of their own pockets as well as in terms of economic opportunities for the next generation. We need a clear understanding of the individual and national consequences of our health care decisions both in present and future economic terms.
  • Each of us must identify means where we can make wiser resource allocations both in receiving care and forestalling the consequences of chronic illnesses
  • Organizations that obscure these costs - particularly if done for organizational gain - profit at the expense of the economic future of the country, must be identified and their behavior changed - through self-regulation or through coercion.
  • Every effort to contain costs must be viewed both in terms of the short-term and the long-term. Addition of the long-term costs changes the equation dramatically because some expensive short-term interventions are actually beneficial if they lead to great long-term economic gains. Such interventions include many procedures and therapies that from a short-term perspective are deemed "costly."
  • Information technology must not be directed solely at refining the status quo but must also be directed towards innovations that give consumers and providers better knowledge to create an environment where everyone not only focuses on the short steps ahead but also over the horizon to a lifetime of better health.
  • Incremental steps are not enough. One must hope that beneficial "disruptive" technologies and behavior changes are identified and adopted over time.
Clearly, an economy based solely on delivering health care services under the status quo is not sustainable.
  • Can anyone envision an America whose workforce is composed only of a health care service sector providing service to a country whose population is dominated only by other low-wage service workers?
  • Is it not apparent that rising health care costs will lead not only to the outsourcing not only of most economically-favorable knowledge workers in manufacturing and engineering but also of the outsourcing of the health professional knowledge workers providing these services?
Under these circumstances, reports of marginal impact and improved ROI, although laudable (if credible) will make a difference, but in isolation will not make sufficient difference to change the fundamentals of the relatively dire CBO projections.

Tuesday, December 11, 2007

RHIOs Aren't Often Viable: What's the Big Deal?

Let's quote verbatim from the abstract of a recently-published article in Health Affairs by researchers from Harvard University. Polling 145 "potential RHIOs" the authors conclude:

Electronic clinical data exchange promises substantial financial and societal benefits, but it is unclear whether and when it will become widespread. In early 2007 we surveyed 145 regional health information organizations (RHIOs), the U.S. entities working to establish data exchange. Nearly one in four was likely defunct. Only twenty efforts were of at least modest size and exchanging clinical data. Most early successes involved the exchange of test results. To support themselves, thirteen RHIOs received regular fees from participating organizations, and eight were heavily dependent on grants. Our findings raise concerns about the ability of the current approach to achieve widespread electronic clinical data exchange.

Now let's paraphrase for to create a hypothetical survey from the early '90s:

Internet technology promises substantial financial and societal benefits, but it is unclear whether and when it will become widespread. In early part of the decade we surveyed 145 Internet firms, search engine dreamers, and "web browser" companies, the U.S. entities working to "revolutionize commerce, knowledge management, and consumer interaction." Nearly one in four was likely defunct. Only twenty efforts were of at least modest size and providing Internet-based information. Most early successes involved the communications that could easily have been faxed or sent via postal service. To support themselves, thirteen businesses received regular fees from participating organizations, many received money from "high risk venture capital," and eight were heavily dependent on NSFNet and other grants. Our findings raise concerns about the ability of the current approach to achieve widespread adoption of Internet technologies.

This article attempts to document the high social and financial risks realized by a diffuse collection of efforts all lumped together under the term "RHIO." (But if one more person sends me an email informing me of this "revelation," it may be time to shut down the laptop and seek work in a vineyard.)

What impressions does this article leave?
  1. Hopefully, the reaction of this survey will not discourage what must be an ongoing effort to improve our health care system through innovative use of information technology
  2. Hopefully, the reader will be reminded that innovation is a long shot characterized by risk, failure, and infrequent enormous rewards.
  3. Hopefully readers will not confuse one of many means - RHIOs - with an end - better health care.
  4. Hopefully, readers will understand that even a few winners - as the authors remind us - can serve as models for better health care delivery
  5. Ideally, the reader should ask whether or not this article calls into question Federal claims that RHIOs cry out for "certification."
Perhaps this is really a discussion about genetics. In the final paragraph, the authors ask whether or not the current generation of RHIOs will beget a robust "next generation of RHIOs." It sounds a bit like one is "breeding" policy like canines rather than simply learning from a few good ideas and often rare successful approaches.

Confusing the means with the end

RHIOs are not the "end" and may not even be the "means" in more than a handful of cases, but they are at least one innovative approach to re-thinking the very questions we ask ourselves about how information about our health should be made available.

To many the term "RHIO" was code for whatever dissatisfaction people had with the current system, whatever opportunity they could take to change the system, or whatever revenue they could incur by selling to these often poorly-focused efforts. It seemed popular for a while in this Administration because it did promote technology and mythical organizational structures as a panacea and an appealing alternative to the sweat and toil required for true societal change.

Certification? Really?

A CCHIT Environmental scan from the Network Work Group (September 13, 2007) states the following:

Based on the ... data the number of HIE initiatives is probably between 160 and 200. Among these initiatives there are appears to be fewer than 100 that are currently
exchanging data. The number of fully operational data exchanges (that have a sustainable business model) may be fewer than 30.

They cite as their sources the following:
  • eHI’s 2006 survey of HIEs identified 165 HIE initiatives, 45 were in the implementation stage, and 26 identified themselves as being fully operational
  • A 2005 survey by the Texas Institute for Health Policy Research estimated that there are 200 HIEs
  • AHIMA’s report on the state of HIEs estimates over 200 initiatives
  • The HIMSS dashboard identifies records for 611 HIEs.
So at last, Harvard has added its imprimatur and stated (by means of another survey) that one should not believe the previous surveys. Their survey shows that there aren't all that many functioning health information exchanges and that most are having difficulties. Sounds like any other emerging innovation or technology to this writer!

A Battle of Rhetoric

The proclaimed "demise "of RHIOs is really nothing more than a documentation of the demise of a rhetorical construct. These observations should do nothing to hamper innovation that seeks to provide patient-focused care, nor should it dissuade the public from seeking better solutions for key informatics challenges critical to whatever new health care system one believes is necessary. These challenges include:
  • Ensuring basic privacy protection
  • Demonstrating data availability and integrity
  • Developing robust means for authentication and identity management<
  • Creation of systems focused on the individual across the care continuum

Stop and think about what the publications mentioned above really are - a war of "rhetoric" conducted by combating survey instruments wielded by proponents no doubt already prepared for the next paradigm and no doubt eager to analyze almost anything that can lead to perpetuating the hegemony of the academy.

How Will This Play in the Heartland?

The MidSouth eHealth Alliance may have been a subject of this survey. If so, let the reader judge whether or not waiting to see the outcome of this one is as good a strategy as any other.

Here's its status after 18 months of operation:
  • 2.1 million encounters
  • 1.3 million medical records
  • 880,000 lives
  • 80,000 laboratories a day (estimated 50 million since May 2006)
  • 2.6 million diagnosis code records
  • In use by over 200 professionals in every major emergency department
  • Used to access records in over 10% of emergency department visits
  • Patient-controlled with an ability to "opt out"
  • Governed by every major health care system in the region
  • Managed through a publicly available set of policy and data exchange documents
  • Based on an evolving but public financial model
  • Operational costs are between $2-$3 per person per year!
Yes, its funded by AHRQ, state grants, and other means. Just like Medicaid and Medicare are funded by state and federal means and plan-based or provider-based initiatives are funded by our health care dollars.

Memphis may teach us how to create a low-cost model where everyone currently engaged in this overly-complex system can "win" but the individual receiving care - the "consumer" - wins most of all.

Somehow, this writer suspects that none of the many individuals who will seek care in Memphis emergency departments will worry that one survey shows that other surveys aren't really giving the academe and policy-makers the full pictures. They will be unaware of these arguments. Instead, they will receive care from a system that gives their doctors secure access to a large body of their information across traditional competitive boundaries...entirely with their games, no competition - collaboration to support better care for citizens.

Somewhere out there are groups of people who will find better ways of doing this. The failure rate may be high, but the need for innovation is essential and the potential benefits incalculable.

This writer is very glad that the many technology pioneers who collectively - and without much organization - transmit and display these words across the aether. These individuals forged ahead with their dreams undaunted by surveys. Many, many failed. A few succeeded and taught the others how to move forward step-by-step.

Most of us don't want any more patients harmed by our health care system. The appalling rate of error and inequity is sufficient, thank you. But we do want to believe in an opportunity where every one of us may somehow benefit from the innovators who didn't listen to the rhetoric and stayed focused on building approaches more suitable to the times and the need.

Notes / Linksadded since original posting