Mark Frisse's Policy Blog

The Many Meanings of "Shovel-Ready"

2009-02-01T11:48:00.000-06:00

See my posting at my new policy blog site:

http://frissepolicy.blogspot.com/

In it, I ask:

If we are to get out our shovels to build or to improve, aren't there some initiatives, committees, work groups, or programs that should be "buried" or placed in hibernation so that our Nation can focus on critical priorities?

Kibbe and Klepper Reboot America's Health IT Conversation Part 2: Beyond EHRs

2009-01-05T07:21:00.001-06:00

see my new policy blog for updates

David C. Kibbe and Brian Klepper PhD continue their thought-provoking recommendations on the Health 2.0 blog.

Follow this link to the January 5 posting

In a January 5th posting entitled "Let's Reboot America's Health IT Conversation," Kibbe and Klepper state their belief " that most health care professionals are acutely aware that more health IT alone cannot resolve these problems. Despite billions of dollars in health IT investments by health care professionals and organizations, the gap between the health care we believe possible and the current system is widening. persists and is widening."

Kibbe and Klepper argue that we don't need simply more health health IT; instead, we need an array of specific health IT functions and capabilities that can facilitate better care at lower cost, and the adherence to evidence-based rules.

Here are some of the characteristics they ascribe to empowering health IT products:

These systems would focus on Decision Support

New new health IT would help patients, clinicians, managers and purchasers make the best possible clinical and administrative decisions. They would provide guidance with evidence-based approaches that can best mitigate health risks, create alerts and reminders, or help monitor adherence to care plans,.

These systems would untether patients with easily accessible personal health information

These systems would improve care by making summary personal health information available to providers and patients, increasingly independent of location and time.

These systems would empower patients through online linkages to clinicians, other care providers, and other patients

Particularly in the management of chronic illness, these systems would link patients with clinicians, will match problems with the most appropriate solutions, and will use social networking to increase access to patient- and condition-specific information, knowledge, and guidance.

These systems would support participatory medicine, enabling the Medical Home and web-based care

These systems would make data and accountability the routine by-product of the use of health IT

Health IT can help make all health care professionals and organizations - physicians, hospitals, other providers, health plans, drug firms, device firms - more accountable stewards for quality, safety and cost results, and for the engineering required for continuous improvement. Data aggregation and analysis systems would be central to the design of health car information systems and not an afterthought. Incentives would play a significant role here.

These systems would remove the complexity and cost associated with multi-payer claims administration

Kibbe and Klepper envision an all-payer clearinghouse for patient administrative and financial information that is standards- and web-based. As they write, "there also is no good reason why, in the era of PayPal, physicians and hospitals experience Days in Accounts Receivable of 36 and 55, respectively."

These systems would close the collaboration gap

These systems would bridge the gap between the various fragmented delivery and payment systems. As they write, "Clinicians, for example, diagnose disease and set up treatment plans but often are isolated from helping patients cope, manage, or adhere to these plans. Patients, once diagnosed, are motivated to manage their illnesses but often have few tools or methods to assist them. Purchasers and payers want to see clinicians use the most efficacious resources, but typically do not have a way to inform and reward evidence-based purchasing processes. In every case, health IT can facilitate a more collaborative experience that is tailored to the user's purpose, no matter what role that user plays in vast health care space."

The Health 2.0 blog has some of the most insightful perspectives on not just technology but our approach to informatics. Always worth a read. Bravo.

A convergence of altruism and self-interest

2008-12-16T07:26:00.002-06:00

See my new policy blog at: http://frissepolicy.blogspot.com/

These are strange times. There is growing talk of dramatic changes to our health care financing system in response to the economic crisis and renewed commitment to developing a robust national infrastructure, broadly defined. Yet large health care delivery systems - at least middle managers within these systems - follow a well-worn logical local strategy that may worsen their prospects in any reconstituted health care system. Specifically, while at the Federal level there is a Keynesian belief that increased investments will yield transformation, many health delivery organizations are taking the more traditional short-term view and arguing that they cannot invest in new approaches to patient-focused care because they don't have the money to do so in these difficult times. It's a bit like claiming that when one's car is almost out of gas, one doesn't want to pull off the highway to fill the tank because the side-trip will use gas.

Let's be more clear. There is a growing consensus on several factors:

Health information should be "patient-centric" so that information is available to support the care of the individual wherever required in a way that ensures their confidentiality and empowers their ability to use information.
Health care delivery organizations - hospitals, practices, intermediaries - should not compete over possession of data. This comes at the expense of both improved patient care and a badly needed step towards a more effective health care system.
Health information that is in paper form today must be made available in digital form under security and use provisions that ensure individual and public confidence.

But I continue to hear organizations with extraordinary cash flows and assets argue that in this time of financing crisis, they cannot afford the relatively small investments required to collaborate. In so doing, they abrogate to health plans and intermediaries any opportunity to participate in a patient-focused health care information market. Maybe that's what they want.

This is a strategy that General Motors would relate to. Quoting from Tom Friedman in the NY Times:

"As I think about our bailing out Detroit, I can't help but reflect on what, in my view, is the most important rule of business in today's integrated and digitized global market, where knowledge and innovation tools are so widely distributed. It's this:

Whatever can be done, will be done. The only question is will it be done by you or to you.

Just don't think it won't be done. If you have an idea in Detroit or Tennessee, promise me that you‚ll pursue it, because someone in Denmark or Tel Aviv will do so a second later."

Thomas Friedman, Op-Ed Columnist
While Detroit Slept (December 9, 2008)

http://www.nytimes.com/2008/12/10/opinion/10friedman.html

Parker Palmer helps us understand what is going on. In a recent essay entitled "Repossessing virtue: Economic crisis, morality, and meaning: Trusting our Deeper Knowing: On Cataclysms, Contemplation, and Circles of Trust," Palmer says that if we look inside our spirit, we know full well what has happened and what will come. He speaks of broad economic terror but his logic seems to me to reflect the intuitions of both those in need of care and those who provide care.
Quoting Palmer:

"Alexis de Tocqueville, the nineteenth century French scholar famous for Democracy in America, wrote a less well-known book titled The Old Regime and the Revolution, arguing that the French Revolution happened long before it happened. The eruption that shattered French society at the end of the eighteenth century was the result of small seismic shifts that had been accumulating for decades deep underground. If people had paid attention to the tectonic instabilities caused by greed and injustice, and had responded wisely to the nervous needles on their inner seismographs, the "Reign of Terror" might have been avoided.

A parallel point can be made about the economic terrors that now engulf America: at some level, most of us knew they were coming. Who doesn't know that a society in which the rich get richer while the poor get poorer is a society that will someday have to pay the piper? Who doesn't know that when a relatively small fraction of the world's population uses its power to command and consume a disproportionately large fraction of the world's resources, the chickens will come home to roost? Who doesn't know that an economic system that encourages us to live beyond our means and refuses to regulate greed is one in which our avarice will come back to bite us? Who doesn't know that at every level of life, from personal to global to cosmic, what goes around comes around?"

What goes around, comes around. Failure to create a health care system focused around the long-term care of the individual and focusing instead on short-term return for the hours, days, or years during which an individual does business with you leads to risky transitions in care, financial inefficiencies, consumer confusion, and the perpetuation of markets that compete over almost everything but the quality of care and impact on public health. We know this to be the case, but many in positions of power seem unable to pursue a new and very obvious course that will improve their ledgers and in their public perception. It's not about short-term cash flow, it's about long-term public trust and the importance public trust in envisioning a more effective health care delivery and financing system.

As my daughters would say, Duhhhh...

Think Big? Think Small?

2008-11-17T11:40:00.001-06:00

Note: I'm moving to a new policy blog site: http://frissepolicy.blogspot.com/

The New York Times recently posted two contrasting positions from Ezekiel Emanuel (National Institutes of Health) and Stewart Butler (Heritage Foundation). Emanuel's position is entited "Think Big" while Butler's is entitled "Think Small." The articles are a wonderful, cross-referenced exposition of this critical issue. Both resonate

First, Emanuel's major points:

Think big. "In health care, big plans are necessary not only to motivate people but as a matter of sound policy." It's about a system of care, or, as he says "reform must include changing the delivery system and how we pay for care. "
Health policy is fiscal policy. "Forget Social Security or defense, health care costs are the long-term driving force in federal and state budgets." He points out that Orzag and rumored candidates for new positions (Summers, Cooper, and Furman are mentioned) all get health care. (Certainly this fan of Jim Cooper's believes he does like few others).
Comprehensive care is cheaper care. "One of the secrets of health care reform that has not yet sunk in, is that bigger changes to the system actually cost less. " Emanuel references a previous blog posting about a Lewin Group Analysis.
Institutionalize tinkering. Arguing that no plan is perfect, Emanuel believes that "good reform will make addressing these issues easy by not requiring major legislation for each adjustment."
Everything is connected. He is persuasive, arguing that "health care is so big — $1 out of every $6 in the economy, dwarfing automobiles and all other economic segments. Everything is affected by health policy, and every decision should be examined for its impact on health care reform." It works both ways, every issue affects health care and health care policies affect every other issue. He identifies this relationship through example "Similarly, every favor to a constituency should be linked to support for the health care reform agenda. If the automakers want a bail out, then they and their suppliers have to agree to support and lobby for the administration’s health care reform effort."

Butler's pragmatic advice is equally pursuasive. He makes four points:

Make a strong commitment to bipartisanship. Citing bipartisan proposals and state-led initiatives, Butler urgest the President-elect to "tell the more triumphalist liberal supporters on Capitol Hill to chill, and that he’s looking for common ground."
Find better ways to use the money we are currently spending on health. He state that "rather than throwing tens of billions in new money at the health industry in an effort to expand coverage." and emphasizes on the critical need to reallocate the $200 billion tax expenditure on the tax exclusion. The Baucus proposal, released in white paper form last week "opens the door" to this possibility.
Allow states flexibility to redesign existing health programs and use money more efficiently to reach the goal of maximizing affordable coverage. This was covered in one of his previous posts entitled "States are Good Guinea Pigs."
Remember that Americans are very conservative about their health care. Given the President-elects own appeal to this conservative instinct when discussing Senator McCain's phase-out of the employer deduction, it would seem that this awareness is embedded. At the same time, we have a President-elect who often stated that he spent the last year of his mother's life contesting plan exclusions and other bureacratic issues. Perhaps our new President will be the first to have first-hand experience with the difficulties under our current system.

Both of these remarkable thinkers make sound points. Is there a chance to pursue both? Can Medicare be extended and stretch while at the same time allowing some experimentation and differentiation in the states? Is such differentiation even possible given the (as of this date) projected net decreases in State expenditures this year of over $66 billion?

Learning from a Possible Automotive Industry Bail-Out

2008-11-13T14:02:00.002-06:00

Note: I'm moving to a new policy blog site: http://frissepolicy.blogspot.com/

As I write this, the "old" automotive industry - GM, Ford, and Chrysler (most notably GM) - dominates the headlines. They are out of money, we are told. They need loans to innovate. Millions of jobs are at stake. Something must be done.

This is not news. I remember the gas lines of the Carter administration. The first car my wife and I bought was a Dodge Omni Miser introduced as part of Lee Iacocca's government-led Chrylser "bail out" and purchased in by us 1981. It had a four-cylinder engine, a heater, a stick shift, and that was about it. No radio of any kind. It was a great car.

Yet over the ensuing decades, little in the "old" automotive industry seemed to change. Rather than improve mileage significantly, a coalition of manufacturers, unions, and image managers kept us focused on immediate gratification. But in the ensuing decades, an entirely different "new automotive industry" emerged funded largely by foreign producers who created factories and jobs primarily in the "right to work" states. While the "old industry" encumbered greater legacy costs from generous benefits, and aging workforce, and products appealing to those who did not consider energy costs, the "new" automotive industry developed a younger, healthier workforce, products often (but not always) focused on greater economy, and more flexible manufacturing methods. The point is not to compare the "old" and "new" but to recognize that there are two distinct automotive industries in our country and that one is doing better than the other.

Far wiser people have made recommendations, but there are several common themes:

The "old" manufacturers seem to have forgotten they are in the transportation business and not just the automobile business. (This case has been made recently by Robert Goodman who in turn cited a 1972 Stewart Udall article in the Atlantic Monthly).
The "old" manufacturers are not making sufficient quantities of the kind of products people need for transportation
The "old manufacturers are not making products that are affordable to the people who need them
The "old" manufacturers are not addressing thorny problems of workforce equity. These range from exorbitant salaries for their senior leaders, generous benefits packages that for decades place few responsibilities on beneficiaries, and inadequate benefits for the many mechanics and service workforce essential for their industry but employed by dealers, garages, and suppliers.
Advocates for the "old" manufacturers are having trouble breaking free of the very bonds with industry, unions, and selfish public expectation that got us into this mess.

There seem to be parallels between my experience with my automobiles and my experience in the health care system. While I waited for gasoline in the 1970s, I watched the "cost-plus" health care financing methods and saw the inequities even then between those who had access and those who did not. After buying my Omni Miser, I saw the first glimpse of accountability through TEFRA and other health care financing changes. And then, like the auto industry, I saw things stall out. I saw an increased focus on profits, I saw more unnecessary complexity, and I saw organizations competing over the wrong issues at the expense of the long term social and economic good.

Perhaps we can learn from the various "bail-out" proposals for our automotive industry? To what extent do we finance the status quo. (Interesting that one of America's larges corporations is asking for federal financing to "innovate." As Thomas Friedman asks "If we give you another $25 billion, will you also do accounting?"

Aren't there parallels?

Do the organizations that deliver, manage and finance care understand that they are in the health care business and that this business is a system of care focused on the individual?
Are these organizations enabling us to experience the degree of health we need?
Are these organizations delivering these services in a way that is affordable?
Is compensation and workforce development aligned with incentives to improve or is it designed primarily to enrichen the few at the top?

We are in the middle of a rich debate. Should GM be allowed to drift into bankruptcy? Should they be allowed simply to get additional funding from us? Should support be tied with strings managed by our federal government? Should we learn from the "new" automotive industry as we examine what went wrong? Should we look at the automotive industry in the context of the broader transportation crises in our country? A country where railroads are crumbling, bus transportation is second-rate, and mass transportation of other types is virtually non-existent?

I believe we need a transportation policy. Without a clear view of transportation as a whole, an infusion of money will not address a problem that has been apparent for decades. Similarly, I believe we need a health care policy that places the plight of our providers in the context of a populace that is increasingly undermedicated, uninsured, and prone to unhealthy life styles.

Neither the automotive crisis nor our health care crises can be solved by money alone. Neither can be improved overnight. But in each case, a clear understanding of purpose, a focus on what we really need, a renewed commitment to affordability, and a recognition of the workforce seem to be good places to start.

As a country, we are now in the "bail out" business. We must focus on the price we must pay, but even more important, we should focus on fixing the fundamentals. This will not be easy.

Unsolicited Advice for the President-elect

2008-11-04T13:54:00.002-06:00

This blog has moved to: http://frissepolicy.blogspot.com/

As I write this, Americans are still voting in one of the most polarizing and critical elections in modern history. Although our preferences for presidents and other elected officials may differ, we Americans face a common reality, and it is this reality, I believe that must be the cornerstone of the inevitable re-evaluation that comes with an election of this significance.

Here are a few principles I would recommend to the new Administration.

Stop the hype
It is perhaps disingenuous to call for a cessation of exaggerated claims after one of the most acrimonious and expensive campaigns in history, but recipients of the many email press releases and announcements of HIT "accomplishments" are no strangers to the very real disconnect between what people say they are doing and what really works. Debate must be moved forward by a realistic assessment of our past accomplishments, not by exaggerated claims made by vendors, agencies, delivery organizations, and even the HIT "Illuminati." Let's build our delivery system on the basis of what we know can work rather than on what we hope will happen.

Never advance health information technology for its own sake.
Translated. Fix the health care system first, then draft health IT legislation. Information technology is a way to enable processes and realize goals. As Carol Diamond and Clay Shirkey recently wrote in Health Affairs: "If you computerize an inefficient system, you will simply make it inefficient, faster."

Acknowledge scarcity
There is little money for HIT at the federal, state, local, organizational, or individual level. We must do more with less. Demand for health outstrips supply. Priorities must be set. Every effort must be directed towards avoiding a catastrophic recession.

View health care as a central component of our economic infrastructure, not as a service.
Health care - like education and public safety - is essential for economic prosperity. We invest in schools and teachers to help create an educated populace; we invest in law enforcement to ensure the safety necessary for public prosperity. We invest in health to ensure that our citizens are not limited unduly through avoidable illnesses or inadequate treatment. Health care is about the individual! If we start with the goal of a healthier individual, we will realize healthier families and communities and, in the process refine our health care system to assure the achievement of these central aims. We would put an end to delivery silos that do not make sense and would move naturally toward a system where knowledge, coordination of care, self-sufficiency, and evidence dominate.

Build on what works
A lot of good ideas have been advanced over the past eight years (and some rather flawed ones). It is critical to build on the ideas that are gaining momentum and where additional effort can align these efforts with near-term outcomes. These would include ongoing efforts to achieve price and quality transparency, a growing consensus on the problems with our current privacy infrastructure, and our emphasis on prescription medications. Each of these efforts need a lot more work than press releases would imply. But they are important and positive legacies.

Give providers a stable mechanism for payment
If providers have a reasonably reliable forecast of what they are to be paid to do, and if these forecasts treat everyone more or less the same (i.e. fewer networks, differences in payment, coverage for everyone), I have every faith that providers will invest their own funds on systems that work to achieve their aims more efficiently. Right now, we ask providers to invest heavily in EHRs that often cannot realize their potential because communication with labs, pharmacies, and other care providers is not optimized, because critical workflow issues have not been resolved, or because they cannot support ongoing expenses to accommodate an ever-changing payment system growing in complexity. is not available or because

Develop the health care workforce
The aging population will create unparalleled demand for a flexible workforce capable of meeting growing needs. At the delivery level, we do not have sufficient home health aids, nurses, nurse aides, and other care workers required to meet the demand. In many cases, these very care providers are not able to pay for health care coverage for themselves or their families. At the administrative level, cut-backs and early retirements in government threaten to eliminate critical organizational memory at the very time where we must work even harder to simplify program administration and advance coordination. A commitment to a workforce must be a top priority.

Kill all unnecessary complexity
Complexity without measurable value is arguably the most immediate target for change. Every unnecessary administrative step saps our health care system of dollars that could be spent on care. Clinicians are told repeatedly they must standardized care based on best available evidence. I agree. But should not intermediaries do the same thing? If so, will we continue to see the hundreds of different formularies, prior authorization rules, network negotiations, and other administrative nuances that make every plan different than another? Progress is being made here, but there is still much work to be done, and the message must be made loud and clear that best practices will drive both the administration and payment of care as well as care delivery itself.

Incorporate health care services training into our educational system
At the community college level, teach the next generation of computer technicians what HIPAA means and what the differences are between servicing a convenience shop computer and servicing a system in a health care setting
At the work force level, create more programs that produce flexible health care workers who pursue lifelong learning and who are adept at both the humanism and technologies required to provide care for our aging society

Focus on functions, not products
There has been a tendency to objectify nascent efforts instead of viewing these efforts as unique and evolving combinations of specific components and discrete services. When we speak RHIOs, PHRs, and even EHRs we are really talking about combinations of services like medication histories, clinician notes, laboratory values, and alerts alerts. These in turn rely on core principles like data integrity, auditing, non-repudiation, authentication, and authorization. Principles should guide the use of specific services and efforts must be made to encourage secure "data liquidity" to ensure the right information is made available at the right time. By focusing on these services rather than on products, we advance the public trust without immobilizing innovation in the bureaucratic morass or product certification or accreditation.

Simplify NHIN
If there is to be an NHIN, there are about 12 core services that I believe should gain top priority. My priorities are to be found on my blog and has been discussed in a trade press article.

Conclusions
Enormous amounts of effort have been expended over the past eight years to create a more effective health care system. But somehow, things have gone awry. I often make the analogy to a soccer game. Health care is like a soccer game with 10 teams and 14 balls. Everyone is running around kicking, but since there appear to be no rules or order, the "game" is mere exercise. It makes no sense beyond that. The efforts of these countless hours and many projects have contributed to the collective wisdom. We now must be honest with ourselves and ask:

what is the primary problem we want to solve? (I'd claim it is a healthier society)
what preconditions are required to ensure that technologies can make a difference?
what have we done that gets us closer to a solution?
what have we done that has only worsened the "problem" and distracted us from our goals?

I think it is time to take a deep breath and think very hard about what it is we want to accomplish; then ask ourselves how we can help; then re-visit our principles and revise our policies; and only then, start programs and legislation to ensure we get what we now know we need.

And more than anything else, we should - individually and collectively - promise each other that if we are doing things that do not help, we will cease our efforts in these directions and turn towards more positive things.

Is it Time for Comprehensive Health Reform? Revisiting Fuchs and Emanuel

2008-10-14T15:53:00.008-05:00

In November of 2005 Victor Fuchs and Ezekiel J. Emanuel published an article in the Journal Health Affairs entitled "Health Care Reform: Why? What? When?

Follow this link for the abstract and full text (subscription may be required)

This article has been on my mind of late as our world financial system has been dramtically disrupted and the roles played by government have changed in ways few would have predicted only a few years ago. In 2005, when few would have thought such interventions would be necessary, Fuchs and Emanuel were not optimistic that comprehensive health care reform would be easy to realize. They said that "over the long term, reform is likely to come in response to a major war, depression, or large-scale civil unrest."

Their article is worth revisiting. I will quote one paragraph and summarize earlier points. I urge the readers to go back to Health Affairs and take a look.

The authors described three general scenarios in which comprehensive reform may take place:

Quoting (with formatting changes):

What might set the stage for comprehensive reform of healthcare?

A major war, a depression, or large-scale civil unrest might well set in motion a change in the political climate that would overpower the obstacles that prevail in normal times.
A national health crisis, such as a flu pandemic, might also light the fuse of change.
Short of a major economic, social,political, or health crisis, there might be a confluence of forces that together would propel the nation toward comprehensive reform over the next decade, such as widespread dissatisfaction of the business community with employer-based insurance; state governments’ inability to sustain the ever-growing fiscal drain of federally mandated, means-tested insurance; or a financial crisis with Medicare. Leadership from the business community and states might together galvanize comprehensive reform.
Finally,there might be a growing realization by average Americans that the risks of the current system to them personally and to the country as a whole outweigh the risks of comprehensive reform.

Where do we stand today relative to 2005?

We still have a war (or two) - and to some, they are major
We have a serious recession and a new push to "bail out" and incur national investments in vital infrastructure issues - finance, and, one predicts, future infusions to state governments, individuals, and perhaps endangered manufacturing sectors. And this will lead to more support for small business.
We do have a confluence of forces that will lead to some change.
We are experiencing widespread dissatisfaction of the business community with employer-based insurance
Current projections suggest that state governments will not be able to sustain the ever-growing fiscal drain of federally mandated, means-tested insurance
We do have a financial crisis with Medicare.
Average Americans are more driven by fear of losing their health care coverage than they were a few years ago; those who have little recourse have become more vocal; health care costs again are a major source of bankruptcy as was said to be the case in the 60s during the Medicare debate.

The issue isn't whether or not these events are taking place, but the extent to which the public believes that these events compel a serious examination of a more radical system sooner rather than later. As we have seen in financial sectors, the retreat from the "hands off" roll of the federal government has led to a broader interpretation of the term "moral hazard" and issues of fairness are leading many to draw new boundaries between government and private-sector roles. To the extent that a viable and substantive comprehensive new approach must be introduced will, ironically, be advanced by those who traditionally are averse to government intervention and management - until they need it personally. Major manufacturers facing bankruptcy will no doubt look at their health care cost as a drag on their plans for recovery. Small businesses seeking better access to credit may be more amenable to coupling these subsidies with a requirement to provide basic health care coverage for all full-time employees.

In the article, Fuchs and Emanuel provide a brief history lesson. They describe the fragmentation of employer-based health insurance, the disappearance of community-rated premiums, the reality of high administrative costs, and consequences of Medicare's open-ended entitlements. They also provide brief discussions on the implications of health IT, confusion over quality metrics, and disagreements in cost-benefit trade-offs.

The authors summarize both incremental and comprehensive approaches to health care reform and discuss some implications of each approach. Their summary - published shortly after the 2004 elections, seems just as relevant as we approach another election day.

They then list the following incremental reform approaches

Employer mandates
Subsidies
Expanding Medicare and Medicaid programs
Health savings accounts
Managed competition - including caps on tax-exempt plan expenses
Quality incentives

Their comprehensive reform approaches are:

Personal mandates and subsidies
Single-payer proposals
Voucher programs

The overviews help frame the central question: to what extent will the current collapse of the global financial infrastructure change the Nation's appetite for incremental or comprehensive change?

The current financial crisis should not be viewed only as an economic tragedy but perhaps also as a basis upon which we can initiate a meaningful and productive public debate. This writer fears that many of the drivers for comprehensive reform identified by Fuchs and Emanuel are looming. It's time to think about these well-known proposals in the context of our current dilemma.

E-prescribing guidelines

2008-10-03T12:19:00.002-05:00

In an October 3 press release, the Blue Cross Blue Shield Association provided some useful guidelines that serve as reminders of the varying safety, health, and business interests affected by these technologies. Some place great emphasis on what vendors must provide, some argue (indirectly) for simpler formularies and prior-authorization rules, and one addressed the choice between retail and mail order pharmacies.

Follow this link for the Blue Cross Press Release

I attempt below to quote these guidelines verbtim:

E-prescribing systems must ensure patient safety.

Drug – Drug Interaction Check: E-prescribing systems must have the ability to alert providers to the possibility of at least severe interaction with patients' other active medications and dispensed drug history and to guard against duplicate medication therapy.
Drug – Allergy Check: E-prescribing systems must inform providers of potential conflicts with or patient allergies to prescribed drugs. Together, the physician and the patient can make an informed – personalized – decision based on the potential side effects and specific conditions.
Drug Dosing Decision Support: E-prescribing systems must provide a safety check to offer providers maximum dose checking and drug instructions (i.e. route of administration).
Drug and Dosing Guidance: Preferred e-prescribing systems also provide drug and dosing guidance based on age, weight, pregnancy, and lab results.

Patient Medication History: E-prescribing systems must be able to check available sources in real-time and make a patient's medication history available to the provider at the time the prescription is written at the point-of-care. This includes all active medication, as well as dispensed drug history.
Formulary Status: E-prescribing systems must ensure that providers have access to the up-to-date formulary and insurance information (including patient eligibility and authorization), allowing them to prescribe preferred therapeutic and generic alternatives, as well as get coverage information such as co-payments and relative cost.
Renewals: E-prescribing systems must ensure that providers can easily refill existing prescriptions and be able to accept electronic renewals from pharmacies.
Electronic Transmission: E-prescribing systems must be able to transmit prescriptions electronically to and from pharmacies whenever possible. Faxed prescriptions should be used only as a back-up method but should include all aspects of a fully informed decision support tool before faxing (including drug – drug interaction, drug – allergy checks, adult and pediatric dosing checks, and medication history).
Drug Reference Guide: E-prescribing systems must provide access to an accurate, comprehensive drug database with the ability to look-up dosing and usage guidelines, side-effects, indications and contraindications at the time the prescription is written at the point-of-care and can be printed for the patient.
Transaction Certification: E-prescribing systems must be certified by a recognized e-prescribing connectivity entity.
Utilization management (UM): Preferred e-prescribing systems have the ability to assist the physician in administering step-therapy, quantity limits, and other UM programs through incorporation of information from the pharmacy benefit manager (PBM) and decision support within the application.
Mail Order: Preferred e-prescribing systems enable providers to send prescriptions electronically to the patient's mail order pharmacy

E-prescribing and two factor authentication

2008-09-25T12:52:00.005-05:00

The last two weeks have given any sentient American plenty to think about. At the global level, we have seen some remarkable statements about international relations, global warming, and the impact of the near-collapse of our financial system. New Yorkers first - and soon all of America - will be experiencing first-hand more of the adverse consequences of mathematical aerial palaces constructed by financial wizards who seem to have failed to notice the history associated with irrational financial instruments (see: Long-term Capital Management; the Great Depression, etc. etc.)

At these times perhaps the best one can do is focus on the small things first. For this reason, John Moore's September 26, 2008 Government Health IT article entitled "Doctors and the DEA" provides a good summary fo the inherent tension between the e-prescribing enthusiasts (call them the idealists) and the e-prescribing skeptics (call them the cynics). The enthusiasts believe that our current e-prescribing infrastructure - properly applied - will be no different in clinical outcome than the current paper system. Indeed, it should be more efficient, safe, and effective in the long-run. The cynics - noting particularly the consequences of controlled substance prescribing - ask "how do you know the prescriber is who they say they are?" (I know, how do you know that on paper...but people don't seem to compare e-anything with reality but instead with Utopia).

Let's focus on two-factor authentication.

Some say two-factor authentication is costly.

Hmmm..... if it's that costly, why does my PayPal secureID (apparently used by some PHR models) cost me only $5? And it seems pretty secure to me. I'm unlikely to give it to someone who then could more easily, say, buy a vintage 1955 Gibson Les Paul guitar and leave me with the bill. And why is my two-factor ID from e-trade free? And how does Bank of America do such a great job with security that includes using my cell phone as a second factor, texting me with a PIN before I can log on?

Identity management - knowing Dr. X is who they say they are - is costly if done de novo, but hospitals, medical associations, and others with longstanding interest in the identity and integrity of individual practitioners. David Miller - the very brilliant chief security officer at Covisint, says a one-time password "would cost a physician $100 to $500 a year to maintain." I suggest local medical associations and providers seek less costly alternatives from banks and PayPal. Furthermore, the cost of these system should decrease dramatically as identity management - increasingly central to commerce and personal finance - is incorporated into health care in more consistent ways.

Some claim that two-factor authentication is onerous because systems are expected to "time out" with disuse after two-minutes. These critics have a very real point. In particular, a time limit independent of context seems a little crazy. A two-minute time-out makes sense for NSA officials or bank clerks sitting in cubicles and typing all day. It makes sense for portable devices when one is doing refills from an airport and in settings where the device could quickly and easily fall into the wrong hands. But it is hard to conceive of such a requirement in secure practice settings. I would be worried of an anesthesiologist had to re-certify their identity every 2 minutes while keeping me alive through brain surgery. Call me naive, but I'm willing to bet that whomever put me under is the same person who will be there two minutes later. Similarly, practitioners in their offices, clinicians in hospital settings, and health care professionals carrying home health devices should be given a little more slack. And some of the systems they use are very secure because even trained professionals have difficulty using them effectively! Perhaps the only secure information system is one that is turned off!

What are people thinking? Do they imagine that as a clinician working with her professional colleagues in a practice setting will turn away and, in a few brief moments, someone in a black mask will come in and deplete the country's supply of opiates with a few mouse clicks? Is the threat to the public so severe in fixed practice settings (in which much damage can be done through needles, scalpels, and drugs)? Isn't this why we have audits and remedies for irresponsible behavior and fraud?

Time-outs are important, but they have to be context sensitive, and knowing context is more straightforward these days of IP addresses and Wi-Fi.

Let's take an analogy from an industry that worries me more - guns. I still think I can attribute more deaths from guns than I can from illicit prescriptions. But we have developed some practical policies. If you are really afraid of the power of e-prescribing, think of these technologies as handguns.

You can keep your gun loaded when standing in a shooting range
You can keep your guns loaded when hunting (hopefully with the safety on)
You should not keep your gun loaded in the home - indeed, you should keep it locked up away from ammunition (I'm guessing here; I'm not a gun guy).
No matter what you do, some people are going to mess up; the task is to minimize the consequences, not to imagine they aren't somewhat inevitable.

As a Nation and as an industry we can develop low-cost, reliable, two-factor authentication infrastructures. It's just going to take us time to couple the new technologies with our existing organizations that manage prescriber identity for other reasons. Similarly, with a little common sense, we can arrive at context-specific guidelines for time-outs. Portable devices would have one limit, land-based devices would have others depending on their location. We can work this out. And our systems generally know where they are.

Where are the common-sense approaches? I hope people are thinking them through. I would imagine in particular that the e-prescribing and EHR vendors have plenty of reason to figure this out. At some point a successful software has place more emphasis on creating valuable systems than on simply closing deals.

Why are clinicians reluctant to adopt e-prescribing? Perhaps because they see polarity and conflict rather than middle-road common-sense, evolutionary approaches. Perhaps it our penchant for creating conflict and win-lose that leads to impasse. Perhaps its just our collective inability to get ahead of these problems and solve them. No matter what the behavioral cost, two-factor authentication devices should be commodities under a strong, federated identity management framework. Parties already certifying the identity and roles of health care professionals should find low-cost ways of embracing two-factor authentication. And common sense must prevail in all of this.

And I do not have the energy to elaborate on my confusion over the enormous discrepancies between practical audits and security checks and the alleged costs associated with SysTrust audits.

Where are the entrepreneurs here? If the whole world were run like some proposed eHealth constructs, my express mail package would cost $2,000 and my annual automotive emission test would cost $10,000.

I am strongly in favor of solid authentication mechanisms, time-out requirements, security checks, and audits. We know what we have to do, we're just haggling about the real price.

We can do it well and inexpensively. We've only got to try.

Bailing Out

2008-09-21T12:52:00.008-05:00

Much will be written about the unprecedented steps taken by the Federal government to halt the growing fear in the world financial market. The current emphasis is on the big and the small; the "moral hazard" and the compromises that may be required to make sure the "average person" feels they get something out of all of this.

One set of facts is quite evident and when examined in light of demographics should cause concern:

Our economy is smaller
Many employers will have to tighten their budgets even more
Most of us will have less money to spend
State governments will have less revenue
Poverty will increase
We are getting older, fatter, sicker, and, from recent history, not much wiser

That's why a recent illustration in the NY Times (Sunday September 21) causes so much consternation. (A snapshot is included in the hope that such use is within "fair use" copyright provisions.) It brought home several realities:

Since 2000, our national debt has skyrocketed past 9 trillion on its way to 12 trillion by 2010.
Of our 3.13 trillion federal budget (2009) expenditures include:

$632 b - Medicare and Medicaid
$651 b - Social Security
$738 b - National Security
$1.1 t - Other

Add to that:

$700 b - Wall Street bail-out (conservative)

A recent posting by former Senator Bill Frist points on the real dilemma we face. As we address our problems - including our imperfect health care system, two wars, and a crumbling infrastructure, how can we possibly afford to dig out of the health care hole? Or, as I think the Secretary of the Treasury would say about the financial markets - how can we afford not to invest more now to stabilize our future. For me, at least, health care is every bit the crisis that we see in our financial markets; it's just not a global problem. Foreign banks and governments have invested heavily in our debt and to let the banking system collapse would jeapardize our role in the world and a global economy.

Here's the sad thing - we are the sole owners of our health care - not foreign countries, banks, or others (outside of the national debt, bonds, and other capital instruments). Bank bailouts are not designed primarily to rescue the individual who makes the payments, they are designed to rescue the individual by ensuring there is a system that will make sure that we - and our children - can borrow what we need in the future to own a home. One wonders, even in this time of crisis, why is it easier to get a home loan than to be assured affordable health care?

Senator Frist's quote is as follows:

“You can’t really cost out the impact of the McCain proposal. Basically you’re blowing up the entire system and putting people into individual market. But the cost impact of the Obama plan, 452 billion dollars per year assuming it is implemented immediately…the point is it costs a lot of money and the American people, where 700 million dollars was lost yesterday, are not going to be in the mood for a large, expansive program.”

I am not sure I agree with his sense of the public sentiment. His own extreme price tag - in the context of financial industry bail-outs, wars, and other exigencies, seems worth discussion given the enormous adverse impact a failing health care system has on the individual.

Nina Cordona of National Public Radio covered Dr. Frist's remarks and stated that Dr. Frist "anticipates the formation of a panel to study Medicare, no matter who wins the election."

Could be an important task.

Medicaid MMIS Conference - September 15

2008-09-16T06:19:00.002-05:00

I had the pleasure of delivering a keynote address to the Medicaid MMIS Conference held in Nashville the week of September 15.

The slides are not particularly informative and must be examined in presentation mode.

The conference theme was "harmony"
I linked three major concerns with three definitions of harmony and addressed some simple approaches to each concern. The concerns and definitions were:

Complexity - congruity of parts with one another and the whole
Quality - Agreement
Value - Compatibility in opinion and action

These slides do not stand "on their own" but I've received requests, so here they are.

There is - rightly so - a lot of activity around MITA. As State budgets are shrinking with the economy and demand for services grow, the MMIS community - and Medicaid programs as a whole - are at a critical juncture. My primary theme was the balance between badly-needed innovation and personalization and unnecessary complexity. I also discussed the tensions between what we want as individuals and what society wants and can pay for. I discussed the Memphis health information exchange in the context of broader state and national initiatives.

Puerto Rico Releases Health Care Reform Report

2008-09-06T12:32:00.002-05:00

For a few brief days in March, citizens in the Commonwealth of Puerto Rico gathered together with a wide range of national experts to examine the curent status of their health care delivery system and to propose change. Under the leadership of the University of Puerto Rico, the report this workshop was released on September 5 during a press conference in San Juan. As I worked on this project and served as a primary author on this report, I became aware of just how formidable the challenges are. Because Puerto Rico's situation is relatively extreme, it serves as a potential laboratory both for Medicaid payment reform and for health care delivery reform in general.

Follow this link for the report (PDF)

As I worked on this project, I had other reflections that are not in the report and do not represent the views of the participants.

Among the diverse states and territories constituting the United States, Puerto Rico is unique. Puerto Rico was ceded from Spain to the United States through the Treaty of Paris in 1898; it has governed through a formal civilian structure since the passage of the Foraker Act in 1900. Since the passage in 1917of the Jones-Shafroth Act the United States Congress has characterized the Commonwealth as an “organized but unincorporated” territory of the United States. Under this Act, residents were granted U.S. citizenship by statute and since that time have served in the United States military service. This Act affirmed a primary responsibility of the United States in maintaining control over economic, defense, and other basic governmental affairs and reiterates the United States Congress’s authority to overrule actions taken by the Commonwealth Legislature.

In 1947, the U.S. Congress approved a law allowing the election of the governor by the people of Puerto Rico. On July 3, 1950, the U.S. Congress passed the Puerto Rican Federal Relations Act. This law gave Puerto Rico the right to establish a government and a constitution for the internal administration of the Puerto Rico government and “on matters of purely local concern.

In 1993 most of the government’s health care facilities and services were sold and their management turned over to non-government entities generally under managed care arrangements. This far more decentralized system radically changed the Department of Public Health’s influence and authority in provisioning care services.

Although the impact on efficiency and quality is controversial there is some consensus on the unintended consequences of these moves. As is the case in the 50 states, the health care delivery could benefit from less fragmentation; it would provide more good if organizations providing preventive services, health promotion, and health maintenance were better coordinated; its diverse regions and communities require a better fit of health care services; it needs a stronger infrastructure for monitoring quality, financing health care services, improving outcomes, and providing consumers with greater empowerment and choices. It is, in a nutshell, facing the same challenges as those of the 50 states and other territories - but one can argue that its situation is even more acute.

Puerto Rico’s ability to combine local and federal financing for health care programs is hobbled by its unique relationship with the Federal government. In contrast to “incorporated territories” that may petition for statehood, the “unincorporated territory” of Puerto Rico is not subject to the Constitution’s Tax Uniformity Clause on all Federal duties, imposts, and excise. Although Puerto Ricans do pay import/export taxes, commodity taxes, and payroll taxes (Medicare, Social Security) most are not required to pay Federal income tax.

Although Puerto Ricans do not pay federal income tax, few would have a significant tax burden: the median household income in Puerto Rico is only 34% of the U.S median household income (2000 census) and less than half of that of citizens in the State of Mississippi.

While many health indicators in Puerto Rico are more ominous even than those published for Mississippi, in 2006 the latter state received 78.6% in federal support for every Medicaid dollar spent (the FMAP or federal matching assistance percentage), while Federal spending caps first initiated in 1968 have limited Puerto Rico’s matching percentage to an effective rate of 18%.

The 50 states can receive up to 90% reimbursement through Medicaid for critical health information technologies; Puerto Rico is not eligible for these supplements. According to 2005 Congressional testimony by Governor Anibal Acevedo-Vila, had FMAP been allowed to operate without the cap instead of the 18% effective rate of the previous year, the Commonwealth would have received $1.7 billion dollars in federal Medicaid support instead of the $219 million received. Translated to monthly amounts, federal Medicaid support in the states approximated $330 per month per participant; the amount in Puerto Rico was about $20 per month.

Funding and health care status are only a part of the obstacles Puerto Rico faces. Its health care delivery system, health care resources, and health care financing mechanisms have been said to have been in a state of decline since the introduction of managed care programs in the early 1990s. The hospital beds per capita in the Commonwealth are less than 2/3 the average across the 50 states; salaries for health care professionals of all types are lower and emigration to the 50 states is common. As vital care resources emigrate from the Commonwealth, some believe that a growing number of Puerto Rican residents needing chronic or long-term care will emigrate as well, shifting the financial burden for care to these same states.

It is within this context of controversy, internal dispute, and at times acrimonious dialogue with the Congress and Federal Executive Branch that Puerto Rico must navigate a course to health care reform. The creation, financing, and administration of such reforms very much depends on the perception – in Washington, among the Congress, and within the Commonwealth – on the rights and responsibilities of all parties within this historically unique and volatile relationship.

Puerto Rico's voice - and their subsequent actions - may say a lot about how other parts of the Nation can address similar urgent health care financing and delivery concerns.

Readings:

Systems Integration

2008-08-26T10:11:00.002-05:00

With so much going on, I was surprised that I spent quite a bit of time thinking about a series of questions a writer posed about integrating health care information systems. I think I did this because I believe that the very definition of a "system" more or less dictates the outcomes producting the system and, in my mind, asking "are your current systems integrated?" is not as important as asking "do you know what information sources you must emphasize and integrate to improve health care?" One can either design for the last conflict, or try to anticipate the future and built towards what one knows must be achieved. I have always favored the latter approach.

Effective use of Information is the life blood of health care. Such integration affords greater quality of service, greater economic returns, and - in some instances - may literally save lives. The purpose of integration, therefore, extends beyond short-term efficiency and will either enable or constrain the evolution of a business.

To address any question of integration, health care executives must make assumptions about the very nature of their organization. When one says X is not integrated with Y (or X is integrated with Y) one states that somehow both X and Y are important to the business. When one has systems or information sources that are not even included in the assumptions, one is saying that these systems or information sources are not core to the business. If I say “it never occurred to me to think about integrating A with my integrated X and Y” one is saying either that such integration does not meet business objectives or is not even considered central to the core mission of the business.

So the right questions are not just : Are you integrating your current systems but also “are you developing a road map to integration or coordination of information sources that will improve your short-term prospects and position your organization for leadership in a wildly disruptive and chaotic environment? Integrating the right things propels an organization into a whole new level of business.

One need look only at organizations like Wal-Mart or Amazon to see how systems integration support market dominance. Integrating the wrong things may actually anchor one in the past and accelerate organizational demise.

Think of Clayton Christensen’s “Innovator’s Dilemma.” In this book he noted that the makers of the steam shovel knew about the back hoe, but they were so wedded to their steam shovels that they just couldn’t envision this new market. Similarly, most makers of main frame computers knew as much about early personal computers as those who built them, but they just couldn’t see how focusing on these disruptive technologies could possibly be the best use of their time as their margins were shrinking and their margins declining.

Health care plan executives need to approach their integration strategies to make sure they are answering the right business questions. They need to remember that the last steam locomotive ever built was no doubt one of the very best steam locomotives, but that the market has moved on.

The same issues face health care. Consumers, frustrated with the fragmentation and complexity of the health care system and fairly oblivious to its costs, are taking power - through informal support groups, through new means of care delivery, and through a new generation of personal health records and systems. Health care executives would be wise to try to understand this rising tide.

It appears that even within relatively well-defined boundaries, health care executives often believe that their own information technology houses are not in order. One must be sympathetic. The growing and increasingly absurd degree of coding complexity, regulatory confusion, and changing policy directions make integration of complex systems challenging. Still, given rising costs and the public perception that health plans and other intermediaries are doing very well, executives should be prepared to face a degree of unprecedented public accountability. Employers and individuals should, rightly ask, “if you don’t even have your own houses in order and running efficiently, why should I allow you stewardship over my health care dollars? Why, indeed, should you be in business at all?”

There are answers.

When I was employed by a large company in the health benefits sector that had acquired several other firms (each with its own free-standing information system), our visionary CEO tied a significant fraction of the bonus for every individual to achievement of systems integration targets. His claim was that everyone - in one way or another - could make life better or worse for our IT staff, and if we made it worse, the company would suffer. He recognized that until we got our own IT house in order, our customers would be confused, our employees would be frustrated, and our shareholders would not realize the potential of their investments. His strategy worked.

Other data suggest some integration with external partners or within their own family of companies. In addition, wise executives are uncertain which alignments made sense in this changing world. This explains the reticence to embrace new technologies, be they health information exchanges, personal health records, or other emerging approaches to health information management.

But the reality is this. As more and more health expenses are returned into the hands of consumers and as more complex mechanisms are required to extend coverage to more (or all) Americans and to cushion the impact of catastrophic illness, health care executives simply must try to understand that their organizations are only a part of the overall information flow affecting the lives of Americans. They don’t “own the health information game” but instead must work with others more effectively.

Abandoning a paternalistic approach - particularly if such an approach has been associated with short-term financial success - is not for the feint-of-heart. But a reformulation is as essential to these executives as it is to travel agents facing an emerging Internet or retailers facing Wal-Mart. Things change, and knowing how to change is a skill critical to success if not survival itself.

I am sympathetic with those who face integration challenges. Particularly in a field where billing complexity and reimbursement methods have never been stable and are likely to change radically in the years ahead, it is difficult to commit to 5-year plans where the regulatory and financial environment is at best seen only on a two-year horizon.

So at times it is far wiser to know what systems not to integrate, what systems to radically redefine, and what system to phase out. Simple integration of current systems could actually make things worse by making a broken system only break more efficiently. To paraphrase Mayor Richard Daleys’s comments 40 years ago during the Chicago Democratic Convention: “The police are not here to create disorder, they are here to preserve disorder.”

This is precisely the dilemma faced by health care executives. How do they balance IT investments among: systems that may “preserve disorder” and increase short-term operational margins; new systems that may attenuate disorder at the expense of short-term margins and that are not currently associated with a undeniable strategic advantage; entirely new relationships focused on the individual consumer and provider that both pose grave threats to current business models but significant opportunities if the world is changing as rapidly as many believe.

Rules Doctors Need to Know

2008-08-07T13:40:00.003-05:00

In the August 7 on-line version of the New York Time, Tara Parker-Pope contributes an article entitled "Six Rules Doctors Need to Know." She credits the source as Dr. Robert Lamberts. His blog, Musings of a Distractible Mind will not doubt be overwhelmed, but it's worth a look.

Follow this link to his posting of his six rules

Having spent the last two weeks both in the aether of Washington and in the trenches of New York City, I find the article grounding not just with respect to its resonance with "consumer" discontent but equally as a guide for the very "why" of health care policy. It's not about white papers and legislative mark-ups, it's about people.

Here are his six rules. They are posted only as a teaser to guide the reader to the primary and secondary sources.

Rule 1: They don’t want to be at your office.
Rule 2: They have a reason to be at your office.
Rule 3: They feel what they feel.
Rule 4: They don’t want to look stupid.
Rule 5: They pay for a plan.
Rule 6: The visit is about them.

This posting has generated enormous response both in the addition of more "rules" as well as in commentary on the existing six rules. Most, this writer would argue, apply equally well to the "why" of policy more broadly. In my revision, I change the "they" to "we" since it's the "we" who are beneficiaries.

Rule 1: We don’t want policies and rules until we need them. Lambert points out that patients don't work in the office and most find the experience unnerving. They are, quite often, "naked" to the world when in the office. Ditto for policy makers and those who serve the "system." Lambert says the key to success in practice is "compassion." When was the last time one felt this in a back office or a hearing room?

Rule 2: We have reasons to want our health care system to work. No one wants to go to a health care facility. No one wants to have to think about progressive intermittent frailty, economic catastrophe from health care costs, cancer, heart disease, or the curse of obesity. Yet they are somewhere in everyone's minds. This observation may help focus policy-makers. As Lambert says: "On every visit I try to identify the real reason (or the real fear) that brings them to see me."

Rule 3: We feel what we feel. If in the public eye things don't make sense or one feels one is not being served, it's the responsibility of those serving to try even harder. As Lamert says, "you have to trust your patient...only the really crazy patients up symptoms."

Rule 4: We don’t don’t want to look stupid. Dr. Lamberts describes this from the perspective of the patient who is viewed as over-reacting. I would phrase this from the perspective of an individual seeking answers and and finding acronyms. Just try to understand the long-term care you or your loved ones need. Explain CHHAs, NORCs, SNFs, and the many other acronyms and terms designed, one imagines, to evade actually solving human problems. Acronyms are a symptom of unnecessary complexity. Their use promotes the degradation of the "lay public" and further isolates the voter from those charged to execute in the political realm. Request to those who work in government: successful candidates (from any party), don't use acronyms; neither should you!

Rule 5: We pay for a plan. We don't pay for orders and rules without a rationale that makes sense to us as tax payers and as individuals who will place our lives in the hands of the health care system policy creates. How well does our system actually prepare a plan to help someone adhere to medications and change behaviors rather than just drop the whole thing into the lap of the individual? How well do the components of our system work together on behalf of the individual? Sadly, we know the answer to this question; We should not feel proud.

Rule 6: Policies are about "us" - the beneficiaries - and the services we need; they are not about the policy-makers, lobbyists, health plays, employers, or other intermediaries.

Governor Phil Bredesen: Three Health Care Reform Principle

2008-08-03T17:09:00.003-05:00

In a July 31, 2008 blog posting entitled "Think Gas Prices Are High? Watch Out For Health Care," Governor Phil Bredesen outlines three principles for "Americans of many different political stripes [who] are ready to stop tinkering and instead devise a fresh and national solution to our health-care challenges."

Follow this link for Governor Bredesen's posting

Summarizing the three principles:

Principle 1: Incentives.
"The first principle is to once and for all fix the incentives.....One way to start would be to develop a national standard for what constitutes optimum quality health care in treating some of the more common and expensive diseases: diabetes and various forms of heart disease, for example. With a legally sanctioned standard, payments to providers could be revolutionized to pay for high quality and value — not just quantity."

Principle 2: An Rx for everyone
The Governor argues that we need to "build a solution good enough for all Americans." He cites as examples Social Security or Medicare and contrasts these with the "patchwork and means-tested government programs" that genearally don't "enjoy broad public and political support." He points out that this is not equivalent to "government largesse" but instead should be a benefit "earned by and owned by every American." This is a "national health care solution."

Principle 3: Incremental change
The Governor argues for "incremental change" and argues that one first step "might be federal underwriting of the costs of some of the most expensive diseases..... By insuring some of these costs, we could quickly transition our nation to managing many diseases in organized systems of care and paying for quality and outcomes, not procedures and pills."

These are some tough challenges but carry some popular, consumer-focused concerns. They could be used to tackle some of the big challenges (although all such plans to cover one or another disorder risk lobbying by many special interests). They require a radically different approach to managing the health information that individuals and their care providers need. They require a new view of quality based on meaningful metrics and not diagnostic and procedural claims along.

Governor Bredesen's "three principle" principle.
This is not the first time our Governor has boiled down complex issues into a short list of guiding principles. Three seems to be a magic number.

HIMSS
Take, for example, the three ideas he promoted in his HIMSS keynote of 2007. Paraphrasing his three ideas:

Build version 1.0 first. He commented on the complexity and broad approach without establishing early wins.
Focus on an achievable goal with broad implications. He mentioned e-prescribing and medication management as issues that affect nearly everyone. (Indeed, over year later, arguably the incredible progress that has been made through adoption and the merger of SureScripts and RxHub are the result of industry and congressional action more than emphasis by NHIN.
Focus on adoption. He argued that attenion should be paid on how technologies should be focused on providing new value to providers and patients in "average" communities and not the more advanced and early adopters of technology innovation.

Medicaid
Governor Bredesen gave another three useful principles in a Democratic respose to a Saturday morning presidential radio address on June 11, 2005. Entitled Medicaid 2.0, the address, focused on three principles that are consistent with his most recent blog posting and should reassure those who think a comprehensive approach necessarily means government spending run amok. His principles are:

Everybody pays something. Using the same "shopping in the store" metaphor for moral hazard mentioned in his more recent July 31 posting, the Governor said that "until everyone has a little skin in the game, the system will continue to be inefficient. "
Pay for the important things first. Using acid reflux as an example of what not to pay for, the Governor said "Medicaid 2.0 needs to pare down what it pays for so that everyone has access to basic health care before we bring in the fancy trimmings." Again, looking from the perspective of a health care executive, his most recent address focuses on high overall spending conditions like diabetes and heart disease. (Eight years ago, this writer learned that from a pharmacy benefits management perspective, high spend drugs where not always for high-impact health conditions: non-sedating antihistamines and acid reflux medication topped the list.)
Pay for what works. Although the Governor noted in 2005 the growth in "me too" drugs, the notion of "paing for what works" is very much in the national spotlight and the topic of much discussion under the rubrick of "comparative effectiveness." For more information, refer to recent Roundtable on Comparative Effectiveness activities of the Institute of Medicine.

Lists of three really work - particularly if over time the lists form an internally consistent pattern and drive towards an important goal. This writer is aware of three lists from one enlightened governor: one list focused on health care reform priorities and methods, a second on information technology, and a third paralleling the first and focusing on Medicaid. Some of the entries on the list can be achieved within a year (effective e-prescribing and medication management, for example). Others will take time and depend greatly innovations in quality, payment reform, and the evidentiary basis for care.

The challenge I believe, is to turn a short and easily understood set of guiding principles into an effective plan of action that demonstrates clear progress for the average American. The current fragmented approach drives well-intentioned individuals and organizations into spending an inordinate amount of their resources navigating a bureaucracy made unmanageable by four decades of modification. There is little value in uneccesary complexity. Maybe its time to "think in threes."

A Long Term Care Workshop in New York State

2008-07-30T19:49:00.005-05:00

As part of a workshop we are holding in New York in the coming weeks, we have created a background paper and a set of additional readings in preparation for the conference.

The goal of the workshop is to develop a comprehensive vision for the State of New York in the care of the frail elderly across a continuum. It will address need, capacity, workforce, financing, and organization. As the many "additional readings' on the site will attest, this is one of the most pressing issues facing our country. New York has extraordinary capabilities here and is at this critical juncture taking a fresh look at all that need be done.

E-prescribing provisions of the 2008 Medicare Bill

2008-07-20T09:42:00.001-05:00

E-prescribing provision from the recently passed Medicare bill (H.R. 6331) as submitted to me by a colleague and reformatted.

The Bill is entitled: The Medicare Improvement for Patients and Providers Act of 2008

Follow this link for the bill text (PDF)

SEC. 132. INCENTIVES FOR ELECTRONIC PRESCRIBING.

(a) INCENTIVE PAYMENTS.—Section 1848(m) of the Social Security Act, as added and amended by section 131(b), is amended—
(1) by inserting after paragraph (1), the following new paragraph:
(2) INCENTIVE PAYMENTS FOR ELECTRONIC PRESCRIBING.—

(A) IN GENERAL.—For 2009 through 2013, with respect to covered professional services furnished during a reporting period by an eligible professional, if the eligible professional is a successful electronic prescriber for such reporting period, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) or, in the case of a group practice under paragraph (3)(C), to the group practice, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to the applicable electronic prescribing percent of the Secretary’s estimate (based on claims submitted not later than 2 months after the end of the reporting period) of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or, in the case of a group practice under paragraph (3)(C), by the group practice) during the reporting period.

(B) LIMITATION WITH RESPECT TO ELECTRONIC PRESCRIBING QUALITY MEASURES.—The provisions of this paragraph and subsection (a)(5) shall not apply to an eligible professional (or, in the case of a group practice under paragraph (3)(C), to the group practice) if, for the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year)—
(i) the allowed charges under this part for all covered professional services furnished by the eligible professional (or group, as applicable) for the codes to which the electronic prescribing quality measure applies (as identified by the Secretary and published on the Internet website of the Centers for Medicare & Medicaid Services as of January 1, 2008, and as subsequently modified by the Secretary) are less than 10 percent of the total of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or the group, as applicable); or
(ii) if determined appropriate by the Secretary, the eligible professional does not submit (including both electronically and nonelectronically) a sufficient number (as determined by the Secretary) of prescriptions under part D.
If the Secretary makes the determination to apply clause (ii) for a period, then clause (i) shall not apply for such period.

(C) APPLICABLE ELECTRONIC PRESCRIBING PERCENT.— For purposes of subparagraph (A), the term ‘applicable electronic prescribing percent’ means—
(i) for 2009 and 2010, 2.0 percent;
(ii) for 2011 and 2012, 1.0 percent; and
(iii) for 2013, 0.5 percent.’’;
(2) in paragraph (3), as redesignated by section 131(b)—
(A) in the heading, by inserting AND SUCCESSFUL ELECTRONIC PRESCRIBER’’ after REPORTING’’; and
(B) by inserting after subparagraph (A) the following new subparagraph:

(B) SUCCESSFUL ELECTRONIC PRESCRIBER.—

(i) IN GENERAL.—For purposes of paragraph (2) and subsection (a)(5), an eligible professional shall be treated as a successful electronic prescriber for a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year) if the eligible professional meets the requirement described in clause (ii), or, if the Secretary determines appropriate, the requirement described in clause (iii). If the Secretary makes the determination under the preceding sentence to apply the requirement described in clause (iii) for a period, then the requirement described in clause (ii) shall not apply for such period.

(ii) REQUIREMENT FOR SUBMITTING DATA ON ELECTRONIC PRESCRIBING QUALITY MEASURES.—The requirement described in this clause is that, with respect to covered professional services furnished by an eligible professional during a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year), if there are any electronic prescribing quality measures that have been established under the physician reporting system and are applicable to any such services furnished by such professional for the period, such professional reported each such measure under such system in at least 50 percent of the cases in which such measure is reportable by such professional under such system.

(iii) REQUIREMENT FOR ELECTRONICALLY PRESCRIBING UNDER PART D.—The requirement described in this clause is that the eligible professional electronically submitted a sufficient number (as determined by the Secretary) of prescriptions under part D during the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year).

(iv) USE OF PART D DATA.—Notwithstanding sections 1860D-15(d)(2)(B) and 1860D-15(f)(2), the Secretary may use data regarding drug claims submitted for purposes of section 1860D-15 that are necessary for purposes of clause (iii), paragraph (2)(B)(ii), and paragraph (5)(G).

(v) STANDARDS FOR ELECTRONIC PRESCRIBING.— To the extent practicable, in determining whether eligible professionals meet the requirements under clauses (ii) and (iii) for purposes of clause (i), the Secretary shall ensure that eligible professionals utilize electronic prescribing systems in compliance with standards established for such systems pursuant to the Part D Electronic Prescribing Program under section 1860D–4(e).’’; and (3) in paragraph (5)(E), by striking clause (iii) and inserting the following new clause:
(iii) the determination of a successful electronic prescriber under paragraph (3), the limitation under paragraph (2)(B), and the exception under subsection (a)(5)(B); and’’.
(b) INCENTIVE PAYMENT ADJUSTMENT.—Section 1848(a) of the Social Security Act (42 U.S.C. 1395w–4(a)) is amended by adding at the end the following new paragraph:

(5) INCENTIVES FOR ELECTRONIC PRESCRIBING.—

(A) ADJUSTMENT.—

(i) IN GENERAL.—Subject to subparagraph (B) and subsection (m)(2)(B), with respect to covered professional services furnished by an eligible professional during 2012 or any subsequent year, if the eligible professional is not a successful electronic prescriber for the reporting period for the year (as determined under subsection (m)(3)(B)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph).

(ii) APPLICABLE PERCENT.—For purposes of clause (i), the term ‘applicable percent’ means—
(I) for 2012, 99 percent;
(II) for 2013, 98.5 percent; and
(III) for 2014 and each subsequent year, 98 percent.

(B) SIGNIFICANT HARDSHIP EXCEPTION.—The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access. ‘

(C) APPLICATION.—

(i) PHYSICIAN REPORTING SYSTEM RULES.—Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.

(ii) INCENTIVE PAYMENT VALIDATION RULES.— Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection. ‘

(D) DEFINITIONS.—For purposes of this paragraph:

(i) ELIGIBLE PROFESSIONAL; COVERED PROFESSIONAL SERVICES.—The terms ‘eligible professional’ and ‘covered professional services’ have the meanings given such terms in subsection (k)(3).

(ii) PHYSICIAN REPORTING SYSTEM.—The term ‘physician reporting system’ means the system established under subsection (k).
(iii) REPORTING PERIOD.—The term ‘reporting period’ means, with respect to a year, a period specified by the Secretary.’’.

(c) GAO REPORT ON ELECTRONIC PRESCRIBING.—Not later than September 1, 2012, the Comptroller General of the United States shall submit to Congress a report on the implementation of the incentives for electronic prescribing established under the provisions of, and amendments made by, this section. Such report shall include information regarding the following:

(1) The percentage of eligible professionals (as defined in section 1848(k)(3) of the Social Security Act (42 U.S.C. 1395w– 4(k)(3)) that are using electronic prescribing systems, including a determination of whether less than 50 percent of eligible professionals are using electronic prescribing systems.

(2) If less than 50 percent of eligible professionals are using electronic prescribing systems, recommendations for increasing the use of electronic prescribing systems by eligible professionals, such as changes to the incentive payment adjustments established under section 1848(a)(5) of such Act, as added by subsection (b).

(3) The estimated savings to the Medicare program under title XVIII of such Act resulting from the use of electronic prescribing systems.

(4) Reductions in avoidable medical errors resulting from the use of electronic prescribing systems.

(5) The extent to which the privacy and security of the personal health information of Medicare beneficiaries is protected when such beneficiaries’ prescription drug data and usage information is used for purposes other than their direct clinical care, including—

(A) whether information identifying the beneficiary is, and remains, removed from data regarding the beneficiary’s prescription drug utilization; and

(B) the extent to which current law requires sufficient and appropriate oversight and audit capabilities to monitor the practice of prescription drug data mining.

(6) Such other recommendations and administrative action as the Comptroller General determin

AHRQ Solicitations Forthcoming

2008-07-10T13:21:00.002-05:00

The NIH has recently published a Notice of Intent to Publish Program Announcements for Health Information Technology to Improve Health Care Quality.

Follow this link for the notice

What does this notice cover? Quoting:

This Notice announces AHRQ’s intention to publish Research Demonstration Grants (R18), Exploratory Developmental Grants (R21), and Small Research Grants (R03) Funding Opportunity Announcements (FOA’s) to fund health information technology (IT) research.

The R18 FOA will support demonstration research grants that rigorously study the leveraging of health IT implementation to improve the quality, safety, effectiveness and efficiency of health care in ambulatory settings and to support transitions in care between ambulatory settings or ambulatory and non-ambulatory settings.

The R21 FOA will support health IT exploratory and developmental research projects. These R21 health IT research grants will support the conduct of pilot or feasibility studies that are needed to inform future health IT implementation efforts which may include but are not limited to the conduct of a health IT Research Demonstration FOA Grant (R18).

The R03 FOA will support small research grants that can be carried out in a limited period of time. These R03 health IT research grants will support the conduct of small, self-contained health IT research projects; economic analyses of health IT implementation; and, secondary data analyses of health IT research.

Publication and Receipt. The FOAs are expected to be published by the end of August, 2008.

Details on application receipt dates can be found at: http://grants.nih.gov/grants/guide/notice-files/NOT-OD-07-001.html

SureScripts-RxHub

2008-06-28T14:24:00.006-05:00

On July 1, the public was informed that SureScripts and RxHub merged into a single entity called, for the present, SureScripts-RxHub.

This is exciting news for health care and for me personally. As an Express Scripts VP, I had the good fortune to be present through the planning for the formation of RxHub and, until the formation of the new company, was more recently a member of the SureScripts Board. So I've been a direct witness to the great efforts of both organizations. I add as well that the only facts in this posting are publicly available and that any conjecture on my part is simply that; I have not speculated in areas that I may have formally discussed with either entity.

History
RxHub was originally formed in 2001 by three pharmacy benefits managers (PBMs) - Advance/PCS (not yet acquired by CareMark), Express Scripts, and MedCo. With various acquisitions, the current owners of RxHub are Caremark, Express Scripts, and Medco. Other PBMs are planning participation. RxHub was formed primarily to simplify the task of e-prescribing for vendors. Since this organization (and SureScripts as well) were formed before standards were promulgated at a national level, these organizations were de facto standard setting bodies. RxHub derives its revenue from formulary eligibility checks and its costs are offset primarily by PBMs. Medication histories are based on medical claims. The first CEO of RxHub was Jim Bradley, now the Chairman of the Board of Prematics.

SureScripts was also established in 2001 by NACDS (National Association of Chain Drug Stores) and NCPA ( National Community Pharmacists Association) - the leading retail pharmacy associations. SureScripts derives its revenue from true e-prescribing messages (new scripts or refills) but not from fax messages; these costs are payed by pharmacies and additional funding is through various debt mechanisms. Medication histories and messaging is primarily through NCPDP SCRIPT. The founding CEO of SureScripts was Kevin Hutchinson, who now serves as CEO of Prematics under Jim Bradly.

Hence, over the past few years the charismatics founders of both RxHub and SureScripts are now working on the vendor end and hence working through the very organizations they created. Small, small, world.

From the outset, these two organizations both competed in some sectors and demonstrated remarkable collaboration in others. In principle, a direct connection between e-prescribing systems and PBMs through RxHub presented the theoretical opportunity to promote diversion of prescriptions from retail phramcies to PBM mail order pharmacies. An effort by the retail pharmacies to promote direct connectivity would mitigate this risk. Similarly, a direct connection with pharmacies without the presentation of formularly options would not simplify the process of PBM-based drug trend management. Both RxHub and SureScripts, no doubt, saw the need to simplify the process of e-prescribing. Both were committed absolutely to establishing national standards to simplify medication management and both actively participated in standards bodies long before the establishment of the HITSP structure created by the HHS Office of the Network Coordinator.

Standards were the easy part. Progress in medication management has been slow in coming. E-prescribing is a complex "dance" among the prescriber and staff, the pharmacy and staff, and the consumer. Each must re-think their activities and deviate from the norms set by fax-based or paper-based prescribing. In many areas, adoption of e-prescribing has been much slower than many of us would have expected. We underestimated the complexity of the system and the comprehensive effort required to provide incentives sufficient to change the behavior of prescriber, dispensing pharmacist, and consumer.

But recent progress is heartening. Where PBM coverage is high, medication histories are increasingly available through RxHub and eligibility checks are growing in frequency. Particularly where chain drugs stores are dominant, true e-prescribing (digital communications, not fax) is growing and fax is disappearing. Still less than 5% of prescriptions are at present sent in digital format.

The New Organization
The new organization will be governed 50:50 by the organizations that founded RxHub and SureScripts. Board composition will be 3 members from the PBM industry and 3 from the retail pharmacy. Management will be under to interim co-CEOs, J.P. Little and Rick Ratliff, who formerly were acting CEOs of RxHub and SureScripts, respectively.

The joint organization will maintain its prohibition of commercial messaging. Given the numerous tensions and differing business models, one can also reasonably assume that secondary sale or distribution of data will not be practiced (although each source PBM or pharmacy, one would assume, will continue whatever their current business practices are). In my personal view, the combined organization presents no new threat to the public through commercial intrusion or misuse of personal health information.

SureScripts-RxHub can be expected to emphasize the following practices in a more consistent and uniform way:

Prescription routing. One imagines that the SureScripts' capabilites will be enhanced to expedite digital messaging between prescribers and pharmacies to simplify the ordering, dispensing, refill requests, and medication fill status. Perhaps the PBM mail order pharmacies will be added to the SureScripts network.
Payor transactions. The RxHub eligibility checks will presumably continue to be developed to simplify coverage notification and formularies. (Suggestion to the PBM industry; a few hundred - or thousand fewer formulary and nuanced prior authorization rules would simply things immeasurably). Both SureScripts and RxHub supported various repositories of formulary and eligibility information; presumably there is some redundancy here and simplification will be a benefit to vendors and clinicians.
Rx history. This is perhaps the most exciting and uninished piece of work that can be addressed by the joint entity. Currently, historical data - if it is present at all - comes via the RxHub claims database or from SureScripts NCPDP script messages. But the RxHub database is claims-based and may suffer both from latency and incompleteness (if low cost-drugs are not entered into the claims database or if the individual is either self-pay or enrolled in a plan not currently connected to RxHub). Although virtually every chain drug store and the majority of independent pharmacies can communicate through e-presribing standards, many SureScripts member pharmacies have not completed medication history service agreements nationwide, but such agreements are anticipated in the next few months. Much work will have to be done. My guess (often wrong) is that prescribers will demand such a service at no cost as a quid pro quo for e-prescribing. Consumers will demand audit logs and various forms of authentication to ensure their medication histories are only accessed for appropriate reasons. As I have argued repeatedly, echoing the Commission for Systemic Interoperability Report of 2005. One of the major national health information technology priorities should be the creation of services that provide complete, reliable, and confidential prescription medication histories for every American. Sadly, although NHIN, ONC, HHS, and others have endorsed standards (often those emphasized by RxHub and SureScripts), follow-through has been disappointing and, to the best of my knowledge, the merger of these two entities is the result of a private-sector business need in the public interest, not the result of top-down regulatory pressure from the government. Fortunately members from both organizations have worked to simplify and advance the currently somewhat complex ONC medication management use case.
Pharmacy interoperability and care support. One can expect the combined entity to continue its enhancement of patient health information messaging among providers and dispensers to ensure better coordination and safer medication use.
Network support. The at times conflicting interests of the retail, chain, and PBM organizations (as well as the comepition within each sector) will necessitate contiuation of the tradition of neutrality, transparency, and efficiency currently critical to the success of each organizations. Again, the very tensions among the stake holders act, in my view, in the public interest here.

Implications
The announcement is great news for American consumers, health care organizations, intermediaries, and the health information management industries. Pressure for mandatory e-prescribing is mounting. The DEA has been under considerable congressional pressure to allow controlled-substances to be prescribed through digital devices and has issued a Notice of Proposed Rule Making (Federal Register June 27, 2008, volume 73, number 125).

At present, e-prescribing is still an incompletely practiced new form of coordination among prescriber, dispensing pharmacist, and the consumer. It is a system where everyone has to see benefit and change their behavior in some ways. There are many benefits in an ideal world, but in many instances, a lot of work must be done. Change is not easy.

The timing could not be better. Clinicians (both prescribers and dispensers), the staff working within clinical organizations, vendors, and the public are facing a complex array of challenges. In most instances, successful implementation of e-prescribing solutions for communities is the product of de facto collaboration among SureScripts, RxHub, pharmacies, payers, intermediaries, clinicians, and the public. Anything that simplifies the overall process should be applauded.

We are fortunate that the two organizations forming this new entity have complementary missions and have demonstrated a track-record of collaboration. Formalizing this relationship comes at a critical juncture. It is a unique and positive story.

Let us all wish them the best of luck.

The Markle Foundations Connecting for Health Common Framework for Networked Personal Health Information

2008-06-19T11:19:00.007-05:00

On Wednesday, June 25, the Markle Foundation's Connecting for Health Initiative will release a series of materials collectively entitled a "Common Framework for Networked Personal Health Information."

This work will be a follow-on to a much less detailed brief written in the context of the Connecting for Health Framework for Networked Personal Health Information. In this earlier phase, the attention was directed at providers and the means by which one assured trust was through contracts.

This very detailed and comprehensive set of documents will be based on a small set of common expectations; rules and protocols applicable to all exchange; the value of overcoming barriers to information sharing; and the improvement of the public trust. Without such an approach, many fear the policies will be monolithic and not sensitive to the variety of contexts in which health information is used. In lieu of a clear approach, piecmeal efforts may slow progress and innovation; implementation efforts may be disconnected from policies; and these approaches may place excessive reliance on consumer consent. Add to that, some approaches may simply not be practical.

What we are facing, many believe, is a "privacy gridlock" where too many parties are seeking the impossible perfect. The alternative is to show that extreme rhetoric is not necessary and that most efforts can rely on the enormous efforts that already have addressed some of the fundamental issues.

Three common expectations often articulated are:

Core privacy principles
Sound network design
Oversight and accountability

These are based on the broader set of guiding principles articulated in the Markle Comprehensive Framework. The three expectations have recently been discussed in Deven McGraw's June 4 testimony to the House Energey and Commerce Subcommittee, Health subcommittee.

The framework could be used as a set of guiding principles for a loose form of "certification" that defines attributes organizations, systems, or products must have to be included in federal health care initiatives, e-prescribing initiatives, health information exchanges, product development, consumer group activities, and other endeavors in which trusted use of health care information is necessary.

The new documents are impressive in scope. They are heavily-referenced and reflect the best thinking of some of the Nation's leaders. These are sound and comprehensive recommendations, but they are not necessarily prescriptive. They allow individuals and organizations to internalize and interpret recommendations in ways that seem most appropriate for their needs.

The Markle Connecting For Health Subcommittee on Quality and Cost Effectiveness

2008-06-19T10:59:00.004-05:00

On June 19, 2008, the Markle Foundation Connecting for Health Steering Group met to discuss means of disseminating the Common Framework for Networked Personal Health Information and to discuss ongoing population health activities.

Now in its fifth year, the Markle Foundation has made remarkable contributions. Established in early 2004, the first public briefing on the Markle Agenda was held at the National Press Club on June 25, 2003.

Zoe Baird led the meeting discussing a meeting held last week by the Senate Finance Committee. Much was said about a universal health care financing vehicle and great attention was paid to costs. Although comprehensive legislation is not expected, incremental steps will be taken and information technology - wisely used - will enable better health care.

Some have lamented the lack of agreement that would allow the Government to use its market power as a payer for care. There is enough focus now with Congresional engagement and presidential campaigns that investments could be anticipated. One must make sure that the right kind of open markets are realized and, for this reason, both a consumer framework and a population health approach will be essential to the debate. There was significant discussion about the CBO report (2976) that pointed out where CBO believed additional congressional support could improve adoption and health.

Response to the CBO Report

Dr. Blackford Middleton noted the report gave a "reasonable review and summary of the literature on HIT value." Some CITL report aspects "were not represented well." These include:

A fundamentally different purpose for the report - the impact of funding
Value of un-standardized (level 3) vs standardized (level 4) interoperability.
They failed to note how CITL accounted for the current HIT context; CBO factored in existing provider-payer data exchanges, and existing lab and pharmacy integration
CBO treated costs of providers information systems but inadequately treated the internal benefits; their notion of data exchange was relatively restricted.
CITL differed with CBO on lab administration costs; phone call rates - but these were not key determinants of overall value
CBO's critique did not discuss some of the limitations of HIEI model limitations. The CITL model was more expansive and included realizing savings through quality improvements and the potential clinical benefit.

In the same discussion Zoe Baird noted that it isn't so much the report as how it is depicted to the public. Initial reports were rather unitarian in the view declaring that benefits are not there. CBO - recruiting a broad and talented array of health care economists - has emphasized a broader and more constructive mesage.

Subcommittee on Quality and Cost Effectiveness

One member of the committee expressed extreme frustration. After years of measurement, we haven't been able to "move the needle even one millimeter." People are "tired of it" and "it's time to move on." We need to measure something that counts and quite measuring for the sake of measuring. We do have measures that work - hospital infections, falls, and adverse events. There are very good programs on this focused primarily in hospitals - and this is done without "micro measurement" and by exploring different ways of including things into the processes.

To make an analogy, it is as if one measures the outcome of the Indianapolis 500 by measuring the piston characteristics, fuel injection performance, and, after adjusting for severity, develop an outcome metric!

It's time to re-think and move past the self-interest.

A second member empahsized the need to focus on a few simple things rather than continuing to expend energy as has been done over the past five years. Examples were providing a medication history for every American and better access to laboratory data.

One physician pointed out that "it isn't funny anymore" and spoke of an ongoing event concerning a relative where his personal presence was critical to pull together the various parties involved in the care of his hospitalized relative. Many providers stated "they really didn't have all the details" and depicted a number of clear outcomes that were the result of failures in the system. (The story rivalled that Regina Herzlinger tells in her recent book, "Who Killed Health Care.")

Five Potential High Impact Ideas

The Subcommittee currently is exploring five simple "high impact ideas"
for discusion as a sub-set of a more extensive list. They are:

Measures that matter. Set big goals, like reducing cardiovascular events in the US over the next Y years by X%. Currently some measure for reporting rather than measure for improving. Measurement of "surrogate outcomes" should be abandon as "futile."

Eliminate nosocomial blood stream infections in the US. This requires widespread adoption of evidence-based work flows involving every provider.

Implement a national device registry. A simple correlation between surgeons and selected devices (e.g., hip prostheses, stents) would reveal variation.

Make formularies on-line. (This writer would like to see no more than 50 formularies in the united states rather than thousands. In other words, "formularies that matter" not automating the thousand-plus variants of dubious value)

Share a visit summary. Trials of interchange of CCR and CCD docments have been successful and hold great promise.

The overall approach is not to create another silo but rather to bridge with focus the gap between the many quality initiatives and the principles in policy and technology that are required to realize these objectives and improve them over time. The emphasis is on simplicity and evolution. Measures that matter, nosocomial infections, and visit summaries can be simplified by the maxim: "quit killing people" by focusing on a few systemic issues.

Some correctly point out that goals like elimination of nosocomial infections will result in part from the CMS regulations that prohibit payment for complications.

One strategy is to try to minimize rules that don't help. An example is the requirement for tamper-resistant prescriptions that require special paper and run counter to the technology imperatives expressed by this same government.

Rather than focus on delivery organizations, one should want to identify the four or five top diseases and measure what is required across the continuum of care. Instead, we get the "where do I fit in?" syndrome where roles are emphasized over results (e.g. "measures for anatomic pathologists").

These notes do not express the opinions of the Markle Foundation and may not accurately reflect the ongoing debate and discussions, but hopefully provide yet additional emphasis on why this vital organization's agenda should be supported.

Two New e-Prescribing Reports

2008-06-12T13:24:00.003-05:00

The Summer of 2008 will not be a time of rest for the e-prescribing and medication management industry. As part of what may be only an initial new round of industry and organizational activity, two reports have been released within the past week.

The Center for Health Transformation has released a report entitled "Electronic Prescribing: Building, Deploying and Using E-prescribing to Save Lives and Save Money"
The eHealth Initiative and the Center for Improving Medication Management have released a report entitled "Electronic Prescribing: Becoming Mainstream Practice"

The CHT report provides an optimistic review with a highlight of many of the activities taking place across the country. The Southeast Michigan initiative, in particular, is worth note. The report emphasizes the value realized when medication management changes are implemented in a systematic and thoughtful way.

The eHI / CIMM report has a more thoughtful, cautionary tone.

The report identifies six issues that require additional work; none of these issues prohibits effective use, but each issue must be considered carefully as policy evolves:

Financial cost
Workflow change
Change management
Ban on transmitting prescriptions for controlled substances
Hardware and software selection
Pharmacy, payer/PBM, and mail order connectivity
Remaining standards require approval: prior authorization, structured and codified SIG, and RxNorm.
Unresolved challenges in medication reconciliation

The steering group also made five very important recommendations. Summarized, they are:

The federal government must address the DEA prohibition on e-prescribing of controlled substances.
Payers, employers, health plans, health systems, and federal and state governments should consider replicating and expanding successful incentive programs.
Care providers across every setting of health care should adopt and effectively use e-prescribing.
Create a public-private multi-stakeholder advisory body to monitor, assess, and make recommendations to accelerate the effective use of e-prescribing.
All stakeholders should advance the e-prescribing infrastructure.The federal government and the private sector should continue, and accelerate, the development of standards for e-prescribing.

These are good reports, well worth the read before the rhetoric increases to an even greater extent.

NPI: Challenges Remain

2008-06-02T12:09:00.003-05:00

In a May 29 Modern Healthcare Posting entitled "Claims processors see
rejections spike with NPI," Joseph Conn mentions the impact of NPI on claim rejection rates. Implemented around a holiday weekend, early "grim reports" suggest a massive increase in claims rejection rates. The lead paragraphs summarizes the posting:

"Healthcare industry claims processors and claims-flow watchers report at least fourfold increases in rejected Medicare claims, similar or even higher rejection rate spikes for Medicaid claims, and a doubling of rejection rates for claims processed by Blues plans on May 23, the first day a federally mandated National Provider Identifier was required."

A senior VP at Emdeon states “We’re seeing a rejection rate of 24%,” ......By Emdeon’s analysis, this individual reports, this represents "$25.8 million in claims that were turned down, which compares with an average rejection rate of 6% or $10.6 million before May 23." Medicaid rates published by Emdeon are similarly high. The rejection rate is 26% compared to a normal rate of 4%. Blue Cross claims however, saw less of a spike according to this authority, jumping from 3% to 6%.

For Medicaid claims processed by Emdeon, the rejection rate on May 23 was 26% compared with a normal rate of 4%; and for Blues claims, 6% were rejected that day compared with a norm of 3%. An industry trade group spokesperson mentioned a 42- physician practice group in which only 12 of the 42 physicians could submit claims without them being rejected. Another spokesperson mentioned a "state Medicaid official who said claims flow had fallen from a normal 100,000 a day to less than 20,000."

What does this mean for our preparedness for health IT? Time and again, there seems to be a disconnect between federal thinking and results on the ground. This disconnect seems to happen even even when the thinking is very sound and accepted by the majority of stakeholders.

What does this mean for e-prescribing? Presumably, problems with a mandate - even with plenty of lead time - might be of a similar magnitude. These possible problems should not deter our industry from pursuing these goals, but it should reinforce our commitment to ensure that transitions are effective. Rejected claims mean money and when money is to be had, people find solutions. Problems with e-prescribing may mean at least a temporary access to medications for those who take these medications to prevent far more serious illness.

These "frightening" reports on NPI should stimulate the medication management industry to ensure that authentication is reliable, authorization is valid, and that the entire process among prescriber/refiller, dispenser, and consumer runs smoothly. We can ill afford stories on e-prescribing similar to the NPI anecdotes provided by Modern Healthcare

The May, 2008 CBO Report: Evidence on the Costs and Benefits of Health Information Technology (Publication number 2976).

2008-05-29T09:11:00.006-05:00

The recently published report by the Congressional Budget Office summarizes well the dilemma faced by those who argue for adoption of health information technology based on formal analyses:

No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits. Some analysts believe that the adoption of such systems could provide substantial savings by lowering the cost of providing health care, eliminating unnecessary health care services (such as duplicate diagnostic tests), and improving the quality of care in ways that might reduce costs (by diminishing the likelihood of adverse drug events, for example). Other analysts expect little effect on costs but some improve-No aspect of health IT entails as much uncertainty as the magnitude of its potential benefits. Some analysts believe that the adoption of such systems could provide substantial savings by lowering the cost of providing health care, eliminating unnecessary health care services (such as duplicate diagnostic tests), and improving the quality of care in ways that might reduce costs (by diminishing the likelihood of adverse drug events, for example). Other analysts expect little effect on costs but some improvement in the quality of care. Another school of thought holds that health IT could bolster the quality of care but also increase expenditures on health care services— because improvements in quality would stimulate demand for additional services.

Rand
CBO's critique of the RAND report is in part due to the difference in mission. RAND more or less measures an idealistic potential outcome. CBO must focus on the likely outcome and the true impact of Congressional intervention. Take gravity as an example. RAND would claim that the impact of a falling rock will depend on mass, resistance, and gravitational pull. CBO would claim that little Congress can do will impact the mass, the velocity, or the resistance. (CBO would perhaps explore the cost of measures mandating attaching a parachute to the rock and the resulting effect on impact.)The RAND research focused primarily on savings that the use of health IT could generate by reducing costs in physicians’ practices and hospitals and hence had a different scope. RAND also ignored neutral or negative reports. CBO questions their rationale for doing this.

The RAND analysis itself notes that its estimate is of health IT’s potential savings and costs depends on an optimal - but perhaps not likely - state : "We use the word potential to mean ‘assuming that interconnected and interoperable EMR systems are adopted widely and used effectively.’ Thus, our estimates of potential savings are not predictions of what will happen but of what could happen with HIT and appropriate changes in health care.”

RAND assumed a constant rate of adoption. CBO would assume the increasing rate of adoption currently observed. Since CBO's savings estimates are based in part on the extent to which legislation encourages adoption, savings due to adoption alone will be exaggerated by the RAND report relative to the CBO report.

RAND assumes that internal hospital costs are reduced to an extent proportional to hospital stay. That is, if the length of stay is reduced by 10%, so will the costs. Although this may be true for fixed costs (beds, personnel) as currently measured, the variable costs are unlikely to change significantly since in many respects throughput efficiencies are realized by performing the same tests and providing the same intensity of services as would have been provided anyway. If a patient is improving, variable costs of care decrease closer to discharge. If the patient is failing and subject to increasingly intense interventions in a effort to save a life, variable costs can be expected to increase until either death or clinical improvement ensues.

Savings incurred by replacing paper medical records with electronic health records exhibit the same dependency on fixed and variable costs. If an organization is large, changes in variable costs can translate to lower labor costs. If an organization is small - a solo practice, for example - personnel costs are essentially fixed and financial benefits are only realized if volume is increased and revenues are therefore enhanced using the same labor pool.

One criticism of the RAND study seems questionable to this reviewer. Using a traditional microeconomic argument, CBO assumes that lower costs will lead to lower prices and, consistent with economic theory, lower prices mean higher demand. This demand would offset some savings. It would be welcome news to see this theory play out where prescription drug adherence is concerned. Many reports suggest that individuals do not take beneficial cholesterol-lowering or other disease-prevention drugs in part because of the relative costs of these drugs; in general, rather than taking such medications monthly for a sometimes indefinite period, individuals take such drugs intermittently or cease taking them after several months. Here, lowered prices through greater efficiency may lead to greater adherence programs - particularly if other means of reminding and encouraging patients can be identified. But translating this to broader interventions is perhaps questionable.

CITL

The CITL study limited its scope to savings from achieving full interoperability of health IT, explicitly excluding potential improvements in efficiency within practices and hospitals. It essentially measured the long-term (15 year) savings when migrating from a theoretical state of complete paper to an equally theoretical state of idealized comprehensive use; it compares the potential savings from a bygone era with a Nirvana which may never be realized.

CBO echoes criticisms already made on unrealistically high estimates for laboratory administrative expenditures. It made equally generous assumptions about high degree of redundant test elimination. CITL, for example, assumed virtually all telephone costs would be eliminated from e-prescribing transactions

General Methodology

CBO helpfully distinguishes between the dynamic of savings incurred "internally" from those that are "externalities". They state:

Internal savings are those that can be captured by the provider or hospital that purchases the system; they are most likely to be in the form of reductions in the cost of providing health care—that is, improvements in the efficiency with which providers and hospitals deliver care.
External savings are those that the provider or hospital that purchases the system cannot realize but that accrue to another such provider or perhaps the relevant health insurance plan or even the patient. Such savings might arise, for example, from the newfound ability of participants in the health care sector to exchange information more efficiently.

CBO points out the relative maturity of internal cost savings examples within highly integrated delivery systems like Kaiser but emphasize the relative immaturity of knowledge where more disparate settings are incurred. They recognize that where health information exchanges are concerned, it is early in the game. They state "estimating the impact of some potential sources of savings, especially those arising from greater exchange of information among providers, insurers, and patients, is especially difficult because health IT networks are in an early stage of development."

Yet CBO does mention the positive effects. Their argument is one of degree. Among the areas in which savings may be realized are:

Eliminating paper records. Savings are less if practices are small (i.e. high fixed personnel costs) or if systems are not used effectively.
Reducing transcription services
Avoidance of duplicate tests. Here the issues are those of actual availability of previous test results; awareness of the test results; and avoidance of revenues if providers have an incentive to repeat the tests. Most estimates of redundant tests are small. These may be larger if test results from a broader range of sites are available
Reduction of radiology services. CBO suggests that most evidence supports the actual type of test ordered but little in the way of test reduction. (Our experience in Memphis suggests that some high-cost tests are reduced using a regional exchange).
Prescription drug costs. Although CBO mentions lack of incentives, their most compelling argument is that because of "strong incentives," health plans and PBMs "may already be capturing a substantial portion of those savings."
Improved productivity. Most studies are restricted to isolate roles and not to overall system productivity. Demonstrations of productivity are more compelling in some hospital environments than in ambulatory environments. Transcription costs can be reduced significantly.
Reduction in hospital length of stay. CBO points out that slight reductions in length-of-stay are not commensurate with cost reductions. They also emphasize correctly that the current financial incentives for LOS reduction are sufficient to accelerate more effective adoption independent of legislative imperative. Adoption just makes good business sense.
Quality. The connection between quality and EHR use remains conjectural but presents many long-term opportunities. One cannot improve what one does not measure so the extent to which one measures the right thing affords promise. CBO discounts the potential savings primarily because they are conferred upon patients and intermediaries rather than those who make the initial investment.
Adverse drug events. CBO reviews the conflicting data on in-patient settings and the dearth of data on ambulatory settings. CBO recognizes that "avoiding even a fraction of the errors that now occur in inpatient and outpatient settings could yield significant savings" but claims that some of these errors may be addressed by current systems. One could argue, however, that although drug-drug interactions are common in pharmacy systems and there are multiple fail-safe mechanisms, comprehensive drug-disease, drug-allergy, and drug-lab interactions are in a relatively primitive state because of lack of standards (e.g., for allergies), lack of uniform clinical decision support mechanisms, and lack of widespread incorporation of these data in uniform ways.

Although lowering of administrative costs are mentioned in a systemic sense, CBO does not mention revenue cycle acceleration and coding accuracy - one of the principle drivers for some practitioners.

CBO brings into light the theoretical value of incorporating clinical decision support and evidence-practice into systems in a effort to improve quality on a systematic basis. Although results again are conflicting at this early stage, the potential seems intuitive.

The CBO report also emphasizes research and comparative effectiveness. The report states: "And some potential areas of research and analysis remain largely unexamined. They include the ways in which the delivery of health care services might change in response to the efficiencies that health IT offers and how the large amounts of clinical data available through EHRs could contribute to analyses of the comparative effectiveness and cost-effectiveness of different treatments." Similarly, public health reporting and disease surveillance are in their early stages; the potential is there but the jury is out.

Costs
CBO report also includes a good summary of costs incurred to incorporate health care technology into ambulatory practice. Total initial costs are said to range from $25 - $45 per physician; ongoing costs range from 12-20%. New subscription based systems may eliminate much of the up-front costs and lower annual operating costs. Smaller practices incur higher per practitioner costs. (Even ASP models will not lower the per-clinician training costs and the considerable practice transformation opportunity costs).

Explaining Low Rates of Adoption
The CBO Report poses many explanations. These include the significant investments in choosing and implementing systems, the lack of identifying measurable financial returns. Although the authors are skeptical of adoption based only on quality or revenue improvements, they suggest that physicians "might change their thinking if they knew that they would be directly compensated for implementing a health IT system or if they could report data on the quality of care that they provided—data for which they were being compensated— only by using such a system."

The CBO report mentions the "free rider" effect of support through intermediaries. Because technology should help practitioners provide care for al of their patients, once a technology is adopted, all intermediaries will benefit whether such intermediaries made an initial investment or not. Only uniform means of enforcing certain outcomes or performance measures would seem to provide an incentive for all intermediaries to participate. This degree of coordination should not be expected and may, in the eyes of some, be viewed as collusion."

CBO identifies two major roles played by the federal government. The first is as a payer; federal contributions to Medicare and Medicaid account for approximately 25% of the total American health car spend. The second role is as a market-maker. Health care may be a public good that cannot be optimally conferred without a federal-government that eliminates the "free-rider problem. Combined, federal roles provide a network effect that, properly managed, could create new opportunities for lower costs and higher clinical values. The returns - one could argue - are to society as a whole.

But the government is not neutral in all of this. By virtue of the CBO charge to examine the marginal benefit of federal intervention to accelerate a trend that is already underway, one has difficulty identifying those who really change their behavior on the basis of a federal incentive from those who would change their benefit anyway. If one wishes to subsidize motive rather than results, one must end with the treacherous logic that favors punishment over incentive. Indeed, the only way to make sure one is not providing a causative reward for uniquely good behavior is to avoid all rewards for good behavior and instead focus on punishing for undesired behavior. But this response is also flawed. One could argue that some who do not adopt technology do so for good reasons but all would be punished without respect to motive.

The CBO report provides an excellent summary of the current challenges in identifying the unique value of health information technology. Left with this conundrum, it is easy to fall into the trap of accelerating mandates and punitive schemes rather than accelerating the need to address the many unanswered questions raised by the current state of technology in health care. The CBO report plainly demonstrates that we do not yet understand how a federal effort can be ideally structured because we do not clearly understand the cause and effect of the various interventions. But the CBO does not refute an obvious conclusion: making this system work and moving from clearly confusing and possibly dangerous paper-based approaches is both essential and inevitable.

This is a report worth reading carefully. The CBO is to be congratulated for their public contribution.

In a talk delivered to the Markle Foundation Connecting for Health Steering Group on June 19, Dr. Blackford Middle noted the report gave a "reasonable review and summary of the literature on HIT value." Some CITL report aspects "were not represented well." These include:

A fundamentally different purpose for the report - the impact of funding
Value of un-standardized (level 3) vs standardized (level 4) interoperability
They failed to note how CITL accounted for the current HIT context; CBO factored in existing provider-payer data exchanges, and existing lab and pharmacy integration
CBO treated costs of providers information systems but inadequately treated the internal benefits; their notion of data exchange was relatively restricted.
CITL differed with CBO on lab administration costs; phone call rates - but these were not key determinants of overall value
CBO's critique did not discuss some of the limitations of HIEI model limiations. The CITL model was more expansive and included realizing savings through quality improvements and the potential clinical benefit.

Puerto Rico

2008-05-25T12:43:00.004-05:00

Because of the close contest between two Democratic presidential candidates, something unusual is happening. For a few brief days, the eyes of the Nation will be turned on the Commonwealth of Puerto Rico. To some, Puerto Rico is an ancestral home; to others, it is a tourist destination; to those who help forge policy, it is a potential laboratory for health care reform.

Among the diverse states and territories constituting the United States, Puerto Rico is unique. Puerto Rico was ceded from Spain to the United States through the Treaty of Paris in 1898; it has governed through a formal civilian structure since the passage of the Foraker Act in 1900. Since the passage in 1917of the Jones-Shafroth Act the United States Congress has characterized the Commonwealth as an “organized but unincorporated” territory of the United States. Under this Act, residents were granted U.S. citizenship by statute and since that time have served in the United States military service. This Act affirmed a primary responsibility of the United States in maintaining control over economic, defense, and other basic governmental affairs and reiterates the United States Congress’s authority to overrule actions taken by the Commonwealth Legislature.

In 1947, the U.S. Congress approved a law allowing the election of the governor by the people of Puerto Rico. On July 3, 1950, the U.S. Congress passed the Puerto Rican Federal Relations Act. This law gave Puerto Rico the right to establish a government and a constitution for the internal administration of the Puerto Rico government and “on matters of purely local concern.

In 1993 most of the government’s health care facilities and services were sold and their management turned over to non-government entities generally under managed care arrangements. This far more decentralized system radically changed the Department of Public Health’s influence and authority in provisioning care services.

Although the impact on efficiency and quality is controversial there is some consensus on the unintended consequences of these moves. As is the case in the 50 states, the health care delivery could benefit from less fragmentation; it would provide more good if organizations providing preventive services, health promotion, and health maintenance were better coordinated; its diverse regions and communities require a better fit of health care services; it needs a stronger infrastructure for monitoring quality, financing health care services, improving outcomes, and providing consumers with greater empowerment and choices. It is, in a nutshell, facing the same challenges as those of the 50 states and other territories - but one can argue that its situation is even more acute.

Puerto Rico’s ability to combine local and federal financing for health care programs is hobbled by its unique relationship with the Federal government. In contrast to “incorporated territories” that may petition for statehood, the “unincorporated territory” of Puerto Rico is not subject to the Constitution’s Tax Uniformity Clause on all Federal duties, imposts, and excise. Although Puerto Ricans do pay import/export taxes, commodity taxes, and payroll taxes (Medicare, Social Security) most are not required to pay Federal income tax.

Although Puerto Ricans do not pay federal income tax, few would have a significant tax burden: the median household income in Puerto Rico is only 34% of the U.S median household income (2000 census) and less than half of that of citizens in the State of Mississippi.

While many health indicators in Puerto Rico are more ominous even than those published for Mississippi, in 2006 the latter state received 78.6% in federal support for every Medicaid dollar spent (the FMAP or federal matching assistance percentage), while Federal spending caps first initiated in 1968 have limited Puerto Rico’s matching percentage to an effective rate of 18%.

The 50 states can receive up to 90% reimbursement through Medicaid for critical health information technologies; Puerto Rico is not eligible for these supplements. According to 2005 Congressional testimony by Governor Anibal Acevedo-Vila, had FMAP been allowed to operate without the cap instead of the 18% effective rate of the previous year, the Commonwealth would have received $1.7 billion dollars in federal Medicaid support instead of the $219 million received. Translated to monthly amounts, federal Medicaid support in the states approximated $330 per month per participant; the amount in Puerto Rico was about $20 per month.

Funding and health care status are only a part of the obstacles Puerto Rico faces. Its health care delivery system, health care resources, and health care financing mechanisms have been said to have been in a state of decline since the introduction of managed care programs in the early 1990s. The hospital beds per capita in the Commonwealth are less than 2/3 the average across the 50 states; salaries for health care professionals of all types are lower and emigration to the 50 states is common. As vital care resources emigrate from the Commonwealth, some believe that a growing number of Puerto Rican residents needing chronic or long-term care will emigrate as well, shifting the financial burden for care to these same states.

It is within this context of controversy, internal dispute, and at times acrimonious dialogue with the Congress and Federal Executive Branch that Puerto Rico must navigate a course to health care reform. The creation, financing, and administration of such reforms very much depends on the perception – in Washington, among the Congress, and within the Commonwealth – on the rights and responsibilities of all parties within this historically unique and volatile relationship.

Puerto Rico's voice - and their subsequent actions - may say a lot about how other parts of the Nation can address similar urgent health care financing and delivery concerns.

Readings: