National health spending rose a slight 3.9 percent in 2010, as Americans delayed hospital care, doctor’s visits and prescription drug purchases for the second year in a row, the Obama administration reported Monday.
The recession, which lasted from December 2007 to June 2009, reined in the growth of health spending as many people lost jobs, income and health insurance, the government said in a report, published in the journal Health Affairs.
There are a couple of takeaways from this news.
First, the reduction in spending on healthcare could mean a welcome, albeit temporary relief to those governments and organizations that pay for healthcare….BUT…no real relief for state and local agencies which provide/finance healthcare for poor people. Recessions, of course, result in greater numbers of people qualifying for government-supported care.
The other point is a reminder that some portion of healthcare services are discretionary. When healthcare spending was growing by 10 percent or more each year in the 1980s, that growth probably wasn’t driven by an increase in the need for services. Likewise the slower growth over the last several years is probably not due to the population getting healthier and needing fewer services. Instead, people moderated their demand for healthcare. They put off diagnostic tests, or did not follow through on treatments or prescriptions. Going in the other direction, hospitals routinely see increases in elective surgeries near the end of a calendar year, as people have already met insurance deductibles, and decide to seek care before those deductibles are reset in the new year.
Is this good news? Not necessarily. To the extent the people put off truly necessary tests and treatments, those delays may cost us more in the long run. To some extent, though, tough economic times force us to be more cautious about discretionary spending, and there may be very little impact on long run health status. There is the old saying that if you get a cold, it will take 7 days to go away, but if you see a doctor you’ll be cured in a week! One important element of effective healthcare reform is to introduce that sense of caution in our population. It is a delicate balance – not wanting to interfere with early testing and early, cost-effective treatment, but also discouraging care that has less impact on long term health.
Prices for medical care services and supplies also stayed roughly on par with general inflation during this last year, which is a change from the decades of the 1980s and 1990s where the medical care component of the consumer price index routinely outstripped regular price increases.
I wouldn’t have to polish my crystal ball very much to predict that spending increases for healthcare will pick up speed as the economy recovers. This remains the single most important issue in our nation’s federal deficit struggles.
When I went into solo practice of internal medicine in 1981, it was very easy to get a doctor to see a Medicare patient. All I had to do was make a phone call. A courteous receptionist answered. If the doctor couldn’t come to the phone right away, I could count on a prompt callback.
Consultants saw patients quickly, and generally called me to discuss their findings and advice. And very often there would also be a letter in the mail: “Thank you for referring this delightful patient to me.”
How things have changed! Now a doctor gets the phone menu, just as the patients do, and it often ends in voice mail. It might be a few days before a staff member calls back—usually with the news that “we are not accepting any new Medicare patients.” At best, my patient might be offered an appointment in several months.
One very fine gentleman, who had recently moved to a rural area, found it easier to fly to Tucson to see me than to get in to see a local internist. That was in 2009. Recently, he has become unable to travel, so I needed to find him a local doctor.
I tried to expedite matters by ordering him an immediate diagnostic test: an abdominal CT scan. I don’t think anyone could argue that it wasn’t indicated under the circumstances. One little problem: I am not enrolled in Medicare and don’t have the proper government-issued number to enter into the computer. A license to practice medicine is not enough. This National Provider Identifier (NPI) is supposed to protect the system against being defrauded. Without that number, the imaging facility could not get paid by Medicare.
“Why not use the radiologist’s number?” I asked. After all, he was the one who would get paid. Nope, a referral was required. How about a self-referral from the patient? Nope, we can’t allow patients to decide what tests they need. “The patient is willing to pay for his own test,” I said. Nope, if he’s on Medicare, they aren’t allowed to take his money.
They gave the patient 24 hours to find a properly enumerated doctor to countersign my order. Fortunately, he found a specialist willing to do so, and assume potential criminal liability for committing “waste, fraud, and abuse” by ordering a “medically unnecessary” study. (Fortunately for the patient, he turned out not to have cancer, but that could be bad news for the doctor.)
So this is the status of retired Americans. They can’t just walk into a facility and request a medical test, and pay for it with their very own money.
A man may be qualified to pilot a 747 across the Pacific, but once he’s on Medicare, he is unfit to make an unsupervised decision about his own medical care.
I did find my patient a doctor. None of the internists within a 150-mile radius who “take Medicare” are willing to take on a new Medicare patient. But through the website of the Association of American Physicians and Surgeons (www.aapsonline.org), I found a link to the Medicare carrier’s list of opted out physicians. They don’t “take Medicare,” but many are pleased to see older patients, for a reasonable fee. There was one internist on the list, 150 miles from my patient. She has a courteous and helpful assistant who actually answers the phone, and told me the charge for a new patient visit: $300.
Things could be worse—and already are much worse in Canada. The “soul-destroying search for a family doctor” is described in the Globe and Mail on Aug 21. The Ontario government’s program called Health Care Connect manages to link only 60 percent of patients with a doctor—although you might find a concierge doctor for $3,000 a year.
That’s the cost of medicine when it’s “free”—if you can find it at all. If ObamaCare is implemented, all Americans will be in the same boat. And guess who will get thrown overboard first.
Some new data out on Small Area Health Insurance Estimates from the census folks.
They have a tool there you can use to look this up yourself, but what I get is that for children (age 18 and under) in Pennsylania, Allegheny County is tied with Montgomery for the lowest percentage without health insurance at 3.9%. The highest: 10% in Lancaster County. Data is for 2009.
The United Kingdom, where, on average, people live longer than in the U.S., spends only about 9 percent of gross domestic product on medicine, compared with our 18 percent. The British control costs in part by having the will to empower a hard-nosed agency, the National Institute for Health and Clinical Excellence, to study treatments and declare some ineffective. Some hope the United States will create a similar agency, but I fear it would be hopelessly politicized and declawed.
My solution: admit we are cost-control wimps, and outsource our treatment evaluation to the U.K. Pass a simple law saying Medicare (and Medicaid) won’t cover treatments considered but not positively appraised by the Britain’s national health institute.
Even better, use clinical evidence evaluations of the British Medical Journal. They’ve classified more than 3,000 treatments as either unknown effectiveness (51 percent), beneficial (11 percent), likely to be beneficial (23 percent), trade-off between benefits and harms (7 percent), unlikely to be beneficial (5 percent) and likely to be ineffective or harmful (3 percent). Let’s at least stop paying for these last two categories of treatments! And to put pressure on doctors to collect evidence, let’s stop paying for “unknown effectiveness” treatments after 10 years of use.
Suppose you went into a grocery store, and found no prices on anything. You ask a clerk how much five pounds of potatoes would be, and he asks you whether you are 65 or older. Youre taken aback, but you tell him you are 64, and he asks whether your income is less than $40,000.00 a year. Startled, you say it is more than that, and then he asks whether you have food insurance. Why would the
price of potatoes depend on the buyers age, income, and insurance status, rather than on the cost of growing, transporting, and stocking the potatoes? That would be absurd.
Yet thats how it is with medical care. I would be unable to find out, for example, the cost of an echocardiogram from the hospital where I did my residency. The price is different for different people. The government instituted this ridiculous situation, in 1965, with Medicare and Medicaid. There is a lot of mythology about these programs, but few people understand them like the physicians who are on the front lines actually seeing the patients. For some of them, it has been a gravy train. They game the system. For others, it has been a disaster to go through medical school and residency, and come out a de facto servant to government programs, but of
course, without benefits or retirement. If you are scrupulously honest, these programs will bankrupt youeven while turning you into Public Enemy #1.
Senators Ron Wyden and Charles Grassley have put forth the Medicare Data Access for Transparency and Accountability Act (the DATA Act) to open a database so that everyone can see how much money Medicare has sent to any physician enrolled in it. Regardless of the cost to provide medical services, the price the taxpayers are forced by the government to pay for other peoples medical care has gone down and down per procedure, per diagnosis, per office visit.
The public wont see that, but it will hear about some isolated cases; for example, an Oregon neurosurgeon who allegedly performed multiple spine surgeries on the same patient, or a Florida physician accused of $3 million dollars in Medicare fraud.
Gaming the system is fraud. But the biggest fraud is the one perpetrated on the working people of this nation who are forced to pay for other peoples medical problems. When Medicare was first instituted, Americans were reassured that it would never cost the taxpayers more than $9 billion a year. It is more like $500 billion a year now.
Patients learn to game the system too. Workers must pay through their taxes for even the most trivial complaint when someone on Medicare makes an appointment for it; say for a cosmetic skin lesion that has been present for 30 years without causing any problem. Working people are also forced to pay for the consequences of other peoples smoking, excess drinking, or risky lifestyle choices. Thats fraud, perpetrated by the government on taxpayers. Its hidden behind political smoke and mirrors.
Amazingly, we managed somehow for 189 years after 1776 without Medicare and Medicaid, and things were getting better and better until Lyndon Johnson came up with a good fraudulent vote-buying scheme, and then a lot of people decided there was money to be made off medical problems with the taxpayers the losers.
So, Wyden and Grassley, open your database. But include a list of all the procedures and diagnoses, and what Medicare and Medicaid actually send the physicians as reimbursement so people can see that physicians who spent years of their life in training while incurring tremendous debtare paid about the same as auto mechanics. And also account for where the rest (about 80%) of the
$500 billion goes.
That would be a good start for medical price transparency. And a good precedent for another database, one detailing just how much value politicians give taxpayers who pay their salaries.
About the Author:
Dr. Tamzin Rosenwasser earned her MD from Washington University in St Louis. She is board-certified in Internal Medicine and Dermatology and has practiced Emergency Medicine and Dermatology. Dr. Rosenwasser served as President of the Association of American Physicians and Surgeons (AAPS) in 2007-2008 and is currently on the Board of Directors. She also serves as the chair of the Research Advisory Committee of the Newfoundland Club of America. As a life-long dog lover and trainer, she realizes that her dogs have better access to medical care and more medical privacy than she has, and her veterinarians are paid more than physicians in the United States for exactly the same types of surgery.
I find the sentiments in the quoted passage objectionable for two reasons. First, preventative health care is not ‘everyone’s business’. Individual adults have primary responsibility for their own preventative health care because no-one is better able to exercise that responsibility than they are. Individuals who are persuaded that preventative health care is a collective responsibility could be expected to look increasingly to the various levels of government, non-government organisations, health professionals and practitioners, communities and families – everyone except themselves – to accept responsibility for what they eat, drink and inhale.
Second, the goal of making Australia the healthiest country by 2020 is being put forward as though it is self-evidently desirable collective good that should be pursued by any and every means available to everyone. The goal is not self-evidently desirable. Individual health is not a collective good. And the end does not justify the means that are being proposed to pursue it.
If you delve behind the spin about making Australia the healthiest country by 2020, the underlying goal seems to be to raise average life expectancy in Australia to the highest level in the world by reducing the incidence of chronic disease. What does this entail? It would be hard to object to the goal of enabling individual Australians to reduce their risk of chronic disease. The problem is that the government’s strategy is more about achieving national goals than providing better opportunities for individuals – more about behaviour modification than about ‘enabling’ individuals to reduce their health risks.
The government claims that analysis of ‘the drivers of preventable chronic disease demonstrates that a small number of modifiable risk factors are responsible for the greatest share of the burden’. The behavioural risk factors led by obesity, tobacco and alcohol apparently account for nearly one-third of Australia’s total burden of disease and injury. The chronic conditions for which some of these factors are implicated include heart disease, stroke, kidney disease, arthritis, osteoporosis, lung cancer, colorectal cancer, depression and oral health problems.
Since these risk factors stem from individual lifestyles it is obviously desirable for individuals to be aware of them. There may be a role for governments in provision of this information. Perhaps governments should also be involved in helping people in various ways to live more healthy lifestyles. It is questionable how far governments should go down this path, but it is difficult to object to modest efforts by governments to improve opportunities for people to live healthier lifestyles.
However, rather than helping people to help themselves the federal government has chosen the path of Skinnerian behaviour modification. It has chosen to drive changes in behaviour through what it describes as the ‘world’s strongest tobacco crackdown’. (This is one instance when I hope the government doesn’t actually mean what it says – some people in Bhutan have apparently been jailed recently for possession of more than small amounts of tobacco products.) The government’s strategy also involves ‘changing the culture of binge drinking’ and ‘tackling obesity’, but in this post I will focus on smoking.
Some of the tactics being used in the tobacco crackdown involve information and persuasion but there is also an element of punishment involved. The tobacco excise has been increased to over $10 for a packet of 30 cigarettes and legislation is proposed to require cigarettes to be sold in plain packaging. It seems to me that this amounts to persecution of smokers and their families. It will reduce the amount of household budgets available to be spent on other products and encourage some to avoid excise by obtaining tobacco from illegal sources.
As a former smoker, I am probably more strongly against smoking than most people who have never smoked. I encourage other people to quit smoking and discourage young people from taking up the habit. But having given up smoking several times, I know how hard this can be. Governments have no basis on which to judge that people are not in their right mind if they consider that the pleasures they might obtain from additional years of life are not worth the pain of giving up smoking.
In my view this question of whether smokers are capable of judging what is in their own best interests is at the crux of the matter. The politicians and bureaucrats who seek to modify the behaviour of smokers may see themselves as enhancing the capability of these people to have lives that they ‘have reason to value’, in accordance with well-being criteria proposed by Amartya Sen. If so, their attitudes highlight a major problem with Sen’s approach. Governments have no business deciding what kinds of lives individuals have reason to value.
Enrolling into a drug rehab program can be the hardest thing to do but it can save a life.
The government might as well argue that, since handicapped people can crawl on all fours or ask for help from strangers, there's no need to make buildings wheelchair accessible, the court said.Justice delayed is justice denied; get to stepping, Mr. Snow!
Three fiscal quarters into my new role at work I am pleasantly surprised to discover that CDHPs have quietly evolved from a disingenuous cost-sharing scheme foisted on workers by employers (see the Pollyannaish video, below) to a proactive, multifaceted approach intended to achieve “a pluralistic system that empowers patients and demands accountability from individuals and the health system, while adequately supporting the needs of the disadvantaged.”
Moreover, the criteria for determining whether or not these lofty goals are met are both simple and progressive:
Granted, the above is only Wye River Group’s take on the matter, but given that it comes directly from their An Employers’ Guide to Healthcare Consumerism which was published in 2006 I am inclined to take them at their word and note this as a sea change in suppliers’ attitudes towards the healthcare crisis in this country.
What Wye River Group refers to as healthcare consumerism is a synthesis of old and new ideas as well as delivery and payment models in the healthcare market. It encompasses consumer-driven health plans, value-based benefit design techniques, and good old-fashioned managed care (as opposed to managed access and/or managed costs).
Despite its name, healthcare consumerism isn’t mutually exclusive of government involvement. Indeed, the techniques it espouses could go a long way towards making the already superior healthcare model in place for US military veterans that much more cost-effective and efficient – not to mention portable to state and local governments and private industry.
There are few people as skeptical of for-profit payers as I am, but in light of this evolution of thought in the consumer-driven healthcare space I am open to – and hopeful at the prospect of being – proven wrong.
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It ain't so.
Every first-year high school debate student learns about fallacious arguments. It's a requirement and something you had better learn well unless you want your argument to fail, your proposal to lose, and what little social standing there is to be had from membership on the debate team to be negated by having your ass publicly handed to you by an even bigger geek at a public (albeit most likely unattended) public event.
I speak from experience here.
As the saying goes, things change.
In our modern era of corporate media, where a powerful and wealthy few dictate what constitutes both entertainment and news, as well as their bastard offspring - infotainment, the validity and coherence of one's argument doesn't matter; volume does.
Volume can be measured in decibels (talk radio), eyeballs (Drudge Report), Nielsen Ratings (Fox News, Desperate Housewives), circulation (The National Enquirer), or some combination thereof. Health Care News apparently knows how to pump-up the volume: according to their masthead they reach 53% of all healthcare professionals.
I know that healthcare is a business, and that even the most selfless non-profit organization has to figure the bottom line into the equation somewhere, but it is my sincere hope that when most healthcare professionals and the organizations they work for need to get a feel for the pulse of the nation on important questions of the day, they'll keep in mind that Charmin is a better quality paper than The Heartland Institute's propaganda organ is.
Why am I being so hard on Health Care News? For starters, they have a widget on their site that is a consistent part of their navigational structure that declares Crichton is Right! This is a reference to science fiction author and 2006 American Association of Petroleum Geologists Journalism Award-winner Michael Crichton, whose novel State of Fear denies the science of the greenhouse effect and slanders The New Republic Senior Editor Michael Crowley.
With both John McCain and Barack Obama in favor of joining some version of the Kyoto Protocols and enacting some sort of carbon cap-and-trade system, this ranks The Heartland Institute right up there with holocaust deniers and The Flat Earth Society in my book.
Is this unfair of me? Am I painting with an overly broad brush? Am I resorting to unjustified Ad Hominem attacks and throwing the baby out with the bathwater just because I think Michael Crichton is a despicable human being and corporate drama whore who is trading on name recognition in lieu of long-since-gone talent?
I don't think so.
Here's a critique of their three-article, red-letter Single-Payer expose'.
Better yet, read the original articles independently of my critiques, and decide for yourself.
Meanwhile, I will be tackling all three of Health Care News' extremely fallacious and biased articles one-at-a-time over three posts. First up:
This article attempts to paint a picture of what universal healthcare in the United States will look like by describing in lurid detail what's going on at the bottom of the barrel in Russia's healthcare system.
For this article alone, the fallacies include:
Many state-run hospitals, particularly in remote areas, do not have hot water, and some do not have running water at all. Even the most basic medicines are often in limited supply.This is an attempt to form a Post Hoc fallacious argument. It fails in this regard, however. Awful Facilities actually Confuses Causes and Effect - the Russian Federation is the successor to the collapsed Soviet Union and the product of more than a decade of economic decline before its recent economic stabilization. Consequently, it's healthcare infrastructure isn't a shambles because the country's national, single-payer healthcare model is a failure; the country's national, single-payer healthcare model is a failure because the country's healthcare infrastructure is a shambles!
Healthcare is far too important to leave to politicians - be the autocrats or Democrats [sic]," said John R. Graham, director of health care studies at the Pacific Research Institute.Did you spot the Ad Hominem fallacy? It's tricky because it's also an example of Guilt by Association. In the above statement, the poor state of the Russian healthcare system is the fault of the autocrats, who are synonymous with Democrats! Since all Democrats are autocrats, and autocrats can't be trusted to administer healthcare, then obviously neither can the Democrats.
"The Russian 'free healthcare for all' system is nothing of the sort," said Jeff Emanuel, research fellow for healthcare policy at The Heartland Institute and managing editor of health Care News. "Instead, it is simply another program built on governmental taking of taxpayer fund and mismanagement of the services it promises to provide."You see, in the neoconservative fantasy land that Jeff Emanuel lives in, any single failed government program from any government anywhere is proof that all government programs from all governments everywhere will fail! And be sure to take a good look at just who Jeff Emanuel is: the editor of the very publication the article appears in! While this isn't a logical fallacy, it certainly makes him a less than objective - and therefore credible - subject matter expert for this particular piece.
Despite the fact that there is currently no legislation before Congress to institute a national, single-payer healthcare system, nor a presidential candidate from either party intending to introduce one (a Factual Error), even if universal coverage and a national, single-payer system were the same thing (which they are not), citing only Russia as a representative example of such a system is not only a Biased Sample fallacy, it also grossly distorts the success of the many other national, single-payer healthcare plans of every other industrialized country, all of whose citizens enjoy a comparable or superior degree of health and wellness than the average American does from healthcare systems that universally consume fewer resources and produce comparable or superior outcomes to our own.
(It is also insulting to the intelligence of anyone who has been paying attention since 1991 and knows that for all of our problems, the United States and the keystone republic of the former U.S.S.R. have about as much in common as William McGuire and Mother Theresa when it comes to infrastructure and other assets to bring to bear on their respective national healthcare concerns!)
In fact, according to the CIA World Factbook, as of 2007, per capita GDP in the Russian Federation was $14,600 - less than .33% (one-third) of per capital GDP in the United States of American ($46,000) during the same period!
Despite the enormous differences between the two counties, the average life expectancy at birth for all Russians is 84.5% that of their American counterparts, a difference of only 15.5%. Based on these numbers, if the United States were to adopt the horrific Russian healthcare system in its current form in its entirety tomorrow, but maintain current U.S. healthcare spending levels, median life expectancy at birth for all Americans would exceed 129 years!
|Life Expectancy at Birth||Russian Federation||United States of America|
Now, I know that this is a Misleadingly Vivid example, but then again so is Health Care News' representation of the Russian healthcare system as a legitimate cautionary tale for healthcare reformers in the United States looking to implement some form of universal coverage or otherwise assure care is made available to nearly 50 million of their fellow uninsured citizens.As I pointed-out above, Rina Shah bases her entire article on a Factual Error when she presents the situation in Russia as an example of a failed universal healthcare system. However , Russia's implementation of universal healthcare is a national, single-payer universal healthcare system; there are no proposals for implementing such a system in the United States from either political party or presidential candidate.
Research conducted by Moscow's INDEM think tank in 2004 showed Russians spent some $600 million each year on under-the-counter payments to health care providers. The Russian Academy of Sciences' Open Health Institute more recently estimated rampant corruption siphons off as much as 35 percent of the money spent on health care nationwide annually.Do you see the Strawman here? The figures presented above only proves that Russia's healthcare market is inadequately policed; it doesn't prove that universal or single-payer healthcare systems are inherently corrupt or result in substandard wages for healthcare professionals. The average pay of Russian healthcare professionals is also something a Red Herring: compensation of individual healthcare practitioners is not an indicator of the likelihood of an overall healthcare market's ability to function efficiently, as the performance of healthcare markets from Canada to Cuba clearly show.
Low wages are another problem. Yearly salaries of physicians average $5,160 to $6,120, while nurses average $2,760 to $3,780. This often results in underpaid physicians accepting bribes for higher-quality care.
Reforms drafted this spring by the Russian Federal Assembly include placing higher emphasis on primary care, shutting down numerous substandard hospitals, scaling down the scope of free medical assistance guaranteed by the state, and increasing physician salaries by reimbursing doctors according to the number of individual treatments given instead of by the number of hours worked.Do you see what's going on here? The reforms proposed by the Russian government are never addressed. Instead, they are summarily dismissed.
"Instead of forcing people to pay into this failed program, Russia's government should allow the market to influence the health care system, which it can begin to do by allowing its citizens to choose how their own health care money is spent," Emanuel said.
So-called "universal" health care does not actually exist, says Graham.
"At best, in a functioning democracy like Canada or Britain, it results in unequal access to health care by government rationing, lack of investment in innovation, and shortage of medical professionals," Graham pointed out. "At worst, in a country with little democratic bona fides, it results in the situation we are seeing in Russia."The author has taken great pains to paint an unfavorable, ugly, and frankly prurient (from a healthcare policy perspective) picture of Russia's national, single-payer healthcare system. Having savaged the concept generally (i.e.: Poisoned the Well), Rina Shah sees no reason to bother backing up the claims made in the concluding paragraph about the failings of universal healthcare systems in functional democracies, which are better and more realistic models for potential universal healthcare solutions in the United States. Which was clearly her intention all along.
I was convinced that Milt Freudenheim's glowing, uncritical puff-piece about Epic in the NYT would not provoke any critical blow-back (see: Digitizing Health Records, Before It Was Cool). I was certainly not expecting any criticism from hospital CIOs and CEOs who are anxious to stay within the good graces of the company and are contractually constrained from any visceral outbursts. However, Vince Kuraitis, who blogs over at e-CareManagement, has informed me via a comment that there is a heated discussion going on at Google+ about the NYT article and Epic in general. You may also want to refer to my recent blog note about Epic (non)-interoperability (see: A Reader Comments on Epic Interoperability and Care Everywhere). Here is Vince's comment:
FYI, there is heated discussion going on about Epic (non)-interoperability on Brian Ahier's Google+ post.
Here are five snippets from the ongoing Google+ dialogue selected on a semi-random basis:
I guess the sad thing about American health IT is that this -- so far -- is the best we got (Matthew Holt)
OMG! All of this anger can't be healthy. However, don't expect much to change in the real EMR/EHR world as a result of this discussion. Link to Google+ if you want to read more in this thread.
One more thing. Has the NYT totally lost its way amidst the Epic adulatory mist? Here's what I think happened. Judith Faulkner NEVER gives interviews to the press. I suspect that Milt Freudenheim was advised by his editors to pitch only softballs to her in exchange for this exclusive audience. I know that the paper maintains that it never cuts such deals but why don't you read the article and judge for yourself. There must be some teeny, weeny problems somewhere in Verona that Milt could have uncovered.
In response to a recent note about Epic's Care Everywhere (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere), a reader (Open Standards) posted a comment which I thought was instructive and worthy of promotion to the level of a note. I present it below in its entirety:
Per the Epic technical manual, Epic's Care Everywhere is [described in] the following [way]: 1. For Epic institutions, it is an XML file containing Epic proprietary extenstions to the continuity of care document. 2. For non-Epic institutions, it is an XML file containing the standard continuity of care document. Both of the above are variations of the same theme: the CCD document, an XML marked up document with the demographic, medication, medical history, and most recent encounter data abstracted from the EMR.
There is nothing particularly innovative about Epic's Care Everywhere. In fact, it is a Mearningful Use requirement for any EMR vendor to have CCD export capability. In this regard, all the 400+ MU certified EMRs in the U.S. have this functionality. A CCD document is vastly different than an HIE, which is an independent server that acts as a translation broker. The whole point of the CCD is to enable point-to-point transfer of a common standard machine readable summary of the patients data as a handoff document between any and all EMR.
In this regard, EpicCare specifically breaks the standard CCD form, and makes it incompatible with the rest of the 400+ EMRs in the USA by adding their proprietary extensions. This is consistent with Epic's proprietary, one-vendor-shop, non-interoperability stance. The statement that "any hospital can interoperate with Epic's Care Everywhere - just so long as they are an Epic institution" aptly summarizes this. Again, the proprietary extension to the CCD by Epic means that the 400+ certified EMR's in the USA won't interoperate with Epic's EMR, because these 400+ EMRs adhere to the government mandated open standard CCD XML form and Epic doesn't.
I would appreciate any further comments if this comment is erroneous or misleading in any way. On this basis, it would not be correct to describe Epic's Care Anywhere as a type of HIE. The name of the product is misleading but that nothing new in the software industry. It seems to be a proprietary version of CCD export capability -- a continuation of the Epic's "walled garden" software model.
There are a number of factors contributing to the financial pressures being placed on community physicians. One of the most significant is that the federal government, the most important payer of medical costs, tends to favor inpatient and ambulatory care delivered by hospitals. A recent story provided the details (see: Doctors going broke). Below is an excerpt from it
Doctors in America are harboring an embarrassing secret: Many of them are going broke. This quiet reality, which is spreading nationwide, is claiming a wide range of casualties, including family physicians, cardiologists and oncologists. Industry watchers say the trend is worrisome. Half of all doctors in the nation operate a private practice...."A lot of independent practices are starting to see serious financial issues," said [ a consultant to physician practices]. Doctors list shrinking insurance reimbursements, changing regulations, rising business and drug costs among the factors preventing them from keeping their practices afloat. But some experts counter that doctors' lack of business acumen is also to blame....[A cardiologist] said recent steep 35% to 40% cuts in Medicare reimbursements for key cardiovascular services, such as stress tests and echocardiograms, have taken a substantial toll on revenue. "Our total revenue was down about 9% last year compared to 2010," he said. "These cuts have destabilized private cardiology practices," he said. "A third of our patients are on Medicare. So these Medicare cuts are by far the biggest factor. Private insurers follow Medicare rates. So those reimbursements are going down as well."....Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.Changes in drug reimbursements have hurt [oncologists] badly. Until the mid-2000's, drugs sales were big profit generators for oncologists. In oncology, doctors were allowed to profit from drug sales. So doctors would buy expensive cancer drugs at bulk prices from drugmakers and then sell them at much higher prices to their patients. "I grew up in that system. I was spending $1.5 million a month on buying treatment drugs," [an oncologist] said. In 2005, Medicare revised the reimbursement guidelines for cancer drugs, which effectively made reimbursements for many expensive cancer drugs fall to less than the actual cost of the drugs.
There is no question that cutbacks in Medicare and Medicaid reimbursement are hurting many physicians in private practice. However, I also agree with the statement above that part of the problem is many doctor's "lack of business acumen." When times are flush and reimbursement is at a high level, faulty business practices can be glossed over. The same rule does not apply to current conditions. It's easy to manage a business on the way up and hard to manage one of the way down. Physicians spend many years in training but spend almost no time learning how to run a business.
I have posted a number of notes about the so-called oncology concession whereby oncologists purchase expensive cancer drugs at a wholesale price to treat their patients and then mark up the prices when they are administered (see: Academic Oncology and the "Chemotherapy Concession"; The Oncology Concession Under Attack by Health Insurance Companies). I have been told that it's easier to manage the expensive, limited-shelf-life chemothrapy inventory in academic oncology infusion centers with a large number of patients than in smaller private practices. Large cancer hospitals also benefit from the discounted volume purchases of such drugs.
The bottom line is that movement toward Big Medicine (Big Health Systems, Big Payers, and Big Pharma) persists unabated (see: Health Insurance Company to Purchase Troubled Pittsburgh Health System; Hospitals Use Their Medical Schools, Residencies for Later Physician Recruitment).
I’d been meaning to do a post about Emdeon‘s EHR lite ...since I first heard about it at MGMA. While I think that EHR Lite might be some good branding, I’m not sure you can really classify Emdeon’s EHR as lite. I’m sure they’re just trying to differentiate themselves from the 300+ EHR companies out there....I think I found the thing that most differentiates Emdeon from many other EMR companies. it’s their network. Here’s a summary they sent me of their network. Emdeon’s network encompasses:
....I strongly believe that healthcare will be a very heterogeneous environment. ...EHR software is still going to have to connect with hospitals, pharmacies, labs, payers, government entities etc. An EHR is going to be key to integrating with these other heterogeneous software as I do believe the EHR will be the “Operating System of Healthcare.” Today a silo’d version of an EHR is not an issue at all. However, the writing on the tea leaves that I read is that healthcare providers that have a well connected EHR are going to be at an advantage. We’ll see if Emdeon can use their current connections as an advantage in this way.
It's quite clear that hospitals need to be interconnected via multiple networks for the exchange of both clinical and financial information. Whether or not the leading EMR companies will move in this direction and function more as as "operating systems" is another story. Epic, for example, might appear to function as an HIE with its Care Everywhere module (see: Sharing Medical Records across Hospitals with Epic's Care Everywhere). However and given that this interconnectivity is provided only to Epic clients, the software would be better called Care with Epic Clients.
In my opinion, Epic has little interest in mobilizing healthcare information electronically across hospitals within a region that are not its clients. The company is all about domination of the higher end of the hospital market and modules like Care Everywhere have been developed to provide additional client functionality and not to serve as a HIE utility across all hospitals in a region (see: A Fresh Look at Epic from a Financial and Strategic Perspective). Epic's business model can be described as a "walled garden" whereas, I think, Cerner is envisioning the development of an interconnected community with its Winona project as one prime example (see: A Different Paradigm for Analyzing the Competition between Cerner and Epic; The Winona Project: Is This a RHIO Success Story?; Cerner's Winona Health Project Featured on the PBS News Hour).
I have posted notes before about the need for a national, agnostic lab network (see: Interpreting the Tea Leaves: Ten Hot Trends in Healthcare, Lab Medicine, and Pathology Informatics; Predicted Migration of "Some" LIS Functionality from Pathology to Central IT). For the labs, a national network is useful for the exchange of lab data but also as a means to access expertise and talent which may be lacking or insufficient locally. Community hospitals labs, and even academic departments, have always turned to regional and national reference labs to provide esoteric testing services that they can't supply. Any lab or hospital national network needs to be agnostic in the sense that it's open to a variety of companies and service providers. Such an approach stimulates competition on the basis of quality and price and is the antithesis of the walled-garden, vertically-integrated approach which is all about domination of the market by a single company (see: iPhones, Physicians, and the Dilemma of the "Walled Garden").
Cleveland Clinic established a ban on hiring smokers more than two years ago and similar policies are now spreading to other hospitals (see: Want a Job at the Cleveland Clinic?: Smokers Need Not Apply; Tobacco-Free Hiring Takes Hold; Both Smoking and Smokers Excluded; The Financial Stakes Escalate for Employees Who Smoke). Geisinger Health System has now introduced a similar policy (see: Hospital Quits Hiring Smokers, Introduces Nicotine Tests For Medical Workers). Below is an excerpt from the story
Smokers in the medical field now have another reason to quit as a Pennsylvania hospital has said it will no longer hire smokers and is introducing nicotine tests in order to enforce the rule....Those exposed to second hand smoke will be exempt from the test, which screens applicants for cigarettes, smokeless tobacco, snuff, nicotine patches, nicotine gum and cigars. For those who fail the test, the hospital says applicants can reapply after six months....According to CNN, Pennsylvania is among 19 states that allow employers to screen job applicants for signs of smoking. While there's certainly an incentive to keep employees healthy for work, the economic benefit of having non-smokers on the payroll is also notable. The U.S. Centers for Disease Control and Prevention (CDC) puts a $3,391 price tag on each employee who smokes: $1,760 in lost productivity and $1,623 in excess medical expenditures.
A few interesting points are brought out in this article relating to the exclusion of smokers as new hospital hires. A twist that was new to me in the article is that a prospective employee can claim an exemption from the hiring ban on the basis of second-hand smoke. I assume that the applicant would show a weakly positive lab test that could be explained by a smoker in his or her household or even in a car pool. I believe that the preferred test for a history of smoking continues to be cotinine (see: Saliva and Urine Tests for Smoking). Secondly and in the article, it seems that there needs to be enabling state laws in place to enable a hospital to pursue a smoking restriction; 19 states currently have such laws in place. I suspect that most of the states that have not yet fallen in line with such legislation will do so shortly. Smokers are becoming an endangered species.
Lastly, there is data presented at the end of the excerpt above that place a cost to employers for employees who smoke, providing convincing financial evidence for the soundness of a "no smokers, no smoking" policy for hospitals. It seems to me that there are three health system that usually take the lead regarding innovative clinical and organizational policies: Cleveland Clinic, Geisinger, and Kaiser. You can now expect many other hospitals, initially in the 19 states, to launch similar policies.
Hepatocellular cancer (HCC) is a common neoplasm in Asian countries because of the high incidence of hepatitis infection. Here are the three most common risk factors for (HCC): (1) alcoholism; (2) hepatitis B; (3) hepatitis C that causes 25% of causes globally (see: Hepatocellular carcinoma). Although HCC has been relatively rare in the U.S., the incidence is now rising quickly (see: Mayo Clinic Studies Identify Risk Factors In Rising Trend Of Liver Cancer). Here's more details from a recent article:
Doctors have known for years that the incidence of deadly liver cancer is on the rise, but what is causing that trend has remained a mystery. Two recent studies...offer a clearer picture of the rise of hepatocellular carcinoma (HCC), or liver cancer, which has tripled in the U.S. in the last three decades and has a 10 to 12 percent five-year survival rate when detected in later stages....[One] study found the overall incidence of HCC in the population (6.9 per 100,000) is higher than has been estimated for the nation based on data from the National Cancer Institute ....The study also found that HCC, which two decades ago tended to be caused by liver-scarring diseases such as cirrhosis from alcohol consumption, is now occurring as a consequence of hepatitis C infection. "The liver scarring from hepatitis C can take 20 to 30 years to develop into cancer," [one study author said]. "We're now seeing cancer patients in their 50s and 60s who contracted hepatitis C 30 years ago and didn't even know they were infected. " Eleven percent of cases were linked to obesity, in particular fatty liver disease. "It's a small percentage of cases overall," [the study author said]. "But with the nationwide obesity epidemic, we believe the rates of liver cancer may dramatically increase in the foreseeable future." Another study looked exclusively at the Somali population, which is growing in the U.S., particularly in Minnesota, where as many as 50,000 Somalis have settled in the last two decades. The East African country is known to have a high prevalence of hepatitis B, a risk factor for HCC. Researchers investigating records in the Mayo Clinic Life Sciences System confirmed that hepatitis B remains a risk factor, but they were surprised to find that a significant percentage of liver cancer cases in the population are attributable to hepatitis C, which had not been known to be significantly prevalent.
What I took away from this article is that the incidence of HCC is rising precipitously due to chronic hepatitis B and C infections in our native-born population, immigrants coming to this country carrying the two viruses, alcoholism, and obesity. It's a "perfect storm." Here's some more information about the relationship between obesity, diabetes, and HCC (see: Obesity and hepatocellular carcinoma):
Both obesity and diabetes are frequently associated with nonalcoholic fatty liver disease, and case reports have shown progression of nonalcoholic fatty liver disease to cirrhosis and hepatocellular carcinoma. Although no study has clearly tied all of these variables together, it is likely that the association of hepatocellular carcinoma with obesity represents the progression of underlying nonalcoholic fatty liver disease to cirrhosis. The mechanism most likely involves replicative senescence of steatotic mature hepatocytes and compensatory hyperplasia of progenitor (oval) cells as a reaction to chronic injury due to ongoing nonalcoholic steatohepatitis and resultant hepatic fibrosis.