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Monday, November 30, 2009

Don't count on information technology to finance health care reform

“Predictions of cost-savings and effciency improvements from the widespread adoption of [health information technology] are premature at best,” says David Himmelstein, MD, lead author of a new study in the American Journal of Medicine (login required), which concludes that increased computerization in U.S. hospitals hasn’t saved money or improved efficiency. Himmelstein is associate professor at Harvard Medical School and former director of clinical computing at Cambridge Hospital in Massachusetts.

The study analyzed data from approximately 4,000 hospitals for the years 2003 to 2007. The data came from the Healthcare Information and Management Systems Society (HIMSS) Analytics annual survey of hospital computerization; Medicare cost reports that hospitals submit annually to the Centers for Medicare & Medicaid Services (CMS); and the 2008 Dartmouth Health Atlas.

Although the researchers found that U.S. hospitals increased their computerization between 2003 and 2007, they found no indication that health IT lowered costs or streamlined administration, even in the "most wired" institutions.

Wednesday, November 18, 2009

China questions costs of U.S. health care reform

An interesting read from Reuters Blogs:

"It turns out the Chinese [America's largest creditor] are kind of curious about how President Barack Obama’s health care reform plans would impact America’s huge fiscal deficit. Government officials are using his Asian trip as an opportunity to ask the White House questions. Detailed questions. ..."

"Nothing happening in Washington today should give Beijing any comfort or confidence about what may happen tomorrow. Health care reform was originally promoted as a way to 'bend the curve' on escalating entitlement costs, the major part of which is financing Medicare and Medicaid. That is looking more and more like an overpromised deliverable."

A new study from the Centers for Medicare & Medicaid Services estimates that the health care reform bill recently passed by the House of Representatives would increase health care spending to 21.3 percent of GDP by 2019 and would cost $1 trillion from 2013-2019.

Friday, November 13, 2009

How to fix health care in one fell swoop

The House and Senate have drafted literally thousands of pages of legislation aimed at fixing the U.S. health care system, but the single most important reform according to renowned researcher Barbara Starfield, MD, is "to devolve unnecessary services provided by specialists back to primary care. This would, in one mechanism, reduce costs of care and improve quality of care."

(Note to skeptics: She has hundreds of research articles to back it up.)

In a recent editorial in FPM, Starfield warned the family medicine community not to waste this opportunity for meaningful reform by embracing proposals that do little to further the essentials of good primary care, which she describes as:

• "First contact care, which requires accessibility and responsibility for reducing unnecessary specialist care."

• "Person-focused care over time delivered by the patient's chosen physician, who assumes responsibility over long periods for all health care."

• "Comprehensiveness of care."

"Coordination of care when people have to go elsewhere for problems outside the competence of the primary care practitioner."

Thursday, November 5, 2009

Will accountable care swallow up primary care?

If you've heard something about "accountable care organizations" (ACOs) in discussions of health care reforms, but you're not quite sure what they are or where they're supposed to fit in, you might find this "Perspective" piece from the New England Journal of Medicine useful. In short compass it defines the term and relates it to the other biggie in health care redesign, the patient-centered medical home (PCMH).

To get the definition out of the way, "an ACO is a provider-led organization whose mission is to manage the full continuum of care and be accountable for the overall costs and quality of care for a defined population." (Harks back to the day when managed care wore a white hat, doesn't it?) While the PCMH has been much discussed in family medicine over the past five years, at least, the term ACO seems to have emerged only recently.

The NEJM article makes the point that the PCMH and the ACO are, or can and should be, complementary: The PCMH is a model for redesigned primary care, and the ACO is a model for ensuring that the rest of the delivery system works in concert with the PCMH by aligning incentives for the rest of the system with those of primary care.

Sounds neat, doesn't it? The ACO is a way to get referral specialists, hospitals and all the rest to see things our way. Except ...

As the NEJM article puts it, "The fact that the ACO model does not explicitly require support for primary care has led to considerable concern that ACOs dominated by hospitals or specialists would not adequately invest in primary care – or that hospitals and specialists would garner a disproportionate share of any savings." The ACO may be a "provider-led organization," but the providers leading it may well be hospitals, large multispecialty groups or other entities who have not so far proved to be far seeing or even to understand primary care. The NEJM article lists three requirements for successful integration of PCMHs into ACOs:

  • Alignment of accreditation and certification criteria for the two organizations: "No ACO accreditation or certification process has yet been developed, but when one is, it will be critical to include criteria that ensure sufficient primary care capacity for the patient population and to closely align the standards with those of PCMH recognition."
  • A common set of primary care performance measures: "Performance measurement for determining the amount of shared savings or other financial incentives for ACOs must weight primary care measures heavily rather than focus narrowly on metrics related to hospital care."
  • Wise alignment of incentives: "The payment mechanisms used must align the incentives of the two models to increase accountability for total costs across the continuum of care while ensuring that a sufficient investment is made in primary care capacity."

So all we need to do to achieve a health care delivery system we can be proud of is redesign primary care, redesign the rest of care, avoid the mistakes we've made chronically in past attempts to fix the system, develop system-wide performance measures with a primary care orientation and, oh yes, shift the center of power of the system from secondary and tertiary care to primary care. I hope we're up to the challenge.

Wednesday, November 4, 2009

Red Flags rule deadline delayed

The Federal Trade Commission (FTC) announced Friday that it is delaying the enforcement of the Red Flags Rule until June 1, 2010. The previous deadline was Nov. 1, 2009, which was pushed back from the original Aug. 1, 2009, deadline.

The AMA plans to use this extra time to persuade Congress and the FTC that physician practices should not be subject to the rule:

 "The AMA will utilize this time to convince the FTC and Congress to republish the rule so that there is sufficient opportunity to formally comment and state the AMA's objections to physician inclusion in the program."

If that effort succeeds, physicians everywhere will wave a flag of victory.

Tuesday, November 3, 2009

A detour on the way to the medical home

Last week the Centers for Medicare & Medicaid Services (CMS) published an update on the long-delayed Medicare Medical Home Demonstration. The September announcement from the Department of Health and Human Services of a Multi-Payer Advanced Primary Care Practice Demonstraton initiated by the Obama administration had raised more questions about the future of the medical home project. The explanation from CMS was brief and to the point: “At this time, CMS believes it would be impractical to pursue clearance of the Medicare Medical Home Demonstration, which has been under review at the Office of Management and Budget, given the pending legislation that would repeal it and replace it with a similar pilot.”

CMS describes the similar pilot as “an independent practitioner-based medical home pilot.” The pending legislation that describes it is the House of Representatives health care reform bill (HR 3200). The two pilots do appear similar in many respects, but one needs to read no further than subsection (a)(4) of Section 1302 “Medical Home Pilot Program” to discover a significant difference between the proposed pilot and its would-be predecessor. Under “Participation of Nurse Practitioners and Physician Assistants,” the bill stipulates that nurse practitioners and physician assistants may lead patient-centered medical homes as long they are acting consistently with state law and other requirements are met.  

Family physicians concerned about turf issues may see this as a setback. The good news is that primary care and medical homes are still the focus of discussion and legislation in Washington, even though the first Medicare medical home demonstration, which many believed would help breathe new life into family medicine, is apparently at death’s door.

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