The going rate for a compromised medical record seems to be $1000 (well, at least  that’s the asking price) as seen in papers filed in the eleven class action lawsuits against Sutter Health following the theft of a desktop computer last fall. The computer contained unencrypted protected health information on about 4.24 million members. The eleven class action suits are likely to be consolidated for ease of handling by the courts.

For an outfit whose most recently reported year-end financials show just under $900
million in income on just over $9 billion in revenue, a $4.24 billion claim certainly qualifies as a big deal. The data breach claims against Sutter Health were filed last year following its self-reporting of the computer theft, and are in the news again due to the potential consolidation.

The company had reportedly begun to encrypt its data last year, starting with more
vulnerable mobile devices, and moving on to desktop computers, but had not gotten to the desktop in question by the time of the breach. It remains to be seen how these facts end up affecting the final damages awarded in this case.

The takeaway for other covered entities and business associates out there: If the OCR HIPAA audits aren’t enough of a motivation to get cracking with beefed-up data privacy and security protections, the potential exposure of Sutter Health in this class action suit should be reason enough to get started on this work as soon as possible, and to make it a high priority. Suits like these may be grounded both in state law and in indirect theories flowing from HIPAA/HITECH breaches (since there is no private right of action under HIPAA). The exposure is there, and a number’s been put out there to quantify it. However expensive and inconvenient data encryption and other privacy and security measures may be, they are surely worth avoiding $1,000-a-head lawsuits and months of negative publicity.

There’s a new movement in healthcare – and it’s growing from a surprising place. Instead of emerging from government or industry, it’s budding from the grassroots –from everyday physicians. The movement is democratizing health information and giving birth to a new landscape: Interactive Health.

Interactive Health is transitioning clinical care from real-world, costly encounters to virtual, inexpensive, cloud-based care. And the view from the cloud is better. This transformation is starting with the most fundamental interaction in healthcare: patient question, physician answer.

In late April of 2011, HealthTap decided to help facilitate this movement by bringing together physicians to engage online and create a road map for “care in the cloud.” Nine months later, the growth of physician engagement on HealthTap and beyond proves that Interactive Health is here to stay.

Today, HealthTap announced that 10,000 physicians have joined their Medical Expert Network, where they are sharing and evaluating the best health information online, dramatically improving care within a transparent meritocracy.

The Three Pillars of the new movement: Quality, Access, and Care

Interactive Health is supported by three pillars: quality, access, and care.

Quality

We live in a world of abundant heath information – but this information can create
confusion, frustration and mistrust. The Interactive Health movement is changing
this by ensuring quality through trust, pluralism, merit and peer review. HealthTap is facilitating this movement in three ways.

HealthTap creates trust by allowing only U.S.-licensed physicians in excellent standing to join its Medical Expert network. Admission is even stricter than state licensing requirements.

HealthTap also supports pluralism by enabling doctors to add better answers to all patient questions, even if already answered by other doctors. These, in turn, are being commented on by additional doctors adding multiple opinions and approaches to the available body of knowledge.

HealthTap supports meritocracy and peer review by ensuring that answers are not based on the assessment of a single individual or organization, but are based on the combined evaluation provided by the medical community, and by allowing participating physicians to review, rank, and evaluate answers.

Access

HealthTap makes the highest quality health information readily available to everyone for free. Physicians can also compare and contrast their own approach to that of other doctors.

HealthTap is built around transparency: when patients view answers, they can see who created them. They can see the physician’s real name, learn where the doctor was educated and practices, and eventually follow up with an appointment.

In real Interactive Health, physician participation is voluntary, not dictated. The participating’s physicians’ goals are to improve care and to make the best health information available to all.

Care

HealthTap helps facilitate better care through creating a culture of gratitude and kindness between doctors and patients. In addition to recognition from fellow physicians, HealthTap lets users “Thank” doctors when they appreciate answers. Hundreds of physicians have written to us that the “Thanks” they receive from patients on HealthTap remind them of why they decided to practice medicine in the first place.

The second element of true care is availability. Interactive Health makes doctor wisdom readily available 24/7 – without additional effort by physicians or cost to patients.

How HealthTap is leading the Interactive Health movement

The democratization of health information involves more than just bringing the best
information to people everywhere – it also means giving an opportunity for top licensed physicians in good standing to have a real voice.

The Medical Experts participating on HealthTap include leading doctors from top
institutions, as well as physicians practicing in rural areas, giving them all the same opportunity to have their voices heard, and to share their knowledge on equal footing.

Physicians on HealthTap are known both locally and nationally. The fast-growing network includes respected medical practitioners in communities of all sizes. Doctors on HealthTap were trained in and practice at top institutions like Harvard (the #1 represented medical school for physicians in our network), Johns Hopkins, and UCSF, and have been published in medical journals, such as JAMAand the New England Journal of Medicine. The network also includes experts who have served as department  chairs or division chiefs at premier medical centers, including Cedars-Sinai, Memorial Sloan-Kettering, and Baylor University.

HealthTap’s Medical Expert community includes physicians like Dr. Barry Rosen, a surgeon listed as one of America’s Top Doctors in U.S. News and World Report; Dr. George Kalber, a Professor of Urology and Pediatrics at the Tufts University School of Medicine; and Dr. Cornelia Franz, a Pediatrician and author of Common Sense Pediatrics.

The HealthTap Medical Expert Network also includes physicians like Dr. R. Wayne
Inzer, an OB/GYN who serves as the program Director for the Obstetrics and
Gynecology Resident training program at Baylor University Medical Center; Dr.
Latisha Smith, an assistant professor in the University of Texas Health Science
Center at Houston’s comprehensive wound care and hyperbaric medicine center; and
Dr. Bert Mandelbaum, the Chairman of the department of pediatrics at the University Medical Center of Princeton.

Together, these six doctors have answered more than 2,200 questions, which have received over 3,400 Agrees from the physician community, and which have helped almost 200,000 people to date (a number that will continue to grow in the future with no additional effort by these doctors as more users find them through their mobile devices and online). This is what moving the best information to the cloud is all about.

By enabling doctors to compete with one another on the quality of their answers, and to assess the answers of other doctors, HealthTap has become both the voice of the most well recognized physicians and the voice of those who are most deserving of recognition. A true meritocracy, HealthTap is the podium for both the super-known, and for those who deserve to be—but are not yet as well known as they will be very soon.

_ Recently, Don Berwick completed his 17 month tenure as administrator of Medicare and Medicaid.   The nation should be grateful that such a visionary was at the helm.  The nation should feel frustrated that he was never confirmed.

In his parting interview with the press, he noted that 20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.

Berwick listed five reasons for the enormous waste in health spending:

*Patients are over-treated
*There is not enough coordination of care
*US health care is burdened with an excessively complex administrative system
*The enormous burden of rules
*Fraud

Certainly regulatory reform is needed, but electronic health records can go far to addressing each of these issues.

Patients are over treated

When I was an emergency department resident 20 years ago, the faculty and staff of Harbor-UCLA medical center taught me best practices for safe, quality, efficiency care.   When I make decisions today, I reflect back on that intense training.  However, thousands of journal articles have been written since then, there’s new evidence suggesting more effective treatment plans, and new therapies are available.   How do I ensure the just the right amount of care is delivered – neither too much, nor too little? Decision support embedded in electronic health records.

EHRs can provide alerts and reminders – just in time advice as to what my patients need.  Educational materials and literature can be embedded in the workflow for easy reference.  Population/panel health tools can identify those patients who need follow-up or are deviating from care plans.

There is not enough coordination

The United States does not have a healthcare system – it has a disconnected array of clinics, pharmacies, labs, hospitals, and imaging centers.   Meaningful Use Stage 2 is likely to require significant healthcare information exchange as well as the transport, vocabulary, and content standards needed to support it.  Although the journey to a completely connected healthcare system will take a few years, the next 24 months will include a quantum leap in care coordination as state health information exchanges connect patients, providers, and payers.

US healthcare is burdened with excessively complex administrative system

Like the tax code, healthcare regulations are dizzying in their complexity and volume.   Some are so arcane that experts cannot agree on the interpretation.    If rules can be built into EHRs such as the precise definitions for quality reporting, automated electronic coding of visits based on structured documentation/natural language processing, and payments made on objectively measured processes/outcomes instead of the quantity of care delivered, regulatory complexity can be reduced and money saved.

The enormous burden of the rules

Approximately 25% of my IS staff work on compliance related software requests – building new functional or purchasing new products to meet every increasing numbers of rules.    We all want to do the right thing, but if no one can understand the rules and the amount of overhead needed to comply is financially unsustainable, the rules are too burdensome.

Electronic health records can enforce automated care plans, provide feedback at the point of care and support administrative simplification with bidirectional electronic transactions between payers and providers.

Fraud

Although no system is foolproof, electronic health records can reduce fraud by automating the kind of data transfers that will help detect fraud and abuse.    Emerging new analytics companies are already working on techniques to discover patterns of care that do not make sense – Medicare billing for deceased patients, redundant procedures or services, and variation in billing practices among physicians that can identify outliers.

In addition to these 5 areas of waste reduction, electronic health records are an essential part of a learning healthcare system which gathers data for clinical trials, clinical research, and unique population health measurement such as pharmacovigelence, syndromic surveillance, and immunization compliance.   Don Berwick is a great supporter of the EHR’s potential to increase quality, safety, and efficiency while reducing waste.

Although healthcare reform is controversial, healthcare IT reform – the federal 5 year plan to increase the use of electronic health records and healthcare information exchange – has broad bipartisan support.

As Don Berwick returns to the private section, I’m hopeful that he’ll turn his energy back to fixing the US healthcare system and that he’ll be a tireless champion for electronic health records.

_ On Wednesday the Centers for Disease Control and Prevention (CDC) released the results of its yearly survey on Electronic Health Records (EHR) adoption for office-based physicians. No surprises. Generally speaking, the majority of physicians in ambulatory practice are now using an EHR, and over half of surveyed doctors say that they intend to seek Meaningful Use incentives. The report is also presenting results broken down by state, so you can learn what folks are doing in your immediate vicinity. The more instructive exercise is to compare last year’s survey results [Figure 1] to this year’s estimated EHR adoption numbers [Figure 2].

The most immediate observation is that 6.2% of physicians have adopted an EHR in 2011, thus returning to EHR growth rates preceding the 2009 -2010 slowdown, which was largely due to the confusion created by Meaningful Use regulations. The next observation is that the percentage of docs that have at least a basic EHR has gone up by 8.9% in 2011. A basic EHR is one that has “patient history and demographics, patient problem list, physician clinical notes, comprehensive list of patient’s medications and allergies, computerized orders for prescriptions, and ability to view laboratory and imaging results electronically”. Although the survey instrument in 2011 did ask about more advanced functionality, and is practically identical to the 2010 instrument, the CDC did not publish a separate number for those with fully functional systems in 2011. Although I cannot be certain, I would assume that most of the growth in 2011 was fueled by certified EHRs, which by definition should be fully functional. So if I had to guess, and I hope CDC will release the numbers so I don’t have to, I would estimate that in 2011 we have at least 20% of physicians using fully functional systems, which is roughly double what we had in 2010.

Another interesting trend that has been holding since around 2007 is that about a quarter of office-based doctors have some type of bare bones software in their office and they are not upgrading to even a basic EHR. Considering that over half of those surveyed intend to apply for Meaningful Use incentives, this trend is bound to change in 2012.  Some of these folks may have purchased a fully featured EHR, but chose to either not turn features on or chose not to keep up with upgrades to newer versions. For ambulatory EHR vendors these numbers translate into a market opportunity ranging from 50% of the market to a full 80% of ambulatory physicians.

It would be very beneficial if CDC released the complete data set from this survey (anonymous, of course), so we could gain a better understanding of EHR adoption patterns by practice type, size and location. Although it is widely acknowledged that larger practices and employed physicians are further along the curve, the rich details provided by the survey instrument should help both vendors and various organizations engaged in efforts to spur technology adoption, better target their work, and it could also illuminate any disparities which may affect quality of care for vulnerable populations and physicians who serve them.

In summary, the new CDC survey is showing a stable growth in technology use by office-based physicians, modestly improved by government initiatives over the last two years, and well positioned to further improve in 2012 and beyond.

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. So if a cash crunch forces the death of an independent practice, it robs a community of a vital health care resource.

"A lot of independent practices are starting to see serious financial issues," said Marc Lion, CEO of Lion & Company CPAs, LLC, which advises independent doctor practices about their finances.

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.

Dr. William Pentz, 47, a cardiologist with a Philadelphia private practice, and his partners had to tap into their personal assets to make payroll for employees last year. "And we still barely made payroll last paycheck," he said. "Many of us are also skimping on our own pay."

Pentz 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."

Pentz is thinking about an out. "If this continues, I might seriously consider leaving medicine," he said. "I can't keep working this way."

Also on his mind, the impending 27.4% Medicare pay cut for doctors. "If that goes through, it will put us under," he said.

Federal law requires that Medicare reimbursement rates be adjusted annually based on a formula tied to the health of the economy. That law says rates should be cut every year to keep Medicare financially sound.

Although Congress has blocked those cuts from happening 13 times over the past decade, most recently on Dec. 23 with a two-month temporary "patch," this dilemma continues to haunt doctors every year.

Beau Donegan, senior executive with a hospital cancer center in Newport Beach, Calif., is well aware of physicians' financial woes.

"Many are too proud to admit that they are on the verge of bankruptcy," she said. "These physicians see no way out of the downward spiral of reimbursement, escalating costs of treating patients and insurance companies deciding when and how much they will pay them."

Donegan knows an oncologist "with a stellar reputation in the community" who hasn't taken a salary from his private practice in over a year. He owes drug companies $1.6 million, which he wasn't reimbursed for.

Dr. Neil Barth is that oncologist. He has been in the top 10% of oncologists in his region, according to U.S. News Top Doctors' ranking. Still, he is contemplating personal bankruptcy.

That move could shutter his 31-year-old clinical practice and force 6,000 cancer patients to look for a new doctor.

Changes in drug reimbursements have hurt him 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 drug makers 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," he 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.

Wishing all of our past, present and future clients a very happy, healthy and prosperous holiday season and new year. May today's hopes and dreams become next year's reality for all of you. With that in mind, here's a classic holiday poem presented in its entirety for your reading pleasure:

"'Twas the night before Christmas,
when all through the house
Not a creature was stirring,
not even a mouse;
The stockings were hung by the chimney with care,
In hopes that St. Nicholas soon would be there;
The children were nestled all snug in their beds,
While visions of sugar-plums danced in their heads;
And mamma in her 'kerchief, and I in my cap,
Had just settled our brains for a long winter's nap,
When out on the lawn there arose such a clatter,
I sprang from the bed to see what was the matter.
Away to the window I flew like a flash,
Tore open the shutters and threw up the sash.

The moon on the breast of the new-fallen snow
Gave the lustre of mid-day to objects below,
When, what to my wondering eyes should appear,
But a miniature sleigh, and eight tiny reindeer,
With a little old driver, so lively and quick,
I knew in a moment it must be St. Nick.

More rapid than eagles his coursers they came,
And he whistled, and shouted, and called them by name;
'Now, Dasher! now, Dancer!
now, Prancer and Vixen!
On, Comet! on, Cupid! on, Donder and Blitzen!
To the top of the porch!
to the top of the wall!
Now dash away! dash away! dash away all!'

As dry leaves that before the wild hurricane fly
When they meet with an obstacle, mount to the sky;
So up to the house-top the coursers they flew,
With the sleigh full of Toys, and St. Nicholas too.

And then, in a twinkling, I heard on the roof
The prancing and pawing of each little hoof.
As I drew in my head, and was turning around,
Down the chimney St. Nicholas came with a bound.

He was dressed all in fur, from his head to his foot,
And his clothes were all tarnished with ashes and soot;
A bundle of Toys he had flung on his back,
And he looked like a peddler just opening his pack.

His eyes - how they twinkled!
his dimples how merry!
His cheeks were like roses,
his nose like a cherry!
His droll little mouth was drawn up like a bow
And the beard of his chin was as white as the snow;
The stump of a pipe he held tight in his teeth,
And the smoke it encircled his head like a wreath;
He had a broad face and a little round belly,
That shook when he laughed, like a bowlful of jelly.

He was chubby and plump, a right jolly old elf,
And I laughed when I saw him, in spite of myself;
A wink of his eye and a twist of his head,
Soon gave me to know I had nothing to dread;
He spoke not a word, but went straight to his work,
And filled all the stockings; then turned with a jerk,
And laying his finger aside of his nose,
And giving a nod, up the chimney he rose;
He sprang to his sleigh, to his team gave a whistle,
And away they all flew like the down of a thistle,
But I heard him exclaim, ere he drove out of sight,
"Happy Christmas to all, and to all a good-night.'"

Clement Moore
American Author
(1779 - 1863) 

H. Gilbert Welch, MD is a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. He is the co-author of Overdiagnosed: Making People Sick in the Pursuit of Health. This post originally appeared in the L.A. Times.

Everybody knows what the federal budget’s long-term problem is. The president knows. The Republicans in Congress know. The Democrats in Congress know. The policy community knows. You know.

It’s Medicare.

I am a physician who has been studying Medicare data throughout my professional life. But now that I’m closing in on becoming a beneficiary, I am thinking more about what I’d like my Medicare program to look like.

My Medicare would be guided by three basic principles:

It should not bankrupt our children. Let’s be clear: Medicare is rightly the central source of concern in the deficit debate. Its expenditures are totally out of control, and represent a huge income transfer to the elderly from their children. It’s a program crying out for a budget.

So let’s pick a number — more specifically, a proportion of total economic output — to cap Medicare. Now the number is 3% to 4% of GDP. We can live with that. Distribute it to geographic regions based simply on how many beneficiaries live there. Expect howls of protest: Urban areas will complain their labor costs are higher; rural areas will complain they cannot achieve the same economies of scale. And everybody will argue that their patients are sicker.

Ignore them all: Make it a block-grant program. Sure, this raises other issues, but you get the principle.

For those who view this as a tea party solution, consider this: I drive a 1999 Volvo and live in Vermont — that should tell you something.

It should not waste money on low-yield medicine. I don’t change my Volvo’s oil every 1,500 miles, even though some mechanics might argue that it would be better for its engine. Nor do I buy new tires every 10,000 miles, even though doing so would arguably make my car safer. But in Medicare (as well as the rest of U.S. medical care) such low-yield interventions are routine.

Measurements considered normal in the past now trigger treatment for high blood pressure, high cholesterol, diabetes and osteoporosis. Tiny abnormalities that were invisible in the past now trigger follow-up scans, fiber-optic examinations, biopsies and surgery.

Increasingly, all Medicare beneficiaries are being viewed as being “at-risk” for something, particularly heart disease and cancer. We doctors joke that the well person is the one we have not examined thoroughly enough. (The last Medicare skin exam that failed to identify something that might lead to skin cancer occurred in 1970.)

But it’s not funny anymore. Because once you are labeled at-risk, something must be done.

My Medicare would recognize the problems with this approach. Because almost everyone is transformed into a patient needing intervention, it’s an approach that costs a huge amount of money. And no matter what we doctors do, we can’t take you to zero risk.

But we can cause harm. Our medications have side effects; our surgeries and procedures have complications. And occasionally our interventions cause death.

My Medicare would focus on patients who are genuinely sick: those who have symptoms (e.g., chest pain) or are at high risk of something bad happening (e.g., really high blood pressure). These are the patients for whom the benefits of medical intervention clearly outweigh the harms. The rest of us are better off left alone.

That’s right, most of us would do just as well — or better — with less medical care. Restoring balance to the system will first require more balanced information for patients because what they get now systematically exaggerates the benefits and downplays (or ignores) the harms of intervention.

But it will also require that someone take responsibility for deciding which treatments should be provided based on the evidence of which treatments lead to better outcomes. If you don’t want the government to do this, then your doctor will need to step up to the plate. And the only way that will happen is to balance his financial incentives.

Those who believe they have a fundamental right to receive low-yield, ineffective and harmful care are sure to invoke the “R-word”: rationing. But let’s hope they at least have the good sense not to say it while at the same time arguing for less government spending because they don’t want to bankrupt their children.

It should recognize the value of having time to talk with your doctor. The current system rewards physicians for doing things to patients, not for talking with them. Not surprisingly, we do too much. Too many clinic visits lead to another medication being started, another test being ordered and a referral to another physician. The end result is totally predictable: too many medicines, too much testing and too many cooks in the kitchen.

But there is another problem: Subsequent clinic visits are increasingly devoted to going over medicines, reviewing test results and figuring out what the other physicians had to say. No wonder patients are increasingly dissatisfied with the process.

My Medicare would reward doctors for taking time to have a conversation. It would recognize the value of acknowledging suffering, providing reassurance, discussing options and learning how different patients want to approach care.

What would I want to talk about with my doctor? Maybe it’s a topic, however mundane, that means something to me, like whether the Jets will knock off the Patriots again this year. This serves a purpose: I want to know (and like) my doctor.

I want to talk about important things too, things that are bothering me right now. I want my doctor to care, provide insight as to what is going on, and to consider carefully whether or not medicine can help. I don’t want a knee-jerk response to some perceived need to “do something” on my behalf. I value the physician who can candidly discuss what medicine can and cannot to.

By the way, that takes time. It requires a system that rewards doctors as much for thinking about (and talking with) patients as doing things to them.

I want to talk about aging gracefully. My Medicare would be really good at this. It would help patients understand the trade-offs between the length of life and the quality of life. It would help patients understand why the side effects of early detection — overdiagnosis and overtreatment — are even more pronounced as they age (simply because there is less time for abnormalities to become important problems). And it would help patients understand the futility and the suffering caused by aggressive interventions at the end of life.

If you were hoping to play the “death panel” card, now’s your chance. But don’t play it and then pretend you care about the budget.

Let’s say you’ve enrolled in a new health insurance plan and need to find an internist who participates. How do you decide which doctor to choose? My (long deceased) grandmother made her choices by using the following criteria: She looked for a male doctor with a Jewish-sounding last name who graduated from an American medical school—preferably one located in New York City. Nowadays her narrow (and culturally biased) criteria would have excluded some of the most esteemed practitioners around.

If you are like most people, you don’t depend on your grandmother’s advice to find a physician, but rather ask friends, colleagues or other doctors for recommendations. But taking one person’s experience with an internist or surgeon as a signal that he or she is “really good” is still far from the optimal way to choose a practitioner.

Over the years, several commercial websites like HealthGrades and Angie’s List have cropped up that provide such consumer-friendly information as the distance a doctor’s office is from the patient, and whether foreign languages are spoken there. They usually include ratings that reflect consumers’ personal experiences with the practitioner. For people who want to dig deeper, most state medical boards collect data that can be searched to find out where your doctor went to medical school, where he did his residency and what board certifications she has. In some states you can also search to see if the doctor in question has received disciplinary action or been sued for malpractice.

This is a lot of on-line legwork for the average person—a task that even professionals can find difficult. Chip Amoe, assistant director for federal affairs at the American Society of Anesthesiologists told a group recently, “When I tried to go find a primary care physician, I couldn’t. You know, it was very difficult. I had to go on several different Web sites to be able to find [one].”

In the end, you may pick a doctor who graduated from a prestigious medical school, hasn’t been sued often, is only a 10-minute drive away and has a nice, clean waiting room; but none of this information will necessarily increase the likelihood that he or she will provide high-quality, cost-effective care. That’s where the nascent Physician Compare website, designed by the Center for Medicare and Medicaid Services, comes in. The site, which is still under development and will be modeled after CMS’s existing “Hospital Compare” site, was mandated by the Patient Protection and Affordable Care Act and is slated to go up on-line on Jan. 1, 2011.

Don’t expect too much. Next year, the information posted on Physician Compare will be little more than that already available in CMS’s Healthcare Provider Directory. This directory, designed to be used by Medicare beneficiaries, lets consumers search for a physician or other health care professional by specialty and location. Additional search criteria allow the user to search by gender and whether or not the physician or other health care provider accepts Medicare reimbursement as full payment on all claims. Information about languages spoken, education, and hospital affiliation is also available for some providers.

For now, Physician Compare will post information only about physicians enrolled in the Medicare program, and will note those providers who participate in CMS’s voluntary Physician Quality Reporting Initiative (PQRI). The PQRI program requires that doctors report data for at least three of 170 or so evidence-based quality measures (examples include; giving aspirin to patients experiencing heart attack and recording vital signs for patients presenting with community-acquired pneumonia). By reporting this information (positive or negative) for at least 80% of patients over the course of a year, the provider earns an incentive payment from CMS that can reach 2% of total Medicare reimbursement.

This kind of information, if displayed in an easy-to-use format, will be more helpful perhaps than a friend’s recommendation, yet still limited. But over the next several years, the Physician Compare site promises to become something more. For one, health care reform legislation requires that by 2019, doctors must report and the public must have access to the following sources of physician quality and performance data:

• Measures collected under the Physician Quality Reporting Initiative
• An assessment of patient health outcomes and the functional status of patients
• An assessment of the continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
• An assessment of efficiency
• An assessment of patient experience and patient, caregiver, and family engagement
• An assessment of the safety, effectiveness, and timeliness of care

According to Regina Raymond-Chell, a registered nurse who is part of CMS’s quality measurement health assessment group, January 2012 marks the beginning of the reporting period for more detailed physician performance information. A year later, in 2013, the agency will implement a plan for publicly reporting physician performance data through the Physician Compare Web site. By 2015, doctors who fail to report data on quality measures will face penalties—a 1.5% reduction to fee schedule payments the first year; a 2% reduction in 2016. Finally, in January 2019, a demonstration project will begin that will use this performance data to provide financial incentives (i.e. Medicare will reimburse patients’  medical charges at a higher rate) to beneficiaries who use “high-quality” physicians.

On October 17, CMS held a town hall style meeting to hear suggestions from stakeholders in the Physician Compare site about what kind of quality information should be included and where it should come from. Doctors groups insisted that performance information must be risk-adjusted to not penalize those who treat sicker patients. They also worried about how data will be presented for physicians who provide care in a hospital (hospitalists) versus those who see patients in an office or out-patient clinic setting. Finally, they want a physician to have the chance to review all information associated with his listing before it goes public.

The American Medical Association points out that even CMS’s basic physician directory (providing name, address, credentials for physicians) has had problems with accuracy, and the group says they often field complaints from physicians about interacting with this system.

Jennifer Shevchek, assistant director of federal affairs for the AMA said at the town hall meeting; “Physicians and other providers involved in the treatment of a patient must have the opportunity to prior review and comment and the right to appeal with regard to any data that is part of the public review process. Any such comment should be included with any publicly reported data. This is necessary to give an accurate and complete picture of what is otherwise only a snapshot and possibly…[a] skewed view of the patient care provided by physicians and other professionals or providers involved in that patient’s care.”

Meanwhile, consumer advocates want to put a limit on how long doctors can take to “review” their data so that the site is comprehensive and stays up-to-date. They also want Physician Compare to be user-friendly. At the October meeting, Tanya Alteras, associate director of the Consumer Purchaser Disclosure Project, a group that advocates for “a transparent health care market, in which, decision-making is supported by publicly reported comparative information,” said; “Physician Compare needs to be populated with information that’s meaningful to consumers and that is presented in a way that’s simple, intuitive and easy to navigate.” She continued, “We need measures on patient outcomes, patient experience, functional status, care coordination and resource use.”

Steven Findlay, a senior health policy analyst at Consumer’s Union added: “I think we all know that the existing CMS and HHS [Health and Human Services] Compare Web sites have been evolving and improving over recent years, but they’re still struggling to effectively support consumer choice.”

The other “compare” sites Findlay refers to include Hospital Compare, Dialysis Compare, and Skilled Nursing Home Compare. They have all been on-line for several years—although interestingly, they are not used very often by consumers. One study estimated that only 12% of consumers considering nursing homes for themselves or relatives actually used the CMS comparison site.

Why the low utilization? According to Findlay, “Nursing Home and Hospital Compare sites use extracted data from the Medicare database and although it is displayed in a way that’s meaningful and good, it tends to be packaged in a way that’s not easy to use for people who are not well educated or do not have advanced computer skills.” Considering that the majority of folks who would be using these sites are 65 and older, that is a real problem. This is especially apparent, says Findlay in CMS’s site that allows seniors to compare and choose a prescription (Part D) plan available through Medicare. “This site is god-awful,” he says, structured for a very sophisticated population but used primarily by senior citizens who are easily intimidated by on-line information. “I even find it intimidating,” says Findlay.

Besides being hard to use, some of the CMS sites have recently come under attack for providing consumers with inaccurate data or for using the wrong quality measures.

The Dialysis Compare site is one glaring example. This website allows patients requiring dialysis to find centers near where they live and then compare how the facilities rate in anemia control, hemodialysis effectiveness (how much waste is removed from blood), and patient survival.

But a new investigation by ProPublica along with The Atlantic finds that the Dialysis Compare site is not always providing accurate information about this costly medical service and that quality varies widely from site to site. Since 1972, Medicare has covered dialysis treatment for all patients, regardless of age or income. Each year, more than 100,000 Americans start dialysis treatment, according to Robin Fields, a senior editor atProPublica and author of the report. “Taxpayers spend more than $20 billion a year to care for those on dialysis—about $77,000 per patient, more, by some accounts, than any other nation,” writes Fields. Yet the United States continues to have one of the industrialized world’s highest mortality rates for dialysis care: One in four patients will die within 12 months of starting treatment.

Fields says that over the years, clinics have gotten better at hitting biochemical targets (anemia control, removing waste from blood, etc.) that are set by CMS and reported on the Compare site, but “overall rates of death and hospitalization have seen little change.” She continues; “Medicare’s record of making sure that clinics meet health and safety standards has been spotty. Clinics are supposed to be inspected once every three years on average, but as of October, almost one in 10 hadn’t had a top-to-bottom check in at least five years.” The ProPublica investigation found striking problems in some dialysis centers, including unsanitary conditions, high rates of patient infection and no nephrologists or other physician consistently on-site to oversee care.

The Hospital Compare site has also come under criticism recently. Researchers at the University of Michigan published a study this month in the Archives of Surgery that concluded; “Currently available information on the Hospital Compare Web site will not help patients identify hospitals with better outcomes for high-risk surgery. The Centers for Medicare and Medicaid Services needs to identify higher leverage process measures and devote greater attention to profiling hospitals based on outcomes to improve public reporting and pay-for-performance efforts.” The problem, according to the authors, is that CMS has put more emphasis on measuring processes (whether antibiotics were given or measures were taken to prevent blood clots) rather than outcomes—how patients fared after their surgeries.

One surprising result of the study is that there was little correlation between how well hospitals complied with Medicare’s process measures, (the information posted on Hospital Compare) and patient outcomes. In fact, according to a recent post on a blog published by the California HealthCare Foundation, “the hospitals with the poorest compliance rate with Medicare safety measures reported the fewest patient complications, while the hospitals with better compliance records had higher complication rates.”

The lesson from the shortcomings of current CMS Compare sites must be taken into account as Physician Compare develops. At the town hall meeting it was clear that decisions still have to be made about what quality measures will be included on the site and where this data will come from. Besides PQRI, groups like the National Quality Forum also have devised good quality metrics and the Consumer Assessment of Healthcare Providers and Systems (CAHPS) devises free surveys that can help measure patient satisfaction and the communication skills of a given practitioner. Finally, in the next few years, “meaningful use” data generated by the widespread adoption by doctors of electronic health records could provide a powerful resource for measuring the quality of individual practitioners—especially in meeting process goals.

Consumer advocates want to see additional information included on the site that is not specified in the Affordable Care Act. CU’s Findlay believes consumers should know if their physician has kept up with the latest care available, so they will want to see evidence that their doctor’s certification is up to date. Also, he thinks consumers should have access to information about gifts and payments individual doctors and group practices receive from drug companies or device makers to help alert patients to potential conflicts of interests their physician might have. These figures will be publicly available under the Physician Payment Sunshine Act starting in 2013, and could be integrated into the Physician Compare site quite easily. “If they don’t do this, we will,” warns Findlay.

Finally, consumers should have access to some of the valuable volume and outcomes information that is gleaned by analyzing individual physician claims data—both from government insurers and private ones. This includes letting consumers know such relevant information like how many knee replacements a particular surgeon does a year, how many scans or other tests he or she orders compared to similar practitioners, and how much the physician is paid for these procedures.

Making claims information public will be a challenge. Three decades ago, the AMA successfully sued the government to keep billing and reimbursement data secret; citing privacy issues. And in the last year the AMA has fought and defended doctors against two other lawsuits from consumer groups that wanted to make physician claim information public to help detect fraud and overuse of certain procedures. In the interest of providing valuable information for Physician Compare, it may be worthwhile for the CMS to take the AMA back to court once again over this issue.

In the end, the short-term goal of Physician Compare is to empower consumers and give them truly useful information in an easy-to-use format so they can make important choices about their health care. One model to consider is the new healthcare.gov site, a comprehensive health insurance comparison website created by HHS that gets high marks from consumers and professionals for ease of use. “It’s a giant leap in the right direction,” says CU’s Findlay.

The longer-term goal of these Compare sites goes beyond consumer empowerment. Eventually CMS and even private insurers will begin using meaningful measurements and data from these sites to promote pay-for-quality schemes. The idea is to offer financial incentives (and disincentives) to encourage providers to improve the quality of their practice, or in the case of nursing homes, hospitals and dialysis centers, improve the quality of their facilities.The government has just begun to embark on its quest toward evidence and quality-driven medicine; for the public, it’s an early step toward making educated choices about care.

All of us have been to fast food establishments. We go there because we are in a hurry and it’s cheap. We love the convenience. We expect that the quality of the cuisine will be several rungs lower than fine dining.

We now have a fast medicine option available to us. Across the country, there are over 1000 ‘minute-clinics’ that are being set up in pharmacies, supermarkets and other retail store chains. These clinics are staffed by nurse practitioners who have prescribing authority, under the loose oversight of a physician who is likely off sight. These nurses will see patients with simple medical issues and will adhere to strict guidelines so they will not treat beyond their medical knowledge. For example, if a man comes in clutching his chest and gasping, the nurse will know not to just give him some Rolaids and wish him well. At least, that’s the plan.

Primary care physicians are concerned over the metastases of ‘minute-clinics’ nationwide. Of course, they argue from a patient safety standpoint, but there are powerful parochial issues worrying physicians. They are losing business. They have a point that patients should be rightly concerned about medical errors and missed diagnoses at these medical care drive-ins. These nurses, even with their advanced training, are not doctors. It is also true serious or even life threatening conditions can masquerade as innocent medical complaints and might not be recognized by a nurse who treats colds and ankle sprains.

The Annals of Internal Medicine, a prestigious medical journal, reported on the quality of these retail clinics and concluded that the quality of care for ear infections, sore throats and urinary tract infections in fast-medicine outlets was similar to that in physicians’ offices, but at lower cost. While this is ammo for fast-med aficionados, it doesn’t address a more important point. I’ll concede that if I take my kid with an ear infection to a Wal-Mart clinic or the pediatrician, then the outcome will be similar. (Many experienced Moms would also know what to do.) The tricky part is when the symptom is murky and the range of medical possibilities is broad. If my kid were having stomach pain, for example, I want a physician to decide if this is simple constipation, intestinal gas or acute appendicitis that needs urgent surgery.

These clinics are proliferating because the market demands them. The fundamental cause is the inadequate number of primary care physicians in this country. This shortage will become more acute when Obamacare extends coverage to tens of millions of uninsured. Massachusetts discovered this a few years ago when they provided coverage to the uninsured, but didn’t have enough primary care physicians to care for them. These clinics are also providing a service that physicians have been unable or unwilling to match. They offer evening and weekend hours at low prices. Patients come at their convenience and are seen without waiting.

Pharmacies and big box stores benefit from minute clinics. They bring shoppers into the store who are likely to purchase other items after their scraped knee is bandaged. And if a prescription is needed, guess where it gets filled? From a patient’s point of view, this experience sure beats an emergency room adventure.

Are these clinics a good idea? It doesn’t matter because they’re coming and they can’t be stopped. They fill a legitimate need that the medical profession cannot address and the public demands. Market forces created the opportunity and will monitor its success.

Will they survive? Remind me, how long have McDonalds, Burger King and all the rest been around?