_ 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?

EHR adoption rates are picking up significantly, exceeding the most optimistic expectations. Instead of an EHR for every American by 2014, as the President commanded, we will have dozens of EHRs for each American long before that. And in health care, more is always better, not to mention the freedom of choice that comes with having a different EHR in each care setting. Not surprisingly, we are seeing a decrease in health care expenditures taking place in parallel with the uptick in EHR adoption. Following best practices in health care economics research, when two phenomena develop in parallel, the learned assumption is that there is a causality connection between the two. Deciding which phenomenon is the cause and which is the effect is discretionary and commonly based on undisclosed agendas.

It is therefore postulated here that health care expenditures are inversely proportional to EHR usage rates. The following is a rigorous analysis of the mechanisms by which EHRs are reducing health care costs, intended to inform policy makers as customary in most health care related studies, which cannot be completed, or published, without a salient recommendation of interest to policy makers.

Productivity Optimization – Numerous carefully estimated anecdotal studies consistently show that introduction of an EHR in ambulatory practice can reduce provider productivity by 50% or more. This directly translates into 50% (or more) savings in health care expenditures for office visits. Unfortunately, the same studies also show that in most cases this reduction in office visits is transient, with most providers regaining ability to charge for as much as 80% of their pre-EHR visit volume within six months to a year. Still, 20% long term savings is significant and could probably be optimized further by introducing more speed tempering features into certified EHRs. Equally rigorous studies show preliminary evidence that the savings realized from introducing fully functioning EHRs in Emergency Departments far exceed those in the ambulatory sector. Unlike other Socialist countries that were compelled to nationalize the entire health care system just so they can reduce productivity and discourage utilization by creating long waiting lines, Yankee ingenuity is producing better results at lower costs.

Banishment of THE Pen – The Physician Pen has been long known for being the most financially devastating instrument ever invented. In spite of pharmaceutical reps efforts to the contrary, EHRs are successfully removing all pens from medical practice, including but not limited to, the Physician Pen. Where physicians used to carry several handsome pens in that little pocket right under their embroidered name and title, they now carry an EHR contained in a device that may or may not fit in a less accessible pocket and either way requires both hands, ample light and an adequate supply of battery power to order the simplest thing. The better EHRs also provide various speed bumps on the road to ordering by popping up multiple warnings and good financial advice equidistantly placed at 10 to 15 milliseconds intervals. Data from the very similar retail industry shows that impulse buying is greatly increased by simplifying the process, such as the one-click checkout at Amazon. The reverse logic must also be true, so increasing complexity should reduce impulse ordering in medicine. Judging by Amazon’s successful strategy, the savings in health care are expected to be spectacular.

Customer Intimidation – As EHRs become better at measuring the abysmal state of our health care non-system, and expose the horrors and frequency of medical errors by either careless omission or profit-driven commission, it is estimated that health conscious consumers will increasingly avoid dangerous encounters with the medical complex, thus further reducing utilization and cutting costs. Strategic publicity campaigns advertising security and privacy breaches in other computerized industries, and in health care if any are found, should eliminate another segment of customers. However, the largest cost savings are projected to come from customers refraining from seeking care for, or even mentioning, potentially embarrassing health problems for fear of public exposure through interconnected EHRs.

Accelerated Attrition – EHRs are very powerful tools. So powerful that the prospect of having to purchase and use an EHR is more than enough to prompt older physicians, particularly those in private practice, to consider retirement or transition to other occupations. The evidence shows that there is direct anecdotal correlation between negative reaction to introduction of EHRs and acceptance of cost-saving team approaches to provision of medical care. The semi-natural attrition of experienced and highly compensated physicians who insist on treating, and charging for, every sore throat and every knee scrape, in spite of mounting evidence that lower paid resources can refer those to appropriate specialists with equal outcomes, should in the course of time increase the amount of savings directly attributable to the prevalence of EHRs.

Free Labor Procurement – EHRs are particularly adept at encouraging and showcasing the historical selflessness and ethical conduct of medical doctors, by providing multiple means for doctors to contribute to the well-being of their patients practically free of charge, at all hours of day and night. From the ubiquitous email to the occasional webcam session to the continuous evaluation of uploaded self-quantification vital data from patients empowered to have their health expertly monitored, physicians using EHRs can provide this simple courtesy service to their customers from the office, the home, the yacht or the golf course. These proactive preventative measures should result in extensive reductions in disease burden. Constantly connected physicians, armed with the latest monitoring tools, could detect strokes, heart attacks and maybe even cancer years before actual manifestation of symptoms. And at no cost to society.

The implications for policy makers are pretty straightforward. EHR adoption should continue to be encouraged at all costs. EHRs must evolve to seamlessly and continuously connect to all consumer monitoring devices, which implies a preference for cloud based technologies, and a security breach here and there is not necessarily an impediment to success. EHRs should continue to increase the levels of automated decision support, improve analytics and increase frequency and scope of various alerts. Basically, keep up the good work. We’re right on target.

He killed the audio CD, but resurrected the music industry.

Forever changed the way we look at pictures and videos of your summer vacation or watch summer blockbusters.

Turned your hand-held into a portal to the World Wide Web.

Historians will long debate the role Steve Jobs and his company played shifting paradigms in all sectors of our economy – from media to manufacturing to the practice of medicine.

Really? The practice of medicine?

Has Jobs and his company really changed the art of practicing medicine as they have changed most other corners of our lives?

And if so, how significantly? As much as – say Vesalius, Hooke, Hood or other giants in the field?

A radical supposition perhaps. But there is no denying the impact of the technologies adopted as a result of his touch.

Medical practitioners these days use mobile/connected devices to learn, stream, take continuing medical education, monitor patients in real time, prescribe, ensure compliance, download and consume digital media, and perhaps most importantly, collaborate and communicate more robustly.

Why?  Well, largely, because there’s an app for that.

Heightening the level and rate of electronic exchange does not necessarily mean change for the better in regards to patient care. It is still unclear whether individual patients will enjoy improved diagnosis and treatment as the gradual shift in medical practitioner from clinician to technician evolves (or devolves, as some believe).

Better patient care is what it is all about… isn’t it?

That we are all wirelessly wired in more unforeseen ways everyday is not all due to Jobs and his company. Not by a long shot. And thousands of companies big and small are breaking new ground in the delivery of healthcare everyday. Apparently, healthcare is a thriving, growing market!

One example – More patient questions are asked and answered on Google everyday than by all the healthcare workers in the world, according to Roni Zeiger, MD – chief health strategist for Google.

Another – patient communities and crowd sourcing solutions to medical conundrums have being embraced by mainstream researchers and institutions.

And I am sure those of you who visit doctors have noticed prescriptions never touching your hands, and doctors talking into their tablets or laptops as they conduct your annual physical.

Medical practice is changing.

Which brings me back to Apple and its founder’s drive for a seamless user experience.

Jobs’ abilities, his unique vision, decision making ability, consumer usability perspective, sense of design, strength of conviction, ability to assemble a great staff, and relentlessness propelled him and his firm – coincidentally or intentionally bearing the same name as the forbidden fruit and as well as Beatle’s record label – to an exalted folkloresque place in corporate America. He wouldn’t be admired if his products didn’t deliver on their aspirational promises.

By the way, I think I forgot communicate in that list above. Jobs had a unique ability to communicate his vision as well.

I say this not personally owning any Apple products. I am not now and have never been a fan-boy of either Jobs or his company.

I admire beautiful design and best in class features and functionality. If I get most of the same for half the price – that is generally the way I go. You are not likely to find me sitting outside on the sidewalk waiting for the latest release at midnight.

But these are my biases.  Clearly there are enough Apple-ites to spur entire Apple store knock-offs in China, and propel the company to #1 on the Market Capitalization Charts – briefly unseating Exxon as the world’s most valued company – worth more than the top 32 banks in the EuroZone!

Not bad for a business started in a garage. For a guy fired from his own start-up.

I do not know whether Jobs will be seen as a healthcare revolutionary.

But I do wish for him – that new collaborative techniques enabled by technology his company helps mainstream will sustain his energy and creativity as he transitions to the next phase of his life.

During the healthcare reform debate, I wrote that most people’s attitudes to it were “confused, conflicted, clueless and cranky.”  A major reason was that the American healthcare “system” is fiendishly complicated and few people really understand it.   As a result hardly anyone knows much about what is actually in the reform bill (but that does not prevent them from having strong opinions about it).  Sadly, the reforms, whatever their merits, will make the system even more complicated, the administration more Byzantine and the regulatory burden more onerous. System complexity.

The American healthcare system is already by far the most complex and bureaucratic in the world.  We were once asked to spend ninety minutes explaining American healthcare to a group of foreign health care executives.  Ninety minutes?  We probably needed a few weeks.  Most other countries have relatively simple systems, whether insurance coverage is provided by a government plan or by private insurance or some combination of these.  But in the United States insurance coverage, for those who have it, may be provided by Medicare Parts A, B, C, and D, 50 different state Medicaid programs (or MediCal in California), Medicare Advantage, Medigap plans, the Children’s Health Insurance Plan, the Women, Infants and Children Program, the Veterans Administration, the Federal Employees Health Benefits Program, the military, the hundreds of thousands of employer-provided plans and their insurance companies, or by the individual insurance market.  This insurance may be paid for by the federal or state governments, by employers, labor unions or individuals.  Some employers’ plans cover retirees, others do not. The result is that the system is pluralistic, mysterious, capricious and impossible for most patients and providers to understand.

Administrative complexity

The administrative complexity is amplified by the multiplicity of insurance plans.  About half of all Americans with private health insurance are covered by self-insured plans, each with its own plan design.  Employers customize their plan documents, led by consultants who make a good living designing their plans and tailoring their contracts. As one prominent consultant told me recently, if all the self-insured plan documents were piled on a table they would not just exceed the 2,700 pages of Obamacare, they would probably reach the moon.  For the rest of the commercially insured population, health plans may be traditional indemnity plans, Preferred Provider Organizations or Health Maintenance Organizations.

The coverage provided by different plans varies dramatically.  They may or may not include large or small deductibles, co-pays or co-insurance.  Beneficiaries may pay a large, small or no part of their health insurance premiums.  Some plans cover dependent family members and children, others do not.  The Medicare Part D pharmaceutical benefit plan involves a “doughnut hole,” which will disappear as health reforms are implemented.  Surveys have found that few people fully understand their own insurance plans let alone the bigger picture.  While health reform takes some steps toward standardization of insurance offerings and improving transparency, overall it is likely to increase complexity.

Physicians may be paid by salary, fee-for-service, or capitation, with “pay for performance” bonuses based on complicated metrics.  In order to get paid, most doctors and hospitals have to use many thousands of codes to describe the care they have delivered.  Doctors can spend hours a day doing this; hospitals employ tens of thousands of coders; insurance companies and government programs spend a small fortune entering and checking this coding.  A substantial proportion of payment claims are disputed, further increasing administrative costs and the “hassle factor.”

Some insurance companies are for-profit, some are not-for-profit.  Hospitals may be for-profit, not-for-profit charities or be run by federal government agencies such as the VA or the DOD or by cities.

The administrative complexity exists in the private and public sectors and in both for-profit and non-profit organizations.  Medicare is relatively efficient because it has a simple criterion for eligibility – your age (although it also covers people with disabilities).   But for many of us administrative complexity is rampant because health insurance is a function of our jobs or our income (or lack of it). Our insurance changes often (because our employers change their plans, because we change jobs or because our income changes), far more often than it does in other countries.  As a result we have armies of people who sell insurance, keep track of who is eligible for what, chase, authorize or deny payments, and lob faxes, emails and assorted missives at us and each other. In Los Angeles County, 1,900 people work on nothing but MediCal  eligibility with a union-mandated productivity target of completing two forms a day.   There are an estimated 150,000 such eligibility workers across the country.  The health reform bill proposes to expand Medicaid by 16 million so the number and cost of these workers will surely increase.

Regulatory complexity

Different parts of the healthcare system are managed or regulated by dozens of Federal government and state agencies, including the Department of Health and Human Services, the Center for Medicare and Medicaid Services, the Centers for Disease Control, the Veterans Administration, the Food and Drug Administration, and the Agency for Healthcare Research and Quality.  One report claims that the health care reform bill will create 183 new agencies, including state insurance exchanges and a Medicare Independent Payment Advisory Board (IPAB) and the Center for Medicare and Medicaid Innovation.

And then there are the acronyms.  If you don’t know them you will not understand much of the health policy debate: PPACA, DHSS, FDA, CMS, VA, CDC, AHRQ, SRG, MLR, HMO, PPO, PBM, COBRA, P4P, CER, EMR, HIT, DRG, FEHBP, WIC, CHIP, DSH, MMA, and many more.

I believe that this complexity is a major reason why we have (and this is very well documented) the most expensive, inequitable, inefficient and unpopular healthcare system of any developed country, with poor to mediocre outcomes.  The problem is not the doctors or the hospitals, but the system. Reimbursement, with its many thousands of points of public and private sector payment and the mindboggling payment rules, creates a bow wave of administrative costs and many perverse incentives.  And these costs are the incomes of powerful interests who fight to preserve them.

The American “system” is exponentially more complicated than the systems in other countries – and the reforms will make it even more complicated.  Unfortunately reform that would simplify the system is probably not politically feasible.  A benign dictator might scrap the system and start over with a much simpler system.   But in a democracy, with powerful interests and 17% of our economy involved, “you can’t get there from here.” We have to build on what we have, heaping complexity on complexity.

It is therefore no wonder that surveys find most people (including, it would appear, many members of Congress) understand very little about the health care system let alone health care reform.  A recent Harris poll asked people which of 18 items are or are not in the reform bill.  Modest majorities  were able to give the right answer for only 4 of the items.   And pluralities got the answer wrong on nine of the items.  For example pluralities believed that the bill includes higher income taxes for the middle class, new ways to ration care, a new government run health plan, cuts in Medicare benefits, increased payroll taxes and “death panels”.