Facilitating Interoperability

October 18th, 2013

Cross-Posted 10/18/13 from The Health Affairs Blog

A Health Affairs report on health information interoperability by staffers of the Office of the National Coordinator for Health Information Technology (ONC) provides a good enough summary of the situation. But it also is not news, and falls under the Bob Dylan Rule: You don’t need a weatherman to know which way the wind blows. From the article: “In general, limited interoperability across vendors, low motivation to share information in a fee-for-service payment environment, and the high cost of interfaces remain substantial barriers to widespread health information sharing.”

Two difficult but solvable structural problems block our exchange of health care information. The first is the “transport protocol.” Most health care data transport approaches lack the strong privacy and security safeguards that other industries now consider essential. The same industry that is moving toward clinical applications of mobile health, genomics, and nanotechnology still primarily relies on cumbersome, expensive faxes to transmit clinical information between organizations.

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The ACP’s Cognitive Dissonance

Brian Klepper

Relative to their specialist colleagues, primary care physicians have been generally passive about the politics that shape their professional lives, and they have been big losers. It is important for them to consider whether their societies are genuinely acting in their interests. I believe the evidence overwhelmingly reflects poor judgment by the societies that has diminished primary care’s prospects and, more importantly, caused significant harm to patients and purchasers.

Over at the ACP Advocate Blog on Wednesday, ACP Senior Vice President of Governmental Affairs and Public Policy Bob Doherty took me to task for asserting that the American Academy of Family Physicians is the only “pure” primary care society. He’s right, of course, in the sense that the American College of Physicians (ACP), the American Academy of Pediatrics (AAP) and the American Osteopathic Association (AOA) have done yeoman’s work in the past few years in promoting the value of primary care. He’s also right, and I stand corrected, on my statement that AAFP is the largest society. The information on Wikipedia shows that ACP has 130,000 members while AAFP has less at around 100,000.

As though any of this matters.

Source: Medscape Physician Lifestyle Report 2012, http://www.medscape.com/sites/public/lifestyle/2012

Continue reading “The ACP’s Cognitive Dissonance” →

A Litmus Test for Elected Officials

Brian Klepper and David C. Kibbe

Six months ago, who could have imagined that a large percentage of rank-and-file Americans would support the Occupy Wall Street (OWS) against special interests’ rigging of the American dream? So why not go to the next step? Why not pointedly ask political candidates, “Will you take money from lobbyists?” and “If elected, what will you do to stop special interest influence?”

Most Americans are deeply disturbed by this issue. In a recent Time Magazine poll of people familiar with the OWS protests, 86 percent thought that “Wall Street and its lobbyists have too much influence in Washington.” Gallup found that 68 percent of Americans think corporations should have less political influence.

These trends didn’t just happen. They resulted from special interests’ vigilant attention to legislative possibility, lubricated by the exchange of money for votes. Influence peddling is now so accepted in American politics that the Center for Responsive Politics (CRP) has established a lobbying data base, Open Secrets. But making lobbying contributions transparent hasn’t slowed the torrent of money that re-shapes law and wealth distribution.

Since 1952, the percentage of gross domestic product (GDP) represented by corporate taxes has plummeted from 6.1 to 1.0 percent, while the percentage represented by employment taxes has skyrocketed from 1.8 to 6.3 percent. Meanwhile, a just released Congressional Budget Office study confirmed that the top 1 percent of earners more than doubled their share of the nation’s after tax income over the last 30 years.

CRP’s numbers show that 13,000 lobbyists contributed $3.5 billion in Congress in 2010. Considering that Congress influences the flow and distribution of a $15 trillion national economy, these investments promote unfair advantages extremely cost-effectively. Politicians from both parties fund their campaigns with the money, shrug off the system’s financial conflicts, and apparently avoid thinking too hard about the consequences.

The intensifying ability of the powerful to buy America’s lawmakers’ votes is the greatest threat to the America that most of us grew up believing in. It is why the rich have gotten much richer, why large, profitable corporations pay no taxes, why health care costs have continued to explode, and why Americans’ social mobility is at an historic low. America has many difficult problems, but lobbying and the way we finance elections are among the deepest, facilitating many others.

Voters can facilitate rapid change by holding their representatives accountable. Asking our political candidates who they think they’re working for would be a simple but powerful way to bring America back into balance.

Brian Klepper, PhD is a health care analyst and the Chief Development Officer for WeCare TLC Onsite Clinic. David C. Kibbe, MD, MBA is Senior Advisor to the American Academy of Family Physicians and an industry advisor on health information technologies.

CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment

Brian Klepper and David C. Kibbe

Posted 10/25/11 on the Health Affairs Blog

By mid-November, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) must respond to the legal complaint filed in a Maryland federal court by six Augusta, Georgia family physicians.

These doctors are not asking for money, but for relief from the negative effects brought about by CMS’ twenty year reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC) for valuing doctors’ work. They are asking CMS to enforce the Federal Advisory Committee Act(FACA), which requires that regulatory agencies shield themselves from undue special interest influence. In the process, they are asking CMS to rethink Medicare’s approach to physician payment, with a mind toward recognizing and valuing primary care’s ability to treat the whole patient within a larger system of care. They are asking CMS to develop payment policy that supports the needs of patients over those of professional groups.

Continue reading “CMS’ Opportunity: A Lawsuit Offers A Chance To Reform Physician Payment” →

Primary Care in Revolt

Brian Klepper

Last Thursday Anna Wilde Mathews of the Wall Street Journal ran an article detailing the activities surrounding primary care’s gradual awakening and mobilization. With Tom McGinty, Ms. Mathews authored a damning expose on the RUC last October that precipitated our efforts on against CMS’ 20 year reliance on the AMA’s RVS Update Committee (RUC) for valuation of medical services.

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A Legal Challenge to CMS’ Reliance on the RUC

Brian Klepper and David C. Kibbe

First posted 8/09/11 on The Health Affairs Blog

This week in a Maryland federal court, six physicians based at the Center for Primary Care in Augusta, GA filed suit against HHS Secretary Kathleen Sebelius and CMS Administrator Donald Berwick. The complaint, spearheaded by Paul Fischer MD with DC-based lead counsel Kathleen Behan, alleges that the doctors have been harmed by the Medicare payment structure developed through the agencies’ reliance on the American Medical Association’s Relative Value Scale Update Committee (RUC).

The suit also claims that the agencies have functionally treated the RUC as a federal advisory committee. But they have not required the RUC to adhere to the Federal Advisory Committee Act’s (FACA) stringent management and reporting rules – e.g., balanced representation, transparent proceedings, and scientifically valid analytical methodologies – that keep the proceedings in the public interest. The plaintiffs request injunctive relief, which would freeze the relationship between CMS and the RUC until the advisory group complies with FACA’s requirements. Of course, compliance would drastically change the way the RUC conducts its affairs, something it is almost certainly loathe to do.

Continue reading “A Legal Challenge to CMS’ Reliance on the RUC” →

Rethinking the Value of Medical Services

Brian Klepper and David C. Kibbe

First posted 8/1/11 on The Health Affairs Blog

One of American politics’ most disingenuous conceits is that health care must cost what we currently pay. Another is that the only way to make it cost less is to deny care. It has been in industry executives’ financial interests to perpetuate these myths, but most will acknowledge privately that the way we value and pay for medical services is a deep root of America’s health care cost explosion.

When the Resource-Based Relative Value Scale (RBRVS) became the framework for Medicare payment nearly twenty years ago, it equated a medical service’s “value” with four categories of physician work inputs: time, mental effort and judgment, technical skill and physical effort, and psychological stress. The assessment process, handled from the outset by the American Medical Association’s (AMA) secretive, specialist-dominated Relative Value Scale Update Committee (RUC), delineates and quantifies a service’s inputs in terms of its Relative Value Units (RVUs) which, with a monetary multiplier, define its worth.

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Why Its OK That EHR Adoption Will Fall Below 2011 Goals

David C. Kibbe and Brian Klepper

First posted 7/06/11 on Kaiser Health News

2011 will be a disappointing year for the Centers for Medicare and Medicaid Services and the Office of the National Coordinator’s electronic health record incentive programs. We predict that few doctors and hospitals will meet the objectives set for the “meaningful use” of certified EHR technology. Meaningful use is, of course, the term that describes the objectives and measures providers and hospitals must meet in order to receive financial bonuses authorized by Congress in the HITECH portions of the economic stimulus bill of 2009. David Blumenthal, the former national coordinator, had hoped large numbers of doctors and hospitals would adopt EHRs starting in 2011, the first year bonuses are available. But, in reality, by the end of the year the percentage of physicians using EHRs won’t likely rise much above the current 20 to 25 percent rate.

This isn’t necessarily a bad thing. This year and, to a lesser extent, 2012, could be for “cleaning house.” Many older, costly and difficult-to-implement legacy EHRs will be replaced by less expensive, more agile systems that have been developed specifically for meaningful use and are deliverable in the cloud as Software-as-a-Service. Transitions like these take time, but the dynamics are foreseeable.

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A Physician Fallow Program To Improve Quality, Safety and Costs

David C. Kibbe and Brian Klepper First published 6/22/11 on the Health Affairs Blog

In a recent New York Times op-ed, Rita Redberg MD, a cardiologist and Chief Editor of Archives of Internal Medicine, described the American health system’s penchant for delivering high volumes of “procedures and devices [to] patients who get no benefit and incur risks from them.” The culprit, of course, is fee-for-service reimbursement, used by Medicare, Medicaid and commercial health plans for the past 50 years, which encourages physicians to order more products and services, independent of appropriateness, with few checks and balances. Dr. Redberg notes the estimate by Medicare’s Chief Actuary that as much as 30 percent of Medicare’s expenditures — up to $150 billion/year, or about 9.4 percent of this year’s US budget deficit of $1.6 trillion — provides no value at all to patients. A 2008 PricewaterCoopers study put the waste estimate at nearly 55 percent of total national health care expenditures, a figure that, in 2011, would translate to almost $1.5 trillion, or just a shade under this year’s deficit. Continue reading →

Creating Value-Based Incentives for Primary Care

Brian Klepper and David C. Kibbe

First published 6/2/11 on the Health Affairs Blog

In a remarkable recent interview, Donald Berwick MD, Administrator of the Centers for Medicare and Medicaid Services (CMS), eloquently described his vision of value-based health care.

Paying for value is an incentive…The underlying idea of improvement is that American health care, historically built in fragments, often cannot achieve for patients what it really wants to achieve…Health delivery system reform refers to really reconfiguring care into much more seamless coordinated-care operations so that people, especially those with chronic illnesses, experience continuity of care over time and space.

So when patients come home from the hospital, there is a smooth handoff, and all the necessary information follows them. When they are seeing a specialist, that specialist is coordinating care with their primary care doctor.

Continue reading “Creating Value-Based Incentives for Primary Care” →

Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?

Brian Klepper and David C. Kibbe

First published 10/30/2008 on The Health Care Blog

Brian’s Note: Recently I received a note from a New Jersey primary care physician who argued that, even more than Medicare, the health plans are killing primary care through extraordinarily low reimbursements. He wrote:

Through state legislation and regulatory changes over the past 10 years commercial carriers are now routinely and consistently paying less than Medicare in New Jersey. Last year Aetna dropped to less than 65% of the local Medicare rate for a complex office visit. This year, in my county, CIGNA dropped to 51.5% for the same office visit, and that’s when the RUC, as flawed as it is, declared that 53.5% of the full Medicare rate was what the practice overhead should be. So now CIGNA is officially paying less than what the undervalued RBRVS system states is the cost of care.

To my mind, this type of reimbursement cannot be interpreted as anything else than an intentional effort to stifle primary care and it’s moderating influence over specialty, outpatient and inpatient excesses. While a robust literature – first by Barbara Starfield and more recently in Health Affairs – has nailed down that more primary care reduces risk and cost while improving quality, America’s health plans continue to pay primary care through volume-based reimbursement that functionally shortens office visits, increases specialty visits and diminishes our supply of primary care doctors.

David Kibbe and I asked about this problem this two and a half years ago. See below.

Sometimes a whisper is more powerful than a shout. Below is a cartoon from Modern Medicine that shows a Medical Home counseling session between a primary care physician (PCP), a specialist and the health plan. The PCP looks forlorn, while the specialist and the insurer have their backs turned, fuming. It is perfectly true.

Along with changing the way we pay for all health care and creating far greater pricing and performance transparency, we need to turn around the primary care crisis if we hope to substantively improve quality and cost.

Continue reading “Can Health Plans Explain Why They Aren’t Re-Empowering Primary Care?” →

EHRs for a Small Planet

David C. Kibbe and Brian Klepper

First published 1/09/10 on The Health Care Blog

Right now, American health care information technology is undergoing two enormous leaps. First, it is moving onto Web-based and mobile platforms – which are less expensive and facilitate information exchange – and away from client-server enterprise-centric technologies, which are more expensive and have limited interoperability. In addition, more EHR development activity is headed into the cloud, driven by large consumer-based firms with the technological depth to take it there. Both these trends will facilitate greater openness, lower user cost, improved ease of use, and faster adoption of EHRs.

But they could also impact the shape of EHR technologies in another profoundly important way. What is often lost in our discussions about electronic health record technology in the US is the relationship these tools have to our health and health care problems…globally. We could be designing our health IT in ways that are good for the health of people both here and around the world, not simply to enhance care in the US.

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AAFP Partners With Surescripts On A New, Secure Electronic Messaging Service For Physicians

BRIAN KLEPPER

Here’s an extraordinary development in the ongoing efforts to break down the barriers of a lack of interoperability standards and incompatible technologies!

The American Academy of Family Physicians has partnered with Surescripts, a firm that connects physicians with drug prescribing services, to announce a new collaboration, AAFP Physicians Direct, that will allow the AAFP’s physician members to easily and securely exchange information electronically.

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Outing the RUC: Medicare Reimbursement and Primary Care

JOSH FREEMAN

Originally published 2/2/11 on Medicine and Social Justice

Along with many others, I have written extensively about the need for more primary care physicians in the US. I have also addressed the various disincentives that exist for medical students to enter primary care specialties, such as family medicine, rather than narrower subspecialties or procedural specialties. One of these is the lower income earned by doctors in primary care; this is felt by many to be one of the major issues in specialty selection, and is increasing in importance as students graduate from medical school with larger and larger debt burdens, often exceeding $200,000. A study by the Robert Graham Center of the American Academy of Family Physicians (AAFP), “Income disparities shape medical student choice”, finds that the difference in income between primary care on subspecialists has been increasing since 1981, and that by now there is a difference of $3.5 million in the lifetime income of the average subspecialist (not even the most highly paid) and the average primary care physician.

Continue reading “Outing the RUC: Medicare Reimbursement and Primary Care” →

Clinical Groupware: Platforms, Not Software

DAVID C. KIBBE and BRIAN KLEPPER

Originally published 4/24/2010 on The Health Care Blog

Clinical Groupware is rapidly gaining acceptance as a term describing a new class of affordable, ergonomic, and Web-based care management tools. Since David first articulated Clinical Groupware’s conceptual framework on this blog early last year — see here and here — we’ve been discussing Clinical Groupware with a growing number of people and organizations who want to know what it is, where it’s going, and what problems it may solve, particularly for small and medium size medical practices, their patients and their institutional/corporate sponsors and networks.

Continue reading “Clinical Groupware: Platforms, Not Software” →

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DAVID C. KIBBE and BRIAN KLEPPER

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