Every once in a while I find that America’s acclaimed free market health care system (it’s a joke, folks, just a joke) has hit a new bottom. Today I found a piece in Health Business Blog that asked

Are you commercially insured with cancer, heart disease or an orthopedic problem? If so, you are a juicy marketing target for hospitals, which drool over the prospect of high fee for service reimbursements. USA Today (Hospitals mine patient records in search of customers) explores how hospitals are combining their own data with information from consumer marketing agencies to pinpoint likely customers for their services.

Give me a break! It’s one thing to mine data for its public health implications, or for clinical trials, but IMHO it is quite another to use my personal health data for marketing purposes. The original article from USA Today told the story of a middle-aged smoker who got a targeted postcard offering him a lung cancer screening. Other people in the service area of the hospital did not get the same postcard.

The non-profit facility is one of a growing number of hospitals using their patients’ health and financial records to help pitch their most lucrative services, such as cancer, heart and orthopedic care. As part of these direct mail campaigns, they are also buying detailed information about local residents compiled by consumer marketing firms — everything from age, income and marital status to shopping habits and whether residents have children or pets at home.

Why, because in our current system, employer-based insurance foots the bill for uncompensated care (the poor) and Medicare/Medicaid patients. That’s the Great American Cost Shift, in which because we don’t have a universal health care system, some of us pay sky-high premiums to insure the rest of us. If I were part of the commercially insured segment,  wouldn’t fight for the continuation of this system for a single minute more.  You are not fortunate, as your premiums go up and your co-pays increase: rather, you are paying for every senior and every poor person whose care is not reimbursed adequately by the government.

I’ve never understood why people whose employers offer health insurance are not in favor of universal health care. Do they think they will lose the ability to choose a physician? I didn’t when I went on Medicare, and my foster kids who are on Medicaid can also choose their physicians.

In the mean time, the system deteriorates and becomes more expensive for those who pay. The hospitals are not forced to change their business models; they are only forced to become better data miners and targeted marketers. But is that what we want our hospital to be known for?

Perfect example of kicking the can down the road: the Senate prevented a cut in Medicare payments for doctors during the month of December, so they could kick it down the road to the new Congress without freaking out seniors. They still haven’t figured out they could fix it permanently, and are only going for a one year fix next time, too. How would you like to run a doctor’s office under these conditions?

I ran a medical office for my husband in 1996.  Even then it was a constant battle to figure out what we could afford during constantly changing reimbursements. It was so complicated: what health plans were “worth” participating in, because they all reimbursed differently, in different time periods? What was the right combination of Medicare and private patients? How did you achieve that combination without turning people away who needed diagnosis (my husband was a radiologist)?  My husband’s office lost money every month.

And how do you staff for this constant change?

At that time, it was the private health plans that called the shots and the government that was the payer you fell back on. Now, the source of uncertainty is more and more about the government as it mangles the legislative process on one end, and then subjects providers to Recovery Audit Contractors on the other end. As of this year, not only will every region be audited for overpayments, waste, and abuse of Medicare funds, every state will also have to look at abuse, waste and fraud in Medicaid funds. And if there’s a mistake, the provider will have to dispute the claim or give the money back to the government.

More paperwork. More staff. More records management and claims management. Mor uncertainty Less treatment.

I usually write from the patient perspective, but today I’m reaching back in time for my provider hat, which is not so different from my entrepreneur hat.

You can’t run a small business with employees if you don’t know what the government will do from one day to the next and if you have to give back money you have already collected and probably used. If you have to pay claims specialists, coding specialists, IT specialists, medical records specialists, you can’t pay doctors or even nurse practitioners.

Everyone points to job growth in health care as an opportunity to get us out of the recession. And yet we all know nurses who have been laid off, and doctors who are leaving practice.  Why? Because health care job opportunities aren’t really in providing care; they are in providing support for audits and management of budgets.

No matter which side of the political fence you are on, this is a startling situation, reported this morning in the Wall Street Journal– not a liberal rag:

For the first time, government programs next year will account for more than half of all U.S. health-care spending, federal actuaries predict, as the weak economy sends more people into Medicaid and slows growth of private insurance.

The figures show how federal and state spending is taking a bigger role while Congress hesitates over a health-care overhaul.

Government health programs are a growing burden on the federal budget, which is running annual deficits of more than $1 trillion, and rising health costs continue to batter private industry.

By 2020, according to the new projections, about one in five dollars spent in the U.S. will go to health care, a proportion far beyond any other industrialized nation.

“It’s going to be a desperate issue five to 10 years out,” said Gail Wilensky, the former top Medicare official in the George H.W. Bush administration. She said the U.S. will have to decide soon between raising revenue to pay for Medicare or reducing benefits.

Public funds accounted for 47% of the $2.34 trillion of national health spending in 2008, the last year for which figures are available. The federal Centers for Medicare and Medicaid Services estimates in a paper to be published Thursday in the journal Health Affairs that the proportion will rise to 50.4% by 2011. Last year, the federal actuaries had predicted the 50% mark wouldn’t be reached until around 2016.

Obama isn’t making this up. Health care is an issue for the entire economy. Let’s imagine for a moment that we want to reduce Medicare benefits. That might be a way to solve the problem, so we ought to look at it first, because no one likes her taxes raised.

But the Baby Boomers started turning 60 last year. They have paid into Medicare for their entire careers. How do you think they, the largest cohort in our history, would feel if their benefits were lowered just as they were coming in to Medicare? That would be pretty fun to watch. And the Seniors come out and vote if someone even threatens Medicare Advantage, the bloated private program that provides gym memberships and other bullshit that regular Medicare does not, and overpays the private insurers for managing the extra benefits. So anyone who advocates for Medicare cuts gets his head handed to him.

As for Medicaid, its growth is a function of the layoffs in the work force. If you let the working population get sick and die, who will support the economy? Not to mention their children, who are already being rejected by government programs in Arizona.

It’s really hard to avoid the cold hard truth: we need comprehensive reform, whether that takes the government further in or further out. Where things are now won’t stand. And that reform has to address COST FIRST. Cost of delivery, cost of private insurance to individuals and small businesses, cost of new technology, cost of pharmaceuticals, and the inevitable cost of doing nothing. The health care industry — and it has become an industry — has to lower its prices and thus its cost of doing business, or it will go out of business, replaced by a disruptive technology, like Ayurveda or naturopathy.

Every year, Medicare tries to cut payments to providers, and can’t. Why? Because if providers are paid little enough, they won’t continue to provide services (that’s already happening). They hold the government hostage, while taking home their profits. Silly government, outsmarted by the private sector again.
That’s why the simplest thing to do would have been to create a single payer system, in which the cost of everything was pre-determined by the single payer (could be either public or private) and everybody in the supply chain had to accept the price. That’s what Wal-Mart does to keep prices down — it squeezes the suppliers. That’s what Wal-Mart does. Why do you think clinics in Wal-Mart have been so successful?

We like Wal-Mart. We like the every day low prices. So much so that we allow the company to control wages. So why not establish a Wal-Mart system of health care. Cheap, and not necessarily of high quality (good enough).

The last alternative is to raise taxes. That will send people into a tailspin. But I bet it happens, because Americans are not willing to settle for reduced benefits, or reduced quality, or reduced cost of care.
In Denmark, if you buy a car, there’s a 200% tax. Sounds shocking to me, but people continue to live in Denmark. And they have health care. It’s a trade-off.

A few years ago, my partners in AHITA.org ( a non-profit organized to help providers implement EHRs)  and I implemented an electronic health record in a physician practice. Along the way, we evaluated every major product and discussed with the physicians in the practice what they needed and how to examine their workflows to automate.  It was very effortful, took almost a year, and cost the physician practice about $50,000 in consulting fees.  At the end of the engagement, the AHITA partners decided in all good conscience that all the products sucked and wouldn’t help a small practice; we kind of drifted away from the idea of electronic health records. Our physician partner, who had written his own EHR, gave up in disgust because he couldn’t get anyone to buy it.

Now, Obama’s administration has given incentives that mandate EHRs. 2010 looks like it is going to be the year. And hopefully, many of the products have improved in their ease-of-use and financing programs during the past couple of years. There’s a lot of behavior change around implementing new technologies, and even practices that already own EHR technology need to learn to use it properly to qualify for the meaningful use incentives the government is offering. For most practices, this will mean an increased focus on workflows around ordering, e-prescribing, and clinical decision support and some attention to improving them, not just automating disfunction.

As far as I can discern from listening to the Allscripts webinar I just heard, many of the incentives revolve around seeing more Medicare and Medicaid patients.  All those physicians who were going to give up Medicare patients will be re-thinking that, because to qualify for the stimulus money they have to prove that 44% of their volume is Medicare, or 30% is Medicaid. And this is calculated by individual physician, not by practice.

For a physician, the Medicare part of the program starts this year. But this year you only have to prove that you used electronic records for 90 days during the year, and that at least 50% of your patient encounters have to be at a practice using a certified EHR. That goes up with every passing year.

Another interesting incentive: the physician’s payment will be based on multiplying his or her allowable charges  by 75%, so seeing a Medicare patient and using an EHR should make the patient (me) worth 75% more to the physician who sees me, especially if he delivers professional services, and doesn’t just send me for an MRI or to a lab. The incentive doesn’t count  fees for surgicenters or technical components of a doctor visit. This will be Medicare Part B services. (A physician aiming to collect $18k in 2011 has to submit allowable charges of $24k to Medicare and she will get paid $24k+$18k).

Physicians have to choose whether they want to participate in the Medicare part of the incentive program, or the Medicaid part. For a busy primary care practice, I bet Medicaid patients begin to look more attractive.

Now, away from the money and on to the part that benefits the patient:

Your doctor will now have to use five decision-support alerts in her software, and will have to give you electronic access to your records within 48 hours of your request. The incentives encourage the patient to become part of the conversation, and the doctor to communicate with the patient electronically. The government wants people to use personal health records, and for the physician to communicate with those PHRs, and that is going to happen FAST.

Here’s what the EHRs these physicians adopt will be required to do for the physician to get the subsidy:

• Electronically select, sort, retrieve, and output a list of patients and patients’ clinical information, based on user-defined demographic data, medication list, and specific conditions.
• Calculate and electronically display quality measure results as specified by CMS or states.
• Electronically submit calculated clinical quality measures
• Electronically generate a patient reminder list for preventive or follow-up care according to patient preferences based on demographic data, specific conditions, and/or medication list.
• Implement automated, electronic clinical decision support rules (in addition to drug-drug and drug-allergy contraindication checking) according to specialty or clinical priorities that use demographic data, specific patient diagnoses, conditions, diagnostic test results and/or patient medication list.
• Automatically and electronically generate and indicate real-time, alerts and care suggestions based upon clinical decision support rules and evidence grade.
• Automatically and electronically track, record, and generate reports on the number of alerts responded to by a user.
• Electronically record and display patient records and connect with other providers
• Patient information: electronic copy upon request in 48 hours80%
• Patient access to electronic information (i.e. lab results) within 96 hours of availability10%
• Clinical summary of each patients’ insurance eligibility, and submit insurance eligibility queries to public or private insurers

All the major products do this in one way or another. This doesn’t make them easier to deploy or train staff on, or use. Or make the change management any easier (that’s the part I do).

However, this sounds very promising for both the patient and the physician. And it’s not part of health care reform legislation, it was part of the stimulus, so we know it’s going to happen.

Makes me remember when electronic claims processing came into widespread use — which was not until Medicare mandated sending them electronically in order for physicians to get paid.  You’d be surprised how fast paper claims disappeared:-)

Now that the big “debate the bill” vote is passed, we have a week for pundits on both sides of the aisle to misinform the public about what the future of the health care reform bill is. There are two tunes, one theme, and melodies underneath both. There’s an unsung chorus or two in there, too.

The Progressive Theme: Reconciliation

Progressives are pressing ahead with petitions, blog posts, and swarms to advance the idea that health care reform — or more specifically, the public option — should pass using the arcane and somewhat unrelated escape hatch of reconciliation to force a vote which requires only a majority to pass.

Proponents argue that reconciliation does an end run around the filibuster and takes the ball to the goal. And it does, in a strange, stripped-down way. Here are some examples of reconciliation legislation in the past:

1. Bush Tax Cuts Because they were passed via the reconciliation process, they expire at the end of 2010. Not particularly helpful to health care reform to have provisional reform that is not permanent.
2. COBRA the last attempt at health care reform that was ultimately diluted to something that screwed laid-off and terminated workers more than not having insurance at all.
3. TEFRA – The Tax Reform Act of 1986 It had something for everyone, but again, no meaningful social legislation and certainly nothing that had a deeper impact than the bottom line of form 1040.

It’s been suggested to me that the purpose of putting the full court press on reconciliation is to let Reid in on the worst-kept secret of our time: The public option matters to progressives and they believe it is the magic amulet to force insurers and providers to keep costs down. More rebuttal to that in my Unsung Chorus sections.

I think pressure is good. I think engagement is good. What I don’t think is good: signalling desperation to one’s opponents. There are other, better ways to work this through the process.

The Conservative Theme: Everyone hates health care reform

This is the current media and pollster theme. Everyone hates it, it’s not popular, so Congress should drop it. I could argue with their logic or foundations for making a statement like this, but it would be a waste of time. Nevertheless, this will be what we will hear from now on — that we, the people do not want health care reform. That we really, really like being denied by insurers, excluded from coverage altogether, or losing everything we’ve worked hard to save and own, like our houses.

Think about that next time you hear the theme. The press wants you to scrap any possibility of equalizing access to health care, because a pollster (and a conservative one at that) is telling us that we really hate ourselves enough to leave the status quo.

That’s logic worthy of Sarah Palin and Glenn Beck. Oh wait! They’re probably the lead singers.

And yes, there is a nod to tort reform, which is such a comprehensive topic it should not be contained in a bill about health care reform. Still, it acknowledges that it’s been suggested as a possible cost-saver in the larger scheme of things.

The Lieberman Riff: It’s all about me

Joe Lieberman. In his quest to get whatever it is Joe wants that he doesn’t have right now, he is standing tall for…Joe. I’m guessing a few more vigils like this one won’t make a huge difference, but ultimately Joe will get what Joe thinks he wants, until Joe gets tossed out of office by constituents who overwhelmingly disagree with him.

Unsung Chorus #1: Conference Committees matter

Back in September, the President held a conference call with progressives where they composed a strategy. The song went like this:

1. Get the bills out of the committees. Check.
2. Get the bills onto the floor of the House and Senate. Check.
3. Pass the House bill. Check.
4. Pass the Senate bill, even if it means adding triggers to the public option. Half a check for opening debate. Let’s see if Snowe introduces an amendment calling for triggers. If she does, it gets a full check.
5. Pass the Senate bill with 60, where one of the 60 is Snowe or Collins. Bill has triggers for public option.
6. House/Senate bills go to conference committee for merge. In Joint Committee, trigger is stripped from public option by House progressives on the committee. Conference report goes back to House and Senate, needs 51 to pass the Senate and we’re done.

Unsung Chorus #2: The whole is greater than the sum of its parts

While progressives’ intone the chorus that without a public option, health care reform is no reform at all, the truth may be something different. What the public option clearly does (and why it’s being fought tooth and nail by moderates and conservatives) is open the door to a single payer system somewhere down the line. Otherwise, it’s another choice bundled with other choices, only a public choice as opposed to a private one. I’ve seen arguments that suggest it will be the only choice that will offer a patient-centered approach, but I really think that’s idealism. Under one administration it may be something different than it would be under another. We’ve seen that with Medicare, and there’s nothing that convinces me it wouldn’t be true with a public option.

That doesn’t mean I’m against it. It just means I want everyone to step back and look at the larger picture.

The more delicate and complex melody lurks underneath the sound and fury; namely this: the entire package makes such fundamental changes to the system that it is indeed major reform that will bring the cost of health care down, with or without a public option, with or without triggers for a public option, with or without opt-outs for a public option.

No, I did not blaspheme.

Consider the analysis done by Tim Jost over at the Health Affairs blog. His evaluation is striking in its clarity:

This year’s health reform legislation has often been criticized for being health insurance reform rather than health care reform, and for not doing enough to control the cost of health care. Those who offer these criticisms have obviously not read the bills or even tried to understand them.

Jost goes on to outline how, between the two bills, just about every viable suggestion by credible sources and/or studies has been incorporated into the bill. Outcomes-based payment systems, payment bundling, quality reporting, electronic health records, patient-centered outcomes research, etc, etc. The list goes on.

These are not provisions contained in the consumer protection section of a nine-section bill. They are part of the other facets, which when put together create a new and wonderous thing. Here are the nine facets of health care reform addressed in the Senate bill.

• Title I – Quality, Affordable Health Care for All Americans
• Title II – Role of Public Programs
• Title III – Improving the Quality and Efficiency of Health Care
• Title IV – Prevention of Chronic Disease and Improving Public Health
• Title V – Health Care Workforce
• Title VI – Transparency and Program Integrity
• Title VII – Improving Access to Innovative Medical Therapies
• Title VIII – CLASS Act
• Title IX – Revenue Provisions

There are some comprehensive and major paradigm shifts in this bill. That list of nine facets adds up to something greater than the presence or absence of a public option. This is what is being lost in the public debate over, and over, and over again. The finer cuts in each of those facets are the best ideas — regardless of the party who introduced them — for reforming the entire system.

It’s easy to fixate on one cut of one facet and think you’ve heard the whole mix, but it’s a little like pointing to “Yellow Submarine” as the seminal Beatles work of their career while ignoring masterpieces like the White Album. President Obama is a man of long strategies, not short-term end runs.

Let’s sing this song, loudly. If we don’t, it won’t matter what passes. It will all play out as some sort of loss for President Obama and the Democrats when in fact, it will be a huge win for each and every person who lives in these United States.

(cross-posted from odd time signatures)