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Saturday, March 8, 2014
CMS opened three “War Rooms” during the start of the Health.gov website. It was a high priority for the White House Chief of Staff, Denis McDonough who commuted almost daily between CMS headquarters in Bethesda, MD (home of CMS) and 1600 Pennsylvania Avenue. It was so disorganized that 3 war rooms were needed either by design or by default.
The ‘Joint Chiefs’ of Health.gov included CMS head Marilyn Tavenner, Jeanne Lambrew, HHS head Kathleen Sebelius. The group failed to find ‘actionable intel’ about how and why the website was failing for all to see They resorted to opening their laptops at the White House and tried to log on to health.gov .
The initial findings were the website was not able to process the number of simultaneous users. Five days after it’s opening Todd Park, the U.S. Chief Technology officer told USA today health.gov was designed for 50,000 and 250,000 attempted to use it at the same time. The real amazing fact was that Todd Park was never involved in the design of the system. Park is a highly successful health-care tech entrepeneur. During the redesign it was found the site was designed to only handle a few thousand users.
Chief of Staff Denis McDonough’s assignment was to determine if it should be abandoned entirely. Yes, on October 17 the President was ready to scrap the whole thing.
Altlhough we have witnessed the growth of EMR acquisition an overwhelming number of remain skeptical. Many plan to dispose of their current EMR and invest in new systems.
Medical practitioners are basically applied practical scientists, and have relied on science based on ‘big data’ derived from clinical trials and peer reviewed data accumulated over many years. It is therefore somewhat of an enigma why they would be unhappy with elctronic medical records which surely has the capability of reliably gathering and recording data and also the availabilty for analytics.
The installed base by fait accompli has established an infrastructure which could be compared to vs DSL as compared fiber-optic internet This was encouraged largely by federal incentives and a rush to establish a national network. The aspects of interoperability were then layered upon the electronic medical record, and also “meaningful use’ which is a misnomer since it has nothing to do with meaningful use on the provider side of the equation. Meaningful functionality was neglected in encouragement of ‘the adoption of EMRs. Caution was advised over a decade ago that the current generation and versions of electronic health records was ill suited to the task.
1. Our study ten years ago revealed that the human-interface was ill-suited to patient-provider interaction. This due to the discontinuity between face-to-face interaction in a patient and provider encounter and the unfriendly user interface
2. The data entry in the form of clinical history, and physical examination input is not in the structure that physicians use in conventional medical written medical records. This creates more distraction and loss of efficiency as the provider struggles to be accurate in recording a clincal encounter. Some EHRs force the provider to enter some date prior to moving along to the next step. After some time Providers familiarize themselves with the routine flow, however many times there may be an entry or section with which the provider is not familiar. These systems were not designed in an era of user friendly, nor intuitive navigation in the Electronic Health Record. Graphic User Interfaces (GUI) are almost unknown in most EHRs.
3. Medical Economics published a recent survey of providers revealing the significant majority of MDs (75%) who are very dissatisfied with their present electronic medical record. And now many plan to replace their current system. 45% of 967 respondents to the survey indicated patient care is worse with EHR devices, and 67% said their investment was not worthwhile.
The good news is that the IT industry is eager to profit from this revolution of Health Information Technology. The Industry has a specialized organization known as the Health Information Society, also known as “HIMSS”. The group has a collection of IT, health consultants, physicians, hospital administrators (CIOs, CTOs) and others who collectively work together to advise the industry, vendors, and software developers about what is needed by health providers and data analystis.
Black Book ranked EHR providers for 2014 scoring vendors across six different client experience categories.
EHNAC and WEDI will certify an assurance of quality and functionality of software for providers..The goal is to enhance usability for providers. This is a step in the right direction.
In late February 2014 the Institute on Medicine’ Roundtable on Value and Science Driven Health Care published a discussion paper on Return on Information….a standard model for assessing institutional return on investments for electronic health records.
The formation of accountable care organizations presents many challenges, and many needs for information technology to synthesize patient care across a continuum.
Measurements and a standard model are needed to compare different institutional experiences implementing different technologies and approaches for accountable care organizations.
While the emerging roles of patient, family and public participation are acclaimed to be a necessary componet for improved health the IOM discussed the changes as possibly disruptive innovations on affordability, quality and outcomes in health and health care.
The Affordable Care Act is much more than health care financing and healthcare. As time elapses and the internal workings of the ACA as well as reactionary events on the part of insurers take hold there will be many surprises.
Some have already ocurred.
Politics and political correctness have created an image of ‘consumerism’ for health care. That image creates a “Wild West”, rather than a scientific approach. It created the illusion that health care has been a ‘free market’. That is not true. Access to care is throttlel by employers who chose what plans employees can access, and there are regional and state differences as well. Layer upon that limitation providers and hospitals select the plans they accept. Some of these plans refuse to accept certain policies due to low reimbursement and/or cumbersome bureaucratic requirements.
The ACA has levelled the field in some respects by standardizing the offerings among health insurance companies.
It is still too early in the adoption of the ACA, however some ‘cracks’ have appeared.
Consumer Power Report
Contributors: Heartland Institute (Benjamin Domenech), The Washington Examiner,Michael Canon, The Arkansas Times, The Hill, Time, the John Loche Foundation, The Daily Beast,
Obamacare is affordable, so long as it’s outside Obamacare
The Washington Examiner reports there are many cheap and affordable plans, if they look outside the Obamacare Exchanges. A careful study compared the offerings of the healthcare.gov health benefit exchanges vs private wesites, such as e-HealthInsurance, and finder.healthcare.gov. President Obama enabled this by unlawfully altering subsidies to include policies outside health.gov.
Since the ACA was passed the Obama administration has used the law of “standing” to implement the act.
This change introduced the concept of ‘moral hazard’ whereby lower copays lead to more demand for provider visits, and conversely higher copays will cause exchange patients to avoid visits to the doctor. This feature creates differences in cost sharing and prompted insurers to consider ‘declatory judgement’ to challenge the new guidance OBAMACARE’s health exchanges will also trigger illegal taxes against employers.
The Obama administration is in a rush to enroll as many people as possible to create as much difficulty for repeal in 2017 . Human nature being what it is , who would give up a free product ? It is still too early to know how effecive, or not the exchanges have been until March 31 when enrollment ends for 2014 and we find how many actually paid their first premium.
Politics play a major role in the recurring delays implementing the Affordable Care Act.
This week the White House will announce a new directive to allow insurers to continue offering health plans that do not meet OBAMACARE’S minimum coverage requirements. The ‘keep your plan’ fix avoids another wave of policy cancellations. The timing of the delays is more than fascinating. The extensions go beyond the midterm November elections and in some cases beyond the the end of Obama’s last term. Obama
Could the Affordable Care Act be a thinly disguised ‘bail out’ for an industry responsible for 1/6th of the economy? We have witnessed bail outs for two other ‘too big to fail’ segments of the economy, the financial and the automobile industry. There are some aspects to this thought.
The initial goal of recruiting young people has still not been accomplished and will not be known until the enrollment deadline of March 31 when final figures become availabale of who has paid premiums.
The 2015 White House Budget includes a ‘slush’ fund of $ 5.5 billion for Obamacare. The ACA creates a temporary pool of money known as risk corridors to pay for insurers who enroll a higher-than-expeted number of sick patients through 2016. The financial device intends to transfer money from lower risk plans to higher ris plans to keep premium prices stable. Republicans say the government is likely to be is likely to make some of those payments, which they say would be tantamount to a taxpayer bailout of the insurance industry.
Our health system developed over the past four decades in a reactionary manner to meet the immediate demands of the time. During this same time science and technology grew so quickly we are now unable to afford these advances for all.
The affordable care act may increase access to more for advanced treatments. Because of the increased demand insurers themselves will increase the necessity for prior authorization according to their own set of parameters. The ACA provides no guidelines for these standards. Undoubtedly in the name of equanimity these standards would apply to non-ACA as well as ACA patients.
In the past there was no overall plan to integrate reimbursement for health providers. The Affordable Care Act, attempts to modify this course, but also creates major challenges for the overall economy, national debt, and business expenses.
Many states have refused to participate in the expansion of Medicaid to cover some of the uninsured, despite federal subsidies for several years to fund the increased cost.
Our approach has been much like that of Henry Ford who created mass production and educated students for specific jobs. The object of public schools at that time was to produce workers for specific jobs.
What has happened is the job market has changed radically. How many college graduates can not find jobs in their chosen area upon graduation ? We have been educating students for jobs of the previous century, which no longer exist. We no longer see vocational schools, no apprenticeships. Certfication has become a lifeline for proving a skill, and education has become expensive as the educational-industrial complex has grown.
Economic productivity can no longer be measured by the number of widgets built, nor can reimbursement for health care continue to be strictly fee for service. True incentives should be available for innovation and creativity in deliverying more health care, while increasing quality of life and wellness.
There are several challenges to this paradigm shift. How do we measure quality improvement or a decrease in quality. What are the metrics ? One of the first measures imposed by CMS has been the readmisson rate to hospital within 30 days of discharge. Patient compliance is a nother measure being used in some practices...how often is blood glucose, blood pressure, weight, and medication complicance. What is the availability and use of patient education, tutorials, and appointment compliance?
A more accurate measurement may be the real measurement of clinical condition such as control of blood pressure, blood glucose, weight, pain control, ambulatory and functionanl ability.
Will there be a reward or improvement, and/or a penalty for failure to improve a measure? What will the factor be for these changes?
Finally are these measures really necessary and/or will they be effective in improving quality or just another means of controlling cost?
Despite pronouncements by Obamacare, and the Republicans that the Republicans had no alternative plan for the Affordable Care Act there were alternatives, The Patient Choice, Affordabilty, Responsibility, and Empowerment Act (CARE) was sponsored by Senators Richard Burr R-NC, Tom Coburn R-OK, and Orin Hatch R-UT. The goals sought to execute te same goals of Obamacare to lower health care costs, eliminate pre-existing condition dilemma and reduce the number of uninsured Americans.
CARE act operates on incentives, not mandates, offering carrots, not sticks. It used consumer-driven principles and patient choice into the health care delivery system.
John Goodman, President of the National Center for Policy Analysis suggested that a universal tax credit for the purchase of health insurance. Surplus tax credits would be funneled to safety-net institutions to provide services which the uninsured cannot pay on their own. The 2017 Project would not auto-entroll anyone in a plan, and would not limit tax-exclusion for employer-sponsored insurance as the CARE Act would. Other age adjusted tax credits, and surpluses going into Health Savings Accounts. States would be allowed to funds to run high-risk pools for individuals with costly, chronic medical conditions.
Saturday, March 1, 2014
Peter Lee, head of the Covered Califonria Health Benefit Exchange announced the removal of it’s provider directories on the Covered California website, effective immediately.
Prospective enrollees will now have to coordinate the insurer, the plan, and the providers by going to the insurer web site directly, ie Blue Shield, Healthnet, Kaiser, Anthem, and others.
This was necessary due to the massive errors in listings of providers who have not been contacted, nor enrolled in the Covered California program. Many patients called the listed providers to find out their provider had not enrolled, and were listed in error. Covered California copied the provider lists for each insurer participating in Covered California.
This is merely the top of the iceberg and we head further into the Affordable Care Act. Many more ‘surprises’ will surface as patients and providers begin using this system.
Nancy Pelosi was correct. We won’t know what is in the Affordable Care Act until it is passed.
Apparently the ‘Amazon” shopping cart model is a FAIL.
It becomes extremely obvious there was little if any congressional oversight in planning and implementing the workings of the exchanges despite several years of forewarning.
Despite Obama’s promises of ‘if you like your doctor, your hospital”…….etc that may not be the case without much head scratching, or even not at all if your doctor has not signed up for the health benefit exchange roster. And many have not enrolled as providers, taking a wait and see attitude how well it is going to work. It will take at least one year for an assessment of each plan by individual providers.
You see it’s no longer about the patient which really exasperates most of us who are licensed and given the responsibility with diminishing authority to care for our patients.
Ignoring these problems will not improve health care delivery. Why was the insurance industry not consulted on the process of enrollment and the administrative process ?