Will HITECH Lead to Innovation? The Continuing Cat/Dog Dialogue

Will the recently passed HITECH legislation — the federal stimulus funding for health IT — encourage innovation?  or will it lock in outdated electronic health record (EHR) technology?

It’s a mixed bag — HITECH legislation  is both dog-like (innovative) and catlike (protecting incumbents).  I’ll refresh your memory below on more specific definitions of cats and dogs.

Among many other reasons, HITECH is dog-like primarily because it has ended the question of WHETHER the U.S. is really serious about health IT reform.  HITECH spells out clear policy goals working toward interoperable health IT and dedicates an initial $19B in federal stimulus funds to begin the work. HITECH begins to create an environment for innovation in health care reform.

There are many open questions as to HOW best to go about this — how to spend the federal stimulus funds in ways that encourage innovation.

HOWEVER, Cat6

On balance, HITECH favors cats by about 60/40.

Why?

How Should Fed HIT Dollars Be Spent? Cat vs. Dog POV.

Catdoghug

“Where’s the single best place to get up to speed on how the Feds should  spend $20 billion to advance health information technology (HIT)?”

A colleague asked me this question a couple of days ago, and at first I hesitated.  Then it struck me — Matthew Holt’s The Health Care Blog has become the focal point for discussion of this critical topic.

Matthew’s very recent article — Cats & dogs: Can we find unity on health care IT change? — summarizes the two schools of thought that have emerged over the past two months.

His article is important and notable for a number of reasons:

  • He crystallizes the two emerging schools of thought — the dog vs. cat POV (see below)
  • He summarizes and links to many other key writings on the HIT spending topic
  • He suggests that the dog and cat POV can be reconciled — that there’s a middle road
  • He suggests several initial options to reconcile the differing schools of thought.  This discussion should continue.

If you’re interested in disease/care management, this is a topic you should be following closely. While the first decade of DM focused on a services based, call center model — the handwriting is on the wall that the next decade will focus much more on a technology based model.

Companies and organizations involved in disease/care management should be positioning themselves to take direct and indirect advantage of the Federal injection of funds.

Here’s Matthew Holt’s summary of the dog vs. cat perspectives:

Medicare Health Support: 8 Takeaways on Building Better Bridges

by Thomas Wilson, PhD, DrPH and Vince Kuraitis

Engineer

What’s the right metaphor for Medicare Health Support (MHS), CMS’ major experiment with disease management for Medicare beneficiaries?  We prefer to look it as a bridge failure that presents an opportunity to improve future engineering and design.

We’ve now had the time to read, reread, and reread again the very recent report from Research Triangle Institute (RTI) — Evaluation of Phase I of the Medicare Health Support Pilot Program Under Traditional Fee-for-Service Medicare: 18-Month Interim Analysis .  Here’s a listing of our 8 key takeaway points:

  1. There’s Sufficient Evidence to Conclude "MHS Didn’t Work As Expected"
  2. Some Quality Measures in MHS Improved, Yet Outcomes Didn’t. Why?
  3. MHS Suffered Execution Nightmares
  4. Ronald Reagan Was Right — “Trust, But Verify”
  5. MHS Has Implications for the Medicare Medical Home Demo (MMHD)
  6. Be Wary of Claims from Pre-Post Studies
  7. Differences Between Medicare and Commercial DM are Dramatic
  8. The Guaranteed Savings Model is a Two Edged Sword

Let’s examine these at these one at a time.

Doctors Bat A Thousand in Year Two of PGP Medicare Demo

Homrun CMS announced today that all 10 participating groups in the Physician Group Practice (PGP) demonstration achieved quality targets, and that the groups are sharing $16.7 million in incentive payments. The program rewards providers for improved outcomes delivered to Medicare patients with congestive heart failure, coronary artery disease, and diabetes.

This goes a long way in explaining Medicare’s seeming lack of enthusiasm for past or future disease management demos with DM companies and/or health plans.

Congratulations doctors!

UPDATE: The doctors might have batted a thousand for quality improvements, but only .400 for getting bonuses.  See  Practices hit Medicare P4P quality targets, but bonuses still fall short , AMNews; September 8, 2008.

Are HIEs a Dead Horse?

Do local Health Information Exchange (HIE) participants have the right economic motivations to make them work?  

A report released this week raises strong doubts. The study — Creating Sustainable Local Health Information Exchanges: Can Barriers to Stakeholder Participation be Overcome? — was  funded by the U.S. Agency for Healthcare Research and Quality (AHRQ) and conducted by the Center for Studying Health System Change (CSHSC). The term HIE is often used interchangeably with RHIO (Regional Health Information Exchange).

What’s different about this study? The CSHSC report goes a step further than other recent reports documenting minimal progress by most HIEs and questioning whether HIEs have a business model. Through interviews with HIE participants — hospitals, physicians, health plans, employers — it brings evidence from the horse’s mouth suggesting

  1. the rationale TO share data is WEAK, and
  2. the rationale NOT TO share data and to preserve the status quo is STRONG. 

The next question becomes “Is it time to get off the dead horse?” Does it make sense to put more time and energy into a flawed model model and further delay national efforts to create interoperable electronic health records?  Are HIEs doing more damage than good?

Here are some of the key conclusions:

HealthSpring “Gets” Physician Engagement.

I’ve written a lot recently about Medicare Health Support (MHS).  We are learning a lot from MHS about what DOESN’T work with the frail, elderly Medicare population.

 

But, what DOES work?

 

One key lesson emerging from MHS is the need to integrate and engage physicians and other local care providers…easier said than done.

 

MHS is just one of many experimental approaches being tried by Medicare.  Other approaches include the medical home model, Medicare Advantage plans, Special Needs Plans (SNPs), P4P, and a variety of other Medicare demos and pilot projects.  I’ve been critical of Medicare’s lack of transparency lately, but I applaud their innovation and experimentation.

 

While we definitely don’t have all the answers, I’d like to bring your attention one company that I believe has the right strategy and mindset: HealthSpring.  HealthSpring owns and operates Medicare Advantage plans in Alabama, Florida, Illinois, Mississippi, Tennessee and Texas and also offers a national stand-alone Medicare prescription drug plan. 

  

HealthSpring recently conducted an Investor Day meeting with financial analysts.  You can read the entire transcript of the meeting here — warning, it’s about 35 pages long.  I’ve culled through this presentation to dig out some best practices that HealthSpring is employing. 

Health Wonk Review at e-CareManagement

Welcome!

Since this is my first time hosting the Health Wonk Review, I really didn’t know what to expect.  I have to say that I’ve learned a lot while poring over the insight and wisdom of my fellow bloggers. Fortunately, this week’s entries fell into neat categories:

  • In-Store Clinics
  • Physicians
  • Problems — U.S. & World Health Systems
  • Solutions — U.S. & World Health Systems
  • Cats, Dogs and Kangaroos

Just in case that last category, doesn’t look too familiar, let’s revisit the whole point of the Health Wonk Review:

Health Wonk Review is a biweekly compendium of the best of the health policy blogs. More than two dozen health policy, infrastructure, insurance, technology, and managed care bloggers participate…

There were a few entries that didn’t “quite” meet this definition, and I’ve included some of the best in the last category.

The PowerPoint — DM Megatrends 2008

Last week I did the major annual tune-up of my presentation on Disease Management Megatrends for the MCOL Future Care Web Summit

I’m pleased to share a copy of the PowerPoint presentation with you, and I hope you find it useful and provocative.  You can view and/or download a copy here (6MB).  This version contains 77 slides, which would be about the length I’d use for a 3 hour workshop; you’d see a more compact version for a conference keynote, Board summary, or management strategy session.

fyi, the DM Megatrends are:

MAGNITUDE: We are just scratching the surface of chronic disease challenges.
INTEGRATION:  The 50 year tide is shifting toward integration, away from specialization.
MEDICARE: While Medicare has endorsed the need for chronic disease management, disappointing results from recent demo projects make future direction unclear.
PROVIDERS: Care providers have woken up to DM opportunities and threats; they are promoting the medical home and the Chronic Care Model.
MAKE, ASSEMBLE, BUY? Fewer are buying as health management becomes increasingly strategic.
TECHNOLOGY:  DM in your home and your pocket.
BEHAVIOR CHANGE: DM is moving from a medical to a social model; behavior change has become the Holy Grail.
CLINICAL AND ECONOMIC ROI:  Round one is over, DM wins; Round 2 has just begun.
WILDCARDS! (employers, P4P, retail clinics, CDHPs, elections)

Comments are always appreciated.

Last week was a podcast of DM Megatrends…next week — the movie.  Brad has signed, Angelina is waffling.

Podcast: The 20 Minute Version of “DM Megatrends”

Over the past week I’ve been doing a major tune-up of my presentation on Disease Management Megatrends for the annual MCOL Future Care Web Summit

More typically, DM Megatrends is 45–90 minute presentation with accompanying PowerPoint slides.

As part of the Web Summit, the good folks at MCOL asked me to do a short podcast on highlights of this presentation. They’re allowing me to share it with you… click here to save or listen to the podcast.

fyi, the DM Megatrends are:

MAGNITUDE: We are just scratching the surface of chronic disease challenges.
INTEGRATION:  The 50 year tide is shifting toward integration,  away from specialization.
MEDICARE: While Medicare has endorsed the need for chronic disease management, disappointing results from recent demo projects make future direction unclear.
PROVIDERS: Care providers have woken up to DM opportunities and threats; they are promoting the medical home and the Chronic Care Model.
MAKE, ASSEMBLE, BUY? Fewer are buying as health management becomes increasingly strategic.
TECHNOLOGY:  DM in your home and your pocket.
BEHAVIOR CHANGE: DM is moving from a medical to a social model; behavior change has become the Holy Grail.
CLINICAL AND ECONOMIC ROI:  Round one is over, DM wins; Round 2 has just begun.
WILDCARDS! (employers, PHRs, P4P, CDHPs)

Today’s BFO: How can P4P Work W/O a QB?

Translation  Todays blinding flash of the obvious (BFO): How can you expect pay-for-performance (P4P) programs in Medicare to work with out a designated physician quarterback (QB)?

Please allow me to elaborate.

P4P programs are based on two assumptions:

  1. Patients are assigned to a physician or a practice that will have primary responsibility for their care, and
  2. That a meaningful fraction of the care physicians deliver is for patients from whom they have primary responsibility

Wouldn’t you expect that this would be problematic for older (Medicare) patients who see multiple doctors over time? How can you assign accountability for performance to one doctor when the patient is seeing a number of doctors for a number of care episodes? (That’s the BFO part for me.) and wouldn’t you expect this to be even more problematic for patients with multiple,chronic conditions?

Shouldn’t somebody study this to figure out whether P4P is doable in Medicare? Well, they have.