Stats and Stories

With the recent passage of the Healthcare Reform bill (meaning more patients will be looking for PCPs), along with HITECH getting closer to reality... we will be seeing more and more stories such as these:

Physician Shortage
WSJ Article (April, 2010)
The new federal health-care law has raised the stakes for hospitals and schools already scrambling to train more doctors. Experts warn there won't be enough doctors to treat the millions of people newly insured under the law. At current graduation and training rates, the nation could face a shortage of as many as 150,000 doctors in the next 15 years, according to the Association of American Medical Colleges. That shortfall is predicted despite a push by teaching hospitals and medical schools to boost the number of U.S. doctors, which now totals about 954,000. The greatest demand will be for primary-care physicians. These general practitioners, internists, family physicians and pediatricians will have a larger role under the new law, coordinating care for each patient. The U.S. has 352,908 primary-care doctors now, and the college association estimates that 45,000 more will be needed by 2020. But the number of medical-school students entering family medicine fell more than a quarter between 2002 and 2007. A shortage of primary-care and other physicians could mean more-limited access to health care and longer wait times for patients....

No surprise, a big part of this is due to:
Gap between PCPs and specialist compensation
MGMA Study (April, 2010)
Annual compensation for primary care and specialty care groups in academic practice slowed between 2008 and 2009, increasing only 2.93 percent for primary care physicians and 2.43 percent for specialists, according to the MGMA Academic Practice Compensation and Production Survey for Faculty and Management: 2010 Report Based on 2009 Data. Primary care physicians reported compensation of $158,218, while specialty care physicians reported compensation of $238,587, a difference of $80,369. From 1999 to 2009, compensation in academic practices continued to trail that in private practices.

Problems with the US Healthcare System, and Kaiser as a shining beacon.
This short story in the Economist (April, 2010) aptly (and somewhat pessimistically describes) how; for the most part, the American health system is dominated by cream-skimming health insurers and the myriad “fee for service” providers they do business with, which drive up costs by charging high prices for piece work. Whereas Kaiser is able to balance quality with cost AND patient satisfaction because it "aligns incentives both to promote parsimony and to improve the quality, rather than merely the quantity, of the care it gives." Thanks for Dr. Ted Eyten for finding and posting this in his blog first.

And we have to deal with this...

The Invisible (Uncompensated) Burden of PCPs
A NYT story (April, 2010) highlighted a NEJM article on this topic and points out the need to change how PCPs are paid — particularly as the new health care law promises to add millions more patients to the system.
The NEJM article (April, 2010) details the uncompensated work burden on PCPs, including about 100 extra tasks a day - including telephone calls and emails for various questions and refills, labs and other studies which need interpretation and communication to patients, as wells as forms and other paperwork for things like school paperwork and medication approval.

The Challenge of Multiple Comorbidity for the US Health Care System
Article in JAMA (April, 2010)
The aging of the US population, combined with improvements in modern medicine, has created a new challenge: approximately 75 million people in the United States have multiple (2 or more) concurrent chronic conditions, defined as "conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living". Is the 21st-century US health care system prepared to deal with the consequences of successfully treating patients who have conditions, often multiple, that they would not have survived in the early 20th century? Current indications suggest that it is not. As the number of chronic conditions affecting an individual increases, so do the following outcomes: unnecessary hospitalizations; adverse drug events; duplicative tests; conflicting medical advice; and, most important, poor functional status and death. Approximately 65% of total health care spending is directed at the approximately 25% of US population who have multiple chronic conditions.

A wider look at health in the US
CDC Report on Health in the United States, 2009
- Use of MRI, CT and PET imaging has soared in the past decade
- Rates of many procedures have increased dramatically: knee replacements (up 70%), Angioplasties with stents (75% of all PTCA in 2006), Fertility treatments (especially in females > 40), Outpatient endoscopies (rose 90%).
- Prescription med use is also up: Diabetes drugs (up 50% in patients over 45), Statin (up 10-fold in past decade), Percent of people on at least 1 drug (increased from 38 to 47%), those taking three or more drugs (increased from 11% to 21%).
- Life expectancy has improved a little. Overall mortality from Cancer, Stroke and Heart disease has declined. Deaths from Respiratory illness and accidents are stable.
- Leading causes of death (by age): 1-44 (accidents), 45-64 (cancer), over 65 (heart disease)
- Chronic conditions: steady at 10% of people reporting chronic conditions limit their activity - most likely arthritis and other musculoskeletal issues. Second leading cause was Mental illness (age 18-44) or heart/circulatory disorders (over 45) - with mental illness a third in that age group.

Meanwhile, with respect to HIT...
Health IT: The Road to 'Meaningful Use'
Health Affairs (April, 2010)
A series of articles that reviews many of the pros/cons of trying to adopt HIT/EMRs to meet our growing needs for quality and care coordination. On one hand, there are definite theoretical advantages to using HIT, and there is a push to do something NOW rather than wait forever for "perfect systems". On the other hand, these systems are still immature and success is often more about workflow re-engineering, executive support, and process and culture change rather than on any specific technology... thus implying that attempting to rapidly adopt IT tools may result in more problems and implementation failures since the other non-IT support needs are so high.

Electronic Medical Records and Communication with Patients and Other Clinicians: Are We Talking Less?
Center for Studying Health System Change (HSC) study (April, 2010)
Commercial electronic medical records (EMRs) both help and hinder physician interpersonal communication—real-time, face-to-face or phone conversations—with patients and other clinicians... EMRs assist real-time communication with patients during office visits, primarily through immediate access to patient information, allowing clinicians to talk with patients rather than search for information from paper records. For some clinicians, however, aspects of EMRs pose a distraction during a visit . Moreover, some indicated that clinicians may rely on EMRs for information gathering and transfer at the expense of real-time communication with patients and other clinicians. Given time pressures already present in many physician practices, EMR and office-workflow modifications could help ensure that EMRs advance care without compromising interpersonal communication. In particular, policies promoting EMR adoption should consider incorporating communication-skills training for medical trainees and clinicians using EMRs.

Re-Inventing Primary Care
From Health Affairs (May, 2010): "The nation’s primary care system is broken, and fixing it is an urgent priority—all the more so because of the enactment of national health reform." The May 2010 issue of Health Affairs examines what it will take to reinvent primary care in the United States. Operational, payment, regulatory, legal, and educational reforms will be necessary to improve care and achieve savings —and to prepare for the influx of millions of Americans who will be insured for the first time as of 2014.

HITECH Showers...really, how come we aren't just focusing on Paying for Value?

I am involved with the Association of Medical Directors of Information Systems (AMDIS), and our list-serv often brings up good topics. I'll often post my thoughts, with my bias of being a very pragmatic, in-the-trenches primary care physician. I've incorporated some of those thoughts into past posts, but will also occasionally blog the (almost) verbatim posts I've made.

Here is a recent one I wrote, in response to discussions about whether the government is doing the right thing by using the HITECH funds ($39 billion) as "EMR Stimulus money" vs. thinking about restructuring how we pay for care so that EMRs will actually make business sense for physicians:


Yep- we've said it all before, the government (and other payors) need to pay for value, not volume. Align the healthcare system wisely, and there is no need for "stimulus dollars" to push for something which does not make business sense in today's environment. Make it valuable for us to practice high quality medicine - and that will happen… and in fact, the level of innovation in making that happen will be much greater than by trying to force untested EMRs onto everyone… it will mean more teamwork, more clinical standards of care, more checklists, more follow up, more competition…

What I don't get is that almost EVERYONE in healthcare policy knows this to be the case - and yet neither the HITECH bill nor the current healthcare legislation really touches on this.

Yes, there is some money for "experiments" - but we need payment reform as one of the foundations for care improvement. Can you imagine how much better the EMRs and other IT applications would be if they were being created in a world where payment didn't:
1. Rely on massive documentation of visits for any payment - and forced doctors to be the one to do this documentation themselves
2. Insist only doctors to be the ones to deliver care
3. Encourage volume over value

Take away those three restraints and replace with these two tenets… and just imagine what would happen:
1. Allow doctors to be part of a team that took care of patients as a whole - the right type of provider can do the right type of care and document in the way that makes the most sense for care
2. Encourages value over volume - so you can take care of many more people, but actually see less people

Sorry… dreaming again…

So what will happen in the meantime? Smart EMR companies will hopefully start making products that at least allow for better efficiency…It's hard to believe how poorly they have done in this arena to date… mainly all they have done is make it easier to document for higher level visits.

But in this real world, I do give HITECH some credit - MU is painful to look at right now, but at least it is making EMR vendors think more about how their systems can deliver quality. And while the overall reimbursement system has not yet caught up, it is fulfilling its promise of being a "stimulus".

The question will be whether this will be more like the April showers bringing May flowers… or a hailstorm that f's up your car.

Meaningful Use Final Matrix Posted

HHS has issued proposed final regulations that list the "meaningful use" criteria which healthcare providers must meet in order to quality for the HITECH incentive payments. This story from Health Data Management has a good breakdown of the Matrix, starting on page 26:
http://digital.healthdatamanagement.com/healthdatamanagement/201002?pg=6#pg26

Quick impression is that the bar is set low in some areas, but higher in other areas. Also, it is not fully clear how to fulfill the criteria. For example, one "box" says to have drug-drug interaction checking (which is pretty routine), but in the same box it says to also have drug-formulary checking... that is much more complex, and involves extra fees to the EMR vendor, as well as an assumption that the system allows for input of a patient's drug benefit plan (which is often different from their insurance).

Other confusing things include allowing patients "timely access" to their healthcare data, and something that says "Reminder sent to at least 50% of all unique patients seen by the EP that are age 50 or over" - reminder about what exactly, and does it matter how/when/where we remind them? But it's a start and I assume there is clarification in the other 553 pages of this document, but I'm just looking at the Matrix for now.

Other good links
* Dr. Blumenthal's summary of all the HITECH monies are going:
http://healthcarereform.nejm.org/?p=2669

* MU summary from Mr. HISTalk:
http://histalk2.com/2009/12/30/onchit-releases-preliminary-definition-of-meaningful-use/

* An MU Excel Spreadsheet created by Mr. HISTalk:
http://drop.io/meaningfuluse/asset/meaningful-use-xls

* Dr. John Halamka's MU Summary:
http://geekdoctor.blogspot.com/2010/01/achieving-meaningful-use.html

* Matrix of Numerators and Denominators
http://mycourses.med.harvard.edu/ec_res/nt/36980CA6-E154-4820-A0ED-8B235138B79F/measures.pdf

If HITECH Does Not Work, What are the Options to help with EMR Adoption?

The HITECH incentive plan (estimated at around $38 billon) was established to provide up to $44,000 to every outpatient physician who uses a "certified" EMR in a "meaningful" way (as well as $2-$3 million to each hospital). While its spirit has good intentions, I don't believe they will create a significant amount of new adoption in the outpatient arena because
- The amounts are too low (most systems cost much more to implement).
- There are severe shortages of qualified staff to help physicians convert from a paper to computerized system - a challenging task that includes IT knowledge, workflow redesign and general change management skills.
- The EMR systems are just not very good - both in form and function. See earlier blogs of mine about poor EMR Usability, from April and August, as well as a nice report by Dr. Peter Basch on the problems with current systems. Also check out a new podcast on EMR Usability in which I, and an IT Usability expert, discuss this topic in detail. Finally, here is the HIMSS WhitePaper on EMR Usability: http://www.himss.org/content/files/HIMSS_DefiningandTestingEMRUsability.pdf

So let's review two reasonable options - which are not mutually exclusive:

Change the Underlying Healthcare Reimbursement System
The government could forget the "on-time incentive" idea, and instead focus on long-term reimbursement changes that support quality and efficiency. As we know, our current reimbursement system mainly pays for the volume of "face-to-face visits". EMRs usually slow providers down, although can help them increase their coding levels for higher reimbursement. At best, it's a draw. What if the reimbursement system were instead based on quality (e.g. Pay for Performance) and efficiency (e.g. take care of patients, whether face to face, email or phone)? An EMR has much more potential to help here - by using decision support, establishing registries, and allowing for easy electronic communications. In other words, the government can just help set the reimbursement guidelines to focus on quality and efficiency, and then let the market work on optimizing care in line with that.

Create a Single Healthcare Data Platform
For a fraction of that same $39 billion dollars, the government could rather easily create a single data model and warehouse upon which all other applications can reside - thus solving standards and interoperability issues, increasing adoption, and creating a free market for the "best applications" out there. In fact, a conspiracy theorist might even suggest that the government assumes the current HITECH plan will fail...and thus they put a clause in the plan that says if there is not significant adoption by 2015 - the government can release some type of universal EMR...maybe the universal health database is what makes the most sense?

Several of us have been talking about this "iPhone" like platform in the past year, and here is a link to an interesting meeting that happened in May 2009, which resulted in the following: Ten Principles for Fostering Development of an “iPhone-like” Platform for Healthcare Information Technology
http://knol.google.com/k/kenneth-mandl/ten-principles-for-fostering/9x9jzgucudo6/2# .

And here are some videos from this meeting:
http://www.itdothealth.org/multimedia/2009-hit-platform/#videos