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Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 2 of 2)

Posted on April 13, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

The previous section of this article provided whatever detail I could find on the costs of poor communications and data exchange among health care providers. But in truth, it’s hard to imagine the toll taken by communications failures beyond certain obvious consequences, such as repeated tests and avoidable medical errors. One has to think about how the field operates and what we would be capable of with proper use of data.

As patients move from PCP to specialist, from hospital to rehab facility, and from district to district, their providers need not only discharge summaries but intensive coordination to prevent relapses. Our doctors are great at fixing a diabetic episode or heart-related event. Where we fall down is on getting the patient the continued care she needs, ensuring she obtains and ingests her medication, and encouraging her to make the substantial life-style changes that can prevent reoccurrences. Modern health really is all about collaboration–but doctors are decades behind the times.

Clinicians were largely unprepared to handle the new patients brought to them by the Affordable Care Act. Examining the impact of new enrollees, who “have higher rates of disease and received significantly more medical care,” an industry spokesperson said, “The findings underscore the need for all of us in the health care system, and newly insured consumers, to work together to make sure that people get the right health care service in the right care setting and at the right time…Better communication and coordination is needed so that everyone understands how to avoid unnecessary emergency room visits, make full use of primary care and preventive services and learn how to properly adhere to their medications.” Just where the health providers fall short.

All these failures to communicate may explain the disappointing performance of patient centered medical homes and Accountable Care Organizations. While many factors go into the success or failure of such complex practices, a high rate of failure suggests that they’re not really carrying out the coordinated care they were meant to deliver. Naturally, problems persist in getting data from one vendor’s electronic health record to another.

Urgent care clinics, and other alternative treatment facilities offered in places such as pharmacies, can potentially lower costs, but not if the regular health system fails to integrate them.

Successes in coordinated care show how powerful it can be. Even so simple a practice as showing medical records to patients can improve care, but most clinicians still deny patients access to their data.

One care practice drastically lowered ER admissions through a notably low-tech policy–refering their patients to a clinic for follow-up care. This is only the beginning of what we could achieve. If modern communications were in place, hospitals would be linked so that a CDC warning could go to all of them instantly. And if clinicians and their record systems were set up to handle patient-generated data, they could discover a lot more about the patients and monitor behavior change.

How are the hospitals and clinics responding to this crisis and the public pressure to shape up? They push back as if it was not their problem. They claim they are moving toward better information sharing and teamwork, but never get there.

One of their favorite gambits is to ask the government to reward them for achieving interoperability 90 days out of the year. They make this request with no groveling, no tears of shame, no admission that they have failed in their responsibility to meet reasonable goals set seven years ago. If I delivered my projects only 25% of the time, I’d have trouble justifying myself to my employer, especially if I received my compensation plan seven years ago. Could the medical industry imagine that it owes us a modicum of effort?

Robert Schultz, a writer and entrepreneur in health care, says, “Underlying the broken communications model is a lack of empathy for the ultimate person affected–the patient. Health care is one of the few industries where the user is not necessarily the party paying for the product or service. Electronic health records and health information exchanges are designed around the insurance companies, accountable care organizations, or providers, instead of around understanding the challenges and obstacles that patients face on a daily basis. (There are so many!) The innovators who understand the role of the patient in this new accountable care climate will be winners. Those who suffer from the burden of legacy will continue to see the same problems and will become eclipsed by other organizations who can sustain patient engagement and prove value within accountable care contracts.”

Alternative factors

Of course, after such a provocative accusation, I should consider the other contributors that are often blamed for increasing health care costs.

An aging population

Older people have more chronic diseases, a trend that is straining health care systems from Cuba to Japan. This demographic reality makes intelligent data use even more important: remote monitoring for chronic conditions, graceful care transitions, and patient coordination.

The rising cost of drugs

Dramatically increasing drug prices are certainly straining our payment systems. Doctors who took research seriously could be pushing back against patient requests for drugs that work more often in TV ads than in real life. Doctors could look at holistic pain treatments such as yoga and biofeedback, instead of launching the worst opiate addiction crisis America has ever had.

Government bureaucracy

This seems to be a condition of life we need to deal with, like death and taxes. True, the Centers for Medicare & Medicaid Services (CMS) keeps adding requirements for data to report. But much of it could be automated if clinical settings adopted modern programming practices. Furthermore, this data appears to be a burden only because it isn’t exploited. Most of it is quite useful, and it just takes agile organizations to query it.

Intermediaries

Reflecting the Byzantine complexity of our payment systems, a huge number of middlemen–pharmacy benefits managers, medical billing clearinghouses, even the insurers themselves–enter the system, each taking its cut of the profits. Single-payer insurance has long been touted as a solution, but I’d rather push for better and cheaper treatments than attack the politically entrenched payment system.

Under-funded public health

Poverty, pollution, stress, and other external factors have huge impacts on health. This problem isn’t about clinicians, of course, it’s about all of us. But clinicians could be doing more to document these and intervene to improve them.

Clinicians like to point to barriers in their way of adopting information-based reforms, and tell us to tolerate the pace of change. But like the rising seas of climate change, the bite of health care costs will not tolerate complacency. The hard part is that merely wagging fingers and imposing goals–the ONC’s primary interventions–will not produce change. I think that reform will happen in pockets throughout the industry–such as the self-insured employers covered in a recent article–and eventually force incumbents to evolve or die.

The precision medicine initiative, and numerous databases being built up around the country with public health data, may contribute to a breakthrough by showing us the true quality of different types of care, and helping us reward clinicians fairly for treating patients of varying needs and risk. The FHIR standard may bring electronic health records in line. Analytics, currently a luxury available only to major health conglomerates, will become more commoditized and reach other providers.

But clinicians also have to do their part, and start acting like the future is here now. Those who make a priority of data sharing and communication will set themselves up for success long-term.

Our Uncontrolled Health Care Costs Can Be Traced to Data and Communication Failures (Part 1 of 2)

Posted on April 12, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

A host of scapegoats, ranging from the Affordable Care Act to unscrupulous pharmaceutical companies, have been blamed for the rise in health care costs that are destroying our financial well-being, our social fabric, and our political balance. In this article I suggest a more appropriate target: the inability of health care providers to collaborate and share information. To some extent, our health care crisis is an IT problem–but with organizational and cultural roots.

It’s well known that large numbers of patients have difficulty with costs, and that employees’ share of the burden is rising. We’re going to have to update the famous Rodney Dangerfield joke:

My doctor said, “You’re going to be sick.” I said I wanted a second opinion. He answered, “OK, you’re going to be poor too.”

Most of us know about the insidious role of health care costs in holding down wages, in the fight by Wisconsin Governor Scott Walker over pensions that tore the country apart, in crippling small businesses, and in narrowing our choice of health care providers. Not all realize, though, that the crisis is leaching through the health care industry as well, causing hospitals to fail, insurers to push costs onto subscribers and abandon the exchanges where low-income people get their insurance, co-ops to close, and governments to throw people off of subsidized care, threatening the very universal coverage that the ACA aimed to achieve.

Lessons from a ground-breaking book by T.R. Reid, The Healing of America, suggests that we’re undergoing a painful transition that every country has traversed to achieve a rational health care system. Like us, other countries started by committing themselves to universal health care access. This then puts on the pressure to control costs, as well as the opportunities for coordination and economies of scale that eventually institute those controls. Solutions will take time, but we need to be smart about where to focus our efforts.

Before even the ACA, the 2009 HITECH act established goals of data exchange and coordinated patient care. But seven years later, doctors still lag in:

  • Coordinating with other providers treating the patients.

  • Sending information that providers need to adequately treat the patients.

  • Basing treatment decisions on evidence from research.

  • Providing patients with their own health care data.

We’ll look next at the reports behind these claims, and at the effects of the problems.

Why doctors don’t work together effectively

A recent report released by the ONC, and covered by me in a recent article, revealed the poor state of data sharing, after decades of Health Information Exchanges and four years of Meaningful Use. Health IT observers expect interoperability to continue being a challenge, even as changes in technology, regulations, and consumer action push providers to do it.

If merely exchanging documents is so hard–and often unachieved–patient-focused, coordinated care is clearly impossible. Integrating behavioral care to address chronic conditions will remain a fantasy.

Evidence-based medicine is also more of an aspiration than a reality. Research is not always trustworthy, but we must have more respect for the science than hospitals were found to have in a recent GAO report. They fail to collect data either on the problems leading to errors or on the efficacy of solutions. There are incentive programs from payers, but no one knows whether they help. Doctors are still ordering far too many unnecessary tests.

Many companies in the health analytics space offer services that can bring more certainty to the practice of medicine, and I often cover them in these postings. Although increasingly cited as a priority, analytical services are still adopted by only a fraction of health care providers.

Patients across the country are suffering from disrupted care as insurers narrow their networks. It may be fair to force patients to seek less expensive providers–but not when all their records get lost during the transition. This is all too likely in the current non-interoperable environment. Of course, redundant testing and treatment errors caused by ignorance could erase the gains of going to low-cost providers.

Some have bravely tallied up the costs of waste and lack of care coordination in health care. Some causes, such as fraud and price manipulation, are not attributable to the health IT failures I describe. But an enormous chunk of costs directly implicate communications and data handling problems, including administrative overhead. The next section of this article will explore what this means in day-to-day health care.

Another Quality Initiative Ahead of Its Time, From California

Posted on March 21, 2016 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

When people go to get health care–or any other activity–we evaluate it for both cost and quality. But health care regulators have to recognize when the ingredients for quality assessment are missing. Otherwise, assessing quality becomes like the drunk who famously looked for his key under the lamplight instead of where the key actually lay. And sadly, as I read a March 4 draft of a California initiative to rate health care insurance, I find that once again the foundations for assessing quality are not in place, and we are chasing lamplights rather than the keys that will unlock better care.

The initiative I’ll discuss in this article comes out of Covered California, one of the Unites States’ 13 state-based marketplaces for health insurance mandated by the ACA. (All the other states use a federal marketplace or some hybrid solution.) As the country’s biggest state–and one known for progressive experiments–California is worth following to see how adept they are at promoting the universally acknowledged Triple Aim of health care.

An overview of health care quality

There’s no dearth of quality measurement efforts in health care–I gave a partial overview in another article. The Covered California draft cites many of these efforts and advises insurers to hook up with them.

Alas–there are problems with all the quality control efforts:

  • Problems with gathering accurate data (and as we’ll see in California’s case, problems with the overhead and bureaucracy created by this gathering)

  • Problems finding measures that reflect actual improvements in outcomes

  • Problems separating things doctors can control (such as follow-up phone calls) with things they can’t (lack of social supports or means of getting treatment)

  • Problems turning insights into programs that improve care.

But the biggest problem in health care quality, I believe, is the intractable variety of patients. How can you say that a particular patient with a particular combination of congestive heart failure, high blood pressure, and diabetes should improve by a certain amount over a certain period of time? How can you guess how many office visits it will take to achieve a change, how many pills, how many hospitalizations? How much should an insurer pay for this treatment?

The more sophisticated payers stratify patients, classifying them by the seriousness of their conditions. And of course, doctors have learned how to game that system. A cleverly designed study by the prestigious National Bureau of Economic Research has uncovered upcoding in the U.S.’s largest quality-based reimbursement program, Medicare Advantage. They demonstrate that doctors are gaming the system in two ways. First, as the use of Medicare Advantage goes up, so do the diagnosed risk levels of patients. Second, patients who transition from private insurance into Medicare Advantage show higher risk not seen in fee-for-service Medicare.

I don’t see any fixes in the Covered California draft to the problem of upcoding. Probably, like most government reimbursement programs, California will slap on some weighting factor that rewards hospitals with higher numbers of poor and underprivileged patients. But this is a crude measure and is often suspected of underestimating the extra costs these patients bring.

A look at the Covered California draft

Covered California certainly understands what the health care field needs, and one has to be impressed with the sheer reach and comprehensiveness of their quality plan. Among other things, they take on:

  • Patient involvement and access to records (how the providers hated that in the federal Meaningful Use requirements!)

  • Racial, ethnic, and gender disparities

  • Electronic record interoperability

  • Preventive health and wellness services

  • Mental and behavioral health

  • Pharmaceutical costs

  • Telemedicine

If there are any pet initiatives of healthcare reformers that didn’t make it into the Covered California plan, I certainly am having trouble finding them.

Being so extensive, the plan suffers from two more burdens. First, the reporting requirements are enormous–I would imagine that insurers and providers would balk simply at that. The requirements are burdensome partly because Covered California doesn’t seem to trust that the major thrust of health reform–paying for outcomes instead of for individual services–will provide an incentive for providers to do other good things. They haven’t forgotten value-based reimbursement (it’s in section 8.02, page 33), but they also insist on detailed reporting about patient engagement, identifying high-risk patients, and reducing overuse through choosing treatments wisely. All those things should happen on their own if insurers and clinicians adopt payments for outcomes.

Second, many of the mandates are vague. It’s not always clear what Covered California is looking for–let alone how the reporting requirements will contribute to positive change. For instance, how will insurers be evaluated in their use of behavioral health, and how will that use be mapped to meeting the goals of the Triple Aim?

Is rescue on the horizon?

According to a news report, the Covered California plan is “drawing heavy fire from medical providers and insurers.” I’m not surprised, given all the weaknesses I found, but I’m disappointed that their objections (as stated in the article) come from the worst possible motivation: they don’t like its call for transparent pricing. Hiding the padding of costs by major hospitals, the cozy payer/provider deals, and the widespread disparities unrelated to quality doesn’t put providers and insurers on the moral high ground.

To me, the true problem is that the health care field has not learned yet how to measure quality and cost effectiveness. There’s hope, though, with the Precision Medicine initiative that recently celebrated its first anniversary. Although analytical firms seem to be focusing on processing genomic information from patients–a high-tech and lucrative undertaking, but one that offers small gains–the real benefit would come if we “correlate activity, physiological measures and environmental exposures with health outcomes.” Those sources of patient variation account for most of the variability in care and in outcomes. Capture that, and quality will be measurable.

Insurance and Pricing as Gateways to Changing the Health Experience

Posted on March 31, 2015 I Written By

Andy Oram is an editor at O'Reilly Media, a highly respected book publisher and technology information provider. An employee of the company since 1992, Andy currently specializes in open source, software engineering, and health IT, but his editorial output has ranged from a legal guide covering intellectual property to a graphic novel about teenage hackers. His articles have appeared often on EMR & EHR and other blogs in the health IT space. Andy also writes often for O'Reilly's Radar site (http://oreilly.com/) and other publications on policy issues related to the Internet and on trends affecting technical innovation and its effects on society. Print publications where his work has appeared include The Economist, Communications of the ACM, Copyright World, the Journal of Information Technology & Politics, Vanguardia Dossier, and Internet Law and Business. Conferences where he has presented talks include O'Reilly's Open Source Convention, FISL (Brazil), FOSDEM, and DebConf.

“So why are you partnering with insurers and employers?” I asked the staff at Maxwell Health, who had just been regaling me with an expansive vision of consumer-centered health and transparency. Co-Founder and Chief Product Officer Vinay Gidwaney laid out a view that’s in line with everything reformers ask for: a long-range view of health care that guides people to proper health at home and not just in the clinic, giving the consumers choices along with the information to let them make good ones, etc. The kind of health system Maxwell Health aims at will be totally different from what we have now–and the current actors will have to change or vanish as it comes into being.

Maxwell Health on phones

Maxwell Health running on phones

But of course I knew why Maxwell Health is dealing with insurers and employers. In our health care system, you must join the guild to hang your street sign. Before you can get access to the consumer, you need access to the professional organizations with whom the health consumer interacts. Individuals may download one or two of the many thousands of available health and fitness apps, but few people stick with them–or with the fitness devices that carve their behavior into eternal records in the cloud.

Although doctors complain that they can’t change people’s behavior, people are more likely to adopt technology if it is recommended by their doctor, their insurer, or even the government. Furthermore, payment models have to reward the right things, or people will continue to engage in risky behaviors and costs will continue to expand.

So Maxwell Health has found a business model on the insurance side of health care’s multi-faceted polygon. Through this they hope to reach the consumer and create change.

Another company I met at the Health 2.0 Boston hackathon, a week after talking to Maxwell Health, is making a related play in order to prosper in the health care market. PokitDok offers health care appointments on both a pay-per-visit basis and using health insurance. To this end, they have relationships with both health care providers and insurers. They can be used by any individual consumer, whereas Maxwell Health deals with people through their employers. A PokitDok API allows developers to create apps that have access to prices, providers, insurers, referrals, etc.

PokitDok screen

Getting started with PokitDok

Let’s start with Maxwell Health. Their salient feature is “bundles” of health care options offered as benefits packages by employers, organized around a core of the insurance plans their staff can choose from. Maxwell Health can direct an employee to an appealing insurance package–for instance, one for people near retirement, another for a young couple about to have a baby. Benefits administrators create personas (hypothetical types of employee) around demographics such as age, income, and family status, then create bundles to offer to employees around these differences. Anyone who has tried to seriously compare his insurance options knows what a headache it is to figure them out. Medicare Advantage is a daunting market, and while no employer has such a large number of choices, they have enough to make the decision a nail-biter. I had trouble just choosing my tax-free flexible spending amounts each year, until the law changed this year and let employees roll unspent money forward. Maxwell Health hopes to turn benefit choices into an experience as appealing, well-integrated, easy as a good online retail shop.

While choosing an insurance plan, employees are prompted also to sign up for services that may help them with their health needs: fitness devices, coaching services, emergency day care, meal delivery services, etc. Bundles also contain services that benefits coordinators think would interest employees with a given persona.

The customer can also load apps from Maxwell Health that help them find services. For instance, they have a contract with Doctor on Demand, a popular telemedicine site. (This one-time telemedicine service is a convenience, not a replacement for developing a relationship with a provider who has a broad knowledge of the consumer and family.) Another service lets employees can take a picture of a confusing medical bill and contact an expert to explain and even change the bill.

On the back end, Maxwell Health provides typical web-based services to benefits administrators, making it easier for them to carry out their routine tasks such as determining participation in plans by employees and tracking the use of services. As PR and marketing associate Meg Murphy says, benefits administrators “can throw away their fax machine.”

The company’s solution requires a lot of work at each employer, but the insurance broker is well positioned to work with each employer to represent the benefits correctly, suggest new benefits, and serve up the benefits through the Web and mobile devices. In addition to its close work with insurers, Maxwell Health also lets fitness devices stream data to a Maxwell Health mobile app. This app has three overall parts: a virtual insurance ID card for every insurance plan in which the employee is enrolled, a wellness program with connections to fitness devices and rewards, and a healthcare concierge who handle requests like the confusing bill already mentioned.

Now for PokitDok. The simplest part of their offering is an app helping consumers find doctors for individual fee-for-service procedures. A consumer can search for the medical procedure he needs and book an appointment through the service. PokitDok determines fees through a rather labor-intensive process (calling the doctors) as well as by checking actual prices paid in the past. The web site guides the user by showing a range of possible insurance costs (low, median, and high).

Once the user chooses a provider and books a procedure, PokitDok charges the posted fee and collects the money online. Hence, the welter of health care costs is managed by simply making each provider advertise his fee (already quite a break from the standard health market in the US.) PokitDok therefore includes a degree of transparency for its providers that Clear Health Costs provides through crowdsourcing for a wide range of popular tests and procedures.

But PokitDok also allows patients to pay through insurance. This is a much steeper challenge. Insurance reimbursements vary from doctor to doctor, plan to plan, and employer to employer. Nor do most of the actors in this masquerade want to reveal their prices and the yawning ranges they span. So PokitDok, once again, checks prices paid in the past to estimate the low, median, and high cost for insurance coverage. The user can also specify one or more insurers when searching for a procedure.

It’s interesting that John Riney, coder and technical evangelist at PokitDok, described their essential goal in terms very similar to those used by Maxwell Health representatives: let’s turn the search for health care into a consumer experience as simple and satisfying as good retail shopping.

Right now, the main actors in the health care space maintain silos. The new players like Maxwell Health and PokitDok feel the way most of us in the health movement feel: they would prefer an open ecosystem where the parts work together and anybody can sign up to play. Piggybacking on a complex payment system set up decades ago may be the necessary focal point on which new companies can press the lever of change.