Based upon the various amalgamations of the data, the conclusion I have reached is that the health reform bill focuses largely on “access” through things such as:

• covering the currently uninsured by requiring (and where necessary, subsidizing) all Americans to purchase insurance,
• removing the ability of insurers to deny coverage based upon pre-existing conditions,
• removing the limits that insurers can place on members through ‘lifetime maximums’ that limit the total amount of money the insurance company spends on any member’s care
• extending the age limit for children to remain on their parents’ policy

I applaud these actions, and recognize that they are an important element of reforming the way we deliver healthcare by ensuring that people have access to care. That said, increasing access alone will not only fail to moderate the cost trend – it is likely to exacerbate it. So what’s missing?

1. Payment reform – much has already been said about the perverse incentives created by the fee-for-service reimbursement model. True health reform must include payment reform that puts the incentive on delivering better outcomes, not simply delivering more care.
2. Limits on litigation – another incentive that doctors have to prescribe care that doesn’t directly correlate to better outcomes is the fear of litigation. True health reform needs to address our litigious nature as a society, and protect doctors from frivolous lawsuits.
3. Patient behavior reform – despite plenty of evidence to the contrary, the predominant mindset among patients is that more care is better care, and that more expensive care is better care. In order to moderate the healthcare cost trend, there will need to be less consumption of healthcare and a shift from late stage medical care to more preventative medicine. Increased access to care will certainly help, but more will need to be done than to simply provide people with the ability to see a doctor – they will need incentives that actually change behavior.
4. Eliminating waste due to fraud and overuse – an obvious way to reduce healthcare spending is by eliminating the 30% that is estimated to go to waste or fraud. Advantages of health IT are that it can limit duplication of healthcare (waste), increase efficiency of the care currently being applied (efficiency) and apply controls to prevent or detect outliers (fraud protection).
5. Reforming the system itself – largely overlooked is the idea of reforming entirely the system of how insurers, patients and providers work together. True Healthcare reform would enable more disruptive innovation in the market – such as allowing members to select whatever combination of wellness and health insurance they like (even across state lines) rather than limiting to 2 or 3 choices by their employer, or allowing members to carry their plan with them for as long as they like, even if they change employers. There are limitless possibilities for new and unique business models that will provide better value at lower cost.

The reform bill that was signed into law this week is a start, but to really change the healthcare landscape in America, we will need to address many (if not all) of the items above as well.

What do you think?

This is just coming across the wire, but some quick thoughts:

1. Coupled with an HIE solution, this could make eClinicalWorks the de facto EHR standard.  With all the debate around where to store data and how to decide upon standards, a proprietary solution now has a sales channel and a price point to dominate the marketplace.  Let’s not underestimate the need for HIE though – without the tools for participating physicians to collaborate and access patient data from other physicians (with all the kosher privacy and security barriers in place, of course), this just creates many, many smaller silos that then need to be connected later.
2. Wal-Mart could become the largest healthcare network in the country.  They are effectively creating the infrastructure to incorporate a great number of doctors into a virtual practice.  Combined with health kiosk models and retail-based health clinics like that of CVS/CareMark, Wal-Mart has the opportunity to explode into the healthcare market and compete for insurance dollars beyond the pharmacy – perhaps even create their own insurance offering.
3. Will the government react adversely? While this announcement is an exciting collaboration between big players in the private sector, the current administration has to feel that this has the opportunity to be monopolistic and counterproductive to their own agenda.  It will be certainly interesting to see if there is an angle longer-term for the Wal-Mart/Dell/ECW team in being the key player in standardization of HIE and EHR protocol.

The return on invesment of Healthcare IT – There are more than a few articles and blogs questioning whether there is an ROI for healthcare IT.   (See HIMSS for one example)  I think that those of us who have blindly assumed that automating current manual processes would guarantee a return on investment could benefit from such a dose of skepticism.  I’ve read in several places what I believe to be an extremely valid suggestion – test out healthcare IT like we do any other healthcare protocol:  using a clinical approach where the new method is evaluated against pre-existing methods.  What I will say though is that any blanket statement about the ROI of the implementation of IT in healthcare is like any other broad statement:  it may be accurate in some cases, but is virtually unthinkable to be true in all cases.   Like any other investment, leveraging IT in any business can be done well or poorly.  It’s a well known fact that some attempts to implement IT in healthcare have been debacles in the largest degree, but there are also success stories.  So in the coming weeks and months, I think we all need to be careful of speaking in platitudes.

Security concerns in going fully electronic – Lost in the din of questions such as “how do you define ‘meaningful use’?”, and “who is going to ‘certify’ EMRs?” has been the question of security.  Security was a brief topic during the panel discussion at the Transforming Healthcare Summit on February 26th in Boston, but it’s going to need to be a big topic to ensure that we proactively avoid any major security breaches of patient information in the next few years.  We need to learn the lessons that the financial, retail and government sectors learned in the past decade – particularly that a “first build it, then secure it” approach is a precursor to disaster.

Using an inclusive process as part of the implementation of health IT – Much has been made of so-called “failed implementations of health IT”, and there are more than a few blogs by doctors who rightly point out that poorly designed solutions have in fact made their lives harder.  (See here for one of a multitude of examples)  These concerns are valid and need to be addressed through good standards and good process.  If this stimulus turns into a gold rush, then it’s a guarantee that one output will be much more of this type of frustration from the user community.  What we need is a patient and methodical approach, as well as a decent set of standards to ensure interoperability between practices and hospitals.  Now that Obama has made his choice for the Secretary of Health and Human Services, high on the list of things she will need to do (once confirmed – which hopefully will be sooner rather than later!) will be to designate some group as the leader to drive these standards to clarity such that the real work can begin.

Lack of clarity around reimbursement and certification – I’ve thought a lot about this in the past few weeks, and at the macro level, I think the message behind what President Obama is doing is the right message:  “We need to move away from paper-based operations into a future of interconnectedness, where information can be shared quickly and effectively to increase quality of care and reduce administrative cost.”  I don’t think anyone would argue with this statement at this level of detail.  The argument starts, instead, at how to get there.  The incentive in the ARRA is to say to doctors – “we will help you to defray the cost of implementing this technology”.   The question that remains is whether cost has been the only barrier that has kept us from already achieving the aforementioned goal all by ourselves (without government intervention).  There is the question of good implementation versus poor implementation.  Like any field, there are individuals and companies in the IT field who are better and there are those who are worse.  Those in the healthcare field who would be consumers of IT products and services need to keep this in mind and push hard for references and other means to understand in which camp their vendor of choice belongs.  There might be ways that other entities (e.g. the Better Business Bureau) can play a role in helping medical practices pick good, capable service providers.

We must also recognize that beyond “good IT service provider vs poor IT service provider”, there is also the question of whether some people just don’t want to change.  There certainly are those in the medical field who are technology phobic and will fight tooth and nail to keep their practice the way it is.  We can’t waste our time and effort to convince these people otherwise.  Instead, the way forward is to find those are are willing to embrace new technology and to work with them to show that it can be done, and when it’s done well, the benefits far outweigh the cost.   This will convince those who are “on the fence” but willing to be convinced that they should join the group who are adopting healthcare IT, and not the naysayers.

The healthcare and IT industry must work together to address all the above items, and we must avoid the urge to rush ahead and do things for the sake of expediency, rather than for the sake of quality.  That said, President Obama has made it clear that it will no longer be acceptable to drag ones feet under the guise of a cautious approach.  We must seek a middle ground.

Change has been on the agenda for a long time in the healthcare industry, but change has been slow to come and implementing change has been fraught with pitfalls along the way.  The Obama Adminstration is giving all indications that addressing this need for change in healthcare is going to be front and center among the key challenges that will be addressed over the next four years.   Since November 4th, much attention within the industry has been given to the question of whether President Obama would still be able to tackle this problem given the issues with the broader US economy.  The industry waited with bated breath to see what investment would be made in healthcare as part of the stimulus package that the President challenged Congress to create.

With the stimulus package signed into law on Tuesday February 17th, it finally seemed that those who had been waiting to see what would transpire could now shift gears and begin the work mapping out the road ahead.  There is much to be done, and there are still many, many more questions than there are answers, but after several months of “wait and see”, it is clearly time for those most able to move the ball forward in healthcare to come together and begin the hard work that lays ahead.  While the Summit of course cannot in and of itself boast to have started the ball in motion, it may prove to be an effective call to action for those of us who have been forced into playing a waiting game over the past three months due to the state of the domestic and global economy.

To hear about the content of the discussion on the summit, I suggest reading my colleague’s blog article here

Everyone came with something important to contribute to the summit and with a mission to take away new perspectives as well. The networking before the night’s speakers and the panel was a good time to meet people and share expectations about the event. Most revealing for me was how connected so many industries are to healthcare. It is reflective of the relative size of healthcare expenditure in the GDP.

Steve Wardell, the head of the HILForum, which organized the event, started his talk with some level setting. By doing a quick poll, he demonstrated that most of the people at the symposium work towards improvement in treatment outcomes for patients and also to reduce the costs associated with healthcare. There is a lot more to gain for everyone involved if these two goals, which are not mutually exclusive, are kept in clear focus. This was the best start for what is almost always a heated debate. I say almost because despite the few points of contention that came up, there was a general consensus in what needed to be done and where most of the waste in health care delivery was happening. There was also widespread acknowledgment of what has been working well – social networking amongst patients – through little or no industry help at all.

One observation as to the biggest problem that needed to be corrected was that Medicare, as it exists today, has inadvertently rewarded specialization for physicians and has discouraged the practice of primary care. Where the population of physicians was about evenly split about 50/50 forty or so years ago, it is now heavily skewed towards specialists and away from primary care practitioners. Charlie Baker of Harvard Pilgrim also made the point that this skewing had taken place gradually but consistently and that undoing this change might also have to happen at this pace. The correction to the rewards and incentives to improve what providers did was a generally agreed-up point.

Another panelist, Jonathan Bush of Athena Health, dramatically made the point that there is a need for pragmatism in addressing health care cost issues, and that without it, the result may be passing along the burden of high costs of healthcare to the generations to come. Both Charlie and Jonathan believe that incremental changes were happening in the right direction and that incentives were helping and would continue to help. The health IT budget in the stimulus was one big incentive, that might trigger the flow of health data which could then be measured by the right authorities, both private and public, in order to improve quality, determine comparative effectiveness, and reduce costs. There was general agreement on this point as well.

A physician in the audience raised the point that she spent a significant amount of time trying to determine if her patients were being compliant with their prescriptions for recovery after being discharged, and that if this time could be saved by making it easier for her to follow up on her discharged patients, it would be worth spending the additional time to use electronic prescription systems (ePrescriptions) as opposed to continuing to write them by hand.

The other panelists were John Glaser and James Roosevelt of Partners Healthcare and Tufts Health Plan respectively. They contributed a wealth of perspective and balance to the issues as well. James Roosevelt was the keynote speaker and his message was that all stakeholders needed to be ready for compromise in order to accomplish change. John Glaser touched on an item that everyone agreed on – what does “meaningful use” mean? It is language included in the recently passed bill that is the qualification for a medical practice to receive some of the stimulus funds, but the exact definition of what that is still has to be clarified. Jonathan Bush made the point that everyone was contemplating – that “meaningful use” will be different for providers, insurers, and patients.

A patient named Dave also brought into perspective another dimension into the conversation when he asked about what was fair for patients who had rare enough conditions that did not attract the industry to accommodate their needs to improved flow of information. A panelist thought that even though a company may be more incentivized to target a larger potential pool of consumers than a smaller pool that might have a rare condition, it might be that through improvements targeted at a larger pool of consumers, a smaller but different group could benefit as well. These would be incremental changes in the right direction.

There were also many ideas from entrepreneurs which were more optimistic in the accomplishment of major impacts, even if from seemingly small and minimally disruptive changes in the delivery of care. David Williams logged perspectives from several CEO’s on his blog. Among those pushing innovation, there remains optimism that big changes can happen fairly quickly if the right solution were matched to the right opportunity.