More woes for NHS

When I was younger, I took an immersion Russian course at Norwich University in Vermont. On the first day, our teacher, who was himself a gifted, fluent non-native Russian speaker, asked each of us why we wanted to learn Russian. One of the students said "I've always dreamed of reading War and Peace in the original." The teacher responded in a joking tone that revealed the hard truth: "Yes, and I too hope to be able to do that someday." We all realized in that moment that we had a hard slog ahead.

I was reminded of that moment when I read an article in this week's Economist magazine about the UK National Health Services's much troubled "Choose and Book" system (see Notional Health Server). The goal of the system is to "allow patients in the National Health Service (NHS), advised by their doctors, to choose the treatment they want, and book an appointment when they want it." Unfortunately, after 3 years of hard work, it still hasn't worked out that way. Over 50% of physicians have a negative view of the system according to the British Medical Association. One of the physicians interviewed said that in her experience the system is so slow that it takes about 2 minutes for each visit request, and even then, it functions properly only 10% of the time.

Those familiar with health IT will immediately recognize how ambitious Choose & Book goals are and, I suspect, feel sympathy for their plight. As the article put it, the system will only perform as designed if everything goes right, meaning that the hospital, physician, and health trust systems that it needs to interact with fit together perfectly, and that the physicians and administrators who use those systems fit together perfectly as well. You would think that this could be accomplished in a government-owned health system...........and you'd be wrong. Which leaves those of us living in a highly decentralized system wondering just how ambitious we should be.

Unfortunately, users, and especially physician users, assume that they'll immediately be able to do the kinds of things that Choose & Book is supposed to, and it's often hard to ratchet expectations back to reality. In the MAeHC pilot projects, we're launching health information exchanges in three pilot communities and we're constantly in the struggle of trying to prevent the perfect from being the enemy of the good by reminding physicians that the first version is "Version 1.0" which will be improved over time. It's fantastic that our users are engaged and they want to get value out of the system; it won't be fantastic if "Version 1.0" isn't good enough to want them to stick around for Versions 2, 3, and 4.

I find managing this tension -- between designing the perfect architecture vs launching something good and attainable -- to be one of the biggest challenges in the health IT space. The most difficult part of the challenge is that the culprit isn't the technology, it's the lack of alignment of the technology and processes used by the most important data sources, hospitals and physician offices. It's the same problem faced by Dossia and Microsoft's Health Vault and Google Health -- will our users be willing to wait for the system to catch up with the technology?

"Strap on the feed bag"

In the constant battle to control health care costs, there has been lots of experimentation with controlling the supply-side (eg, certificates of need, cutting back reimbursement levels to providers, etc) and the demand-side (eg, coverage limits, tiering, co-pays, co-insurance, etc). Health care costs continue to rise rapidly, but that doesn't mean that these methods have failed -- we don't know what cost growth would have been like without them.

There's been a lot of emphasis recently on digging further into the nature of demand -- rather than just cutting back patient choice, why not cut back on patient need by getting patients to be healthier in the first place. Employers pressure health insurers to curb cost growth, but the insurers argue that employers don't do enough to get employees to be healthy in the first place. Physicians and hospitals, pressured to improve quality and efficiency, complain that patient adherance is a large barrier to improved care -- if patients don't take simple measures to be healthy, and/or refuse to follow prescribed treatments, what is a provider to do?

This seems like a win-win-win; people shouldn't need that much encouragement to become healthier, and the results will be beneficial to all. Well, a large employer that is also a very savvy health care business has been experimenting with direct patient incentives to encourage healthier lifestyles, and they're finding that it's not quite as easy as it sounds (see Employers experiment with tough get-healthy regimes).

Clarian Health Partners of Indianapolis is an integrated delivery network that employees 13,000 people. They tried to segment their employee risk pool by setting higher premiums for employees who don't attempt to improve their health in certain ways, such as smoking, obesity, and high cholestorol. We as a society already allow this type of risk segmentation in other areas of insurance, and indeed, it's the very basis of preventing moral hazard incentives that undermine the efficiency gains of insurance to begin with! For example, bad drivers, and those assumed to be bad drivers (like teenagers), pay a lot more for insurance. Seems like a slam dunk, right?

Clarian ran into a buzz-saw and never rolled out the program. Some critics saw it as an intrusion of privacy -- an employer shouldn't be allowed to dictate what employees do outside of work. Others saw it as discrimination -- an employer shouldn't be able to single out certain groups of people based on health history or habits.

One bizarre quote in the article points out how weird this conversation can get. Commenting on why his company doesn't raise premiums for overweight employees, an auto-parts supplier stated that:

"We're a little bit reluctant to go down that path. It's not really the fear of litigation as much as the lack of evidence that it works," he said. "I look at my own reaction and if I were going to be penalized for my weight I'd say, 'If for an extra $15 a month I can strap the feed bag on I'm going to do that and I'm going to make sure I get my money's worth.'"

I can't think of a better summary of the depth of the problems that we face.

P4P may finally be growing up

I've heard anecdotally that health plans are retrenching on so-called pay-for-performance (P4P) reiumbursement programs because they're not getting the return that they hoped to get. There seems to be some evidence of this in the data as well -- projections from 18 months ago suggested gushing growth (see The state of P4P programs), but the trend more recently seems to be on refinement rather than expansion (see It's everywhere but measuring effectiveness of P4P is challenging). There seems to be a trend out there away from pure P4P and toward mixed reimbursement models that blend in capitation with performance-based payment, exemplified by two new approaches.

First is the so-called "medical home" idea, which has been articulated and promoted by a variety of medical specialty socieities (for example, see Medical home could rescusitate primary care and Joint Principles of a Patient-Centered Medical Home Released by Organizations Representing More Than 300,000 Physicians). While a lot of the focus of the medical professionals has been on bolstering primary care, the business community has recently jumped on the bandwagon because of the financial benefits of the approach. Bridges to Excellence estimates that the medical home approach yields savings of $250-$300 per patient per year by reducing unnecessary specialist and emergency room visits and preventing acute medical episodes that result from poor preventative care (see Group Offers Doctors Bonuses for Better Care). Since the average primary care physician cares for roughly 2000 patients, this can add up to real money real fast.

The second approach is in the creation of alternative payment models such as that announced by Blue Cross Blue Shield of Massachusetts earlier this year (see A New and Different Way to Pay for Care). This approach has had some early bumps, but it's still early (see Blue Cross faces uphill climb over flat-sum payments).

The best description I've seen of the benefits of moving back toward some type of capitation model is in Benjamin Brewer's column in yesterday's Wall Street Journal (Finding a Medical Home May Be Just What the Doctor Ordered). Dr. Brewer gives an excellent ground-level view of what it means to pay physicians to manage patients instead of acute episodes, and why such an approach might really offer benefits to patients and physicians alike.

MA Health Policy Forum

The Massachusetts Health Policy Forum has written a pretty comprehensive brief on the various health IT activities going on in Massachusetts. It was written to support an upcoming conference. To download the brief, go to the link at the bottom of the page.

It takes more than money

Just about a year ago I wrote about Britain's Connecting for Health program's privacy policy or, more appropriately, their lack thereof. Their approach at the time can best be described as "opt-NOT" -- patients getting care through the NHS would automatically have their data shared on the "Spine" (the national HIE). No fooling around with the niceties of opt-in vs opt-out -- patients could only opt-out by opting out of getting their care from the publicly-funded health service that they pay dearly for.

The NHS has since backed off from this stance and now allows an opt-out policy. That's still a far cry from the opt-in approach taken by MAeHC, and in the context of a burgeoning US movement toward "personally-controlled" health data management, it's downright archaic.

The latest report is that despite this change in policy, physicians themselves are rebelling against the system: 2/3 of NHS family physicians say that they will boycott data-sharing in the system according to a recent poll (see Family doctors to shun national database of patients' records). In a country where individuals have historically deferred to the government on issues of information access, this is a pretty stunning development.

Our policy in the MAeHC project is to allow patient opt-in, meaning that no information will be made available to other entities without the specific permission of patients. Our current opt-in rate is about 93%.

While an opt-in approach clearly has some short-term risks -- such as, slower adoption of systems by physicians, delays in achieving the benefits of clinical data-sharing -- it provides a firmer foundation for the overall enterprise. In the end, we won't be able to reap the benefits of clinical integration unless we build systems that both patients and clinicians can trust.

Wal-Mart's epiphany

So Wal-Mart is expanding health coverage to more of it's employees -- at least according to a story in today's New York Times. What caught my attention was the description of how they've shifted their view on health benefits -- what were once seen as pure costs are now seen as investments in the work force to improve "presenteeism" and absenteeism and thereby increase overall productivity.

Personally, I'd like to see us get rid of employer-sponsored health insurance, but I recognize that one positive aspect of it is that employers can instill market principles into health care delivery by acting as "smart buyers" of health care services on behalf of their employees. The fact that it's taken Wal-Mart, of all companies, this long to come to the realization that investing in one of their key factors of production just might improve productivity suggests that this "smart buyer" role may not be as compelling as we'd like to think. Maybe Wal-Mart's epiphany will accelerate this type of thinking among other employers.

Now, if we could just get Wal-Mart to invest in technology upgrades for their health care delivery supply chain, we might make better progress on the health IT front.....

Uh-oh....

I hope my Board doesn't read Computerworld:
"Whole Foods to restrict online postings by execs after CEO brouhaha"

Yet another plug I should have made.....

OK, so I'm still catching up. There's another shout-out that I keep meaning to make. The Partnership for Healthcare Excellence launched their website a couple of weeks ago. If you live in Massachusetts and haven't heard of them yet, you will soon.

Every Health Economics 101 class begins with a description of the basic tenets of competitive markets (many suppliers and demanders, homogeneity of products and services, full information, yada yada yada). The class then goes on to show how the health care delivery sector violates every tenet.

Health care markets deviate from the theoretical definition in a few ways. For example, consumers don't have enough incentive to worry about value-for-money (because insurance shields them from transaction prices), and they depend on their suppliers (ie, medical professionals) to tell them what services they need. Some of this deviation is structural -- the health care market is never going to operate like the auto or cereal industries because the stakes are too high and the services are too complex.

There is now a push for more tranparency in health care, which is edging the entire industry toward performance measurement and public reporting. The Massachusetts Health Quality Partners is one of the country's leading efforts in this area, the Massachusetts Quality and Cost Council is gearing up for more public reporting, and a bunch of states are already publishing reports on quality measures, hospital infection rates, costs, and medical errors (among them are Vermont, Pennsylvania, Florida, Missouri, Indiana, New Hampshire, and Massachusetts).

The real question, though, is whether consumers will make use of this information. Some believe that consumers will never act on such information, so it's a waste of time and effort. Others agree that consumers will never act on such information, but if their medical professionals will or their employers will, it's still worthwhile. Regardless, the hope is that public reporting will affect consumers in some way, whether directly or indirectly.

Employers can act as smart purchasers on behalf of patients to a certain extent, by locking in financial incentives to behave in certain ways and by demanding more from their health insurers or providers. The Group Insurance Commission tiers physicians and hospitals, for example, and structures financial incentives accordingly. Putting boundaries around what patients can demand will only get us so far, however.

What we'd all like to see is patients individually acting both as better consumers of their health care dollars AND better users of the health care system. Yet, it's hard for them to do this on their own -- our health care delivery system is too complex, and they've already become accustomed to playing a certain role in the physician-patient relationship. Actionable education is the key to bringing about this change, and that's where the Partnership for Healthcare Excellence comes in. Check out their site -- you might just learn something.....

Geek Doctor Emerges

So I've been greatly remiss in not putting in a plug for John Halamka's blog. I learn something new every time I talk to John, and now the world can too.

Best of luck John!

My kingdom for an inter-operable vendor!

The following was forwarded to me by one of our vendors (which is ironic, once you see the content).

The heads of the two leading health IT projects in the world -- Richard Granger of the UK's Connecting for Health, and Richard Alvarez, the head of Canada's Infoway -- spoke at a recent conference and complained loudly about the state of the health IT industry (see "NHS chief chides vendors for promising more than they deliver").

"Vendors! You can't do these projects without them, but many of the products proferred can't do the job," exclaimed Granger. Adding to the fray, Alvarez stated: "Vendors continue to say they can do it -- but they can't. We don't have a single vendor that is truly interoperable."

Noting that the American approach is to proceed more cautiously -- through standards development, certification, evaluation, ROI calculations and multiple panels and commissions -- Granger quipped: "Some people lack the spine...to bring about systemic benefits and seek only to engineer point-to-point benefits." This approach, he said, is "doomed to fail."

I've got only one thing to say about Granger's comments: Hear, Hear!!