Tuesday, January 19, 2010

Four Interlocking Issues about Fixing American Healthcare

Here are four interlocking issues that must be addressed if we Americans are ever to fix healthcare:
  1. Meaningful use of health IT vs. Minimally acceptable usefulness. I contend that health IT is used "meaningfully" only if it helps increase the effectiveness and efficiency of care (i.e., increases care value to the consumer). Although the Federal government is focusing on this value proposition, pressure from the healthcare industry may end up watering down the meaningful use definition to one of "minimally acceptable usefulness." And to be TRULY meaningfully used, EHRs ought to provide data and functions that support the following three value-enhancing models & processes...
  2. Patient-Centered Medical Homes (PCMH) vs. Uncoordinated care. The PCMH model, which provides oversight and coordination in the delivery of care is, thankfully, gradually gaining acceptance.
  3. Patient-Centered Cognitive Support (PCCS) vs. Inadequate information (ignorance), Information overload, and Lack of computerized decision support. PCCS, which consists of advanced software systems that help clinicians make informed decisions without information overload, is slowly gaining traction.
  4. Pay-for-Value (P4V) vs. Fee-for-Service (FFS). P4V, which focuses on the delivery of cost-effective care (i.e., high value to consumers) is being endorsed by some, but it has a long way to go before crowding out the FFS model in which "pay for volume" or "pay more for doing more" is actually a disincentive for cost-effective care (i.e, cost-effectiveness means less provider income/revenue under FFS).
Unfortunately, current day EHRs are not designed to support all those things, which means we ought to re-think the future of health IT design and capabilities. So, while it's important to have EHRs used widely across all healthcare facilities and disciplines/specialties--and while meaningful use criteria cannot be overly demanding considering their very early stage of today's EHR applications--there ought to be assurance by vendors that their products are flexible/adaptable enough to accomodate TRUE meaningful use.


stimfig said...

Stephen, I think there are many EHR's that have been designed with delivering 'Meaningful Use' capability. Remember that ONC came up with the 'Meaningful Use' criteria in conjunction with many months of back and forth dialogue with HIT vendors and Healthcare professionals.

Dr. Steve Beller said...

I appreciate your comment and agree that ONC is setting the "Meaningful Use" bar high, which is why there is so much push-back.

I contend, however, that if ever-increasing value to the consumer (i.e., care cost-effectiveness) is the ultimate goal, then there will (have to) be greatly increased EHR capabilities over time, especially in support of patient-centered cognitive support and pay for value, as well as the comprehensive, multi-disciplanary, mind-body-environment-genetics research that is needed to fill the knowledge gap. These capabilities could be built into basic EHR functionality and/or be provided by collateral (add-on) health IT tools (such as computerized diagnostic decision support and care pathways) that augment basic EHR capabilities.

Unknown said...

On the flipside, where is the incentive to do a better job of treating the patient?

If the GP or PCP do a better job of treating the patient, then there are fewer visits to the GP/PCP as well as fewer visits to a specialist. To a lot of folks that means the cost has to go up so that everyone can maintain their current income levels and lifestyle.

How does a small clinic say 5 doctors and 8 staffers continue to function if their patient load drops by 20% do to better quality of care?

Are we as a nation ready for that consolidation?

Dr. Steve Beller said...

Excellent question! How can we expect the focus to be on high value for the patient/consumer when (a) the income for providers is based on the number of tests and procedure done, and (b) revenue for suppliers is based on the amount of medications and supplies purchased, while (c) more care is NOT associated with better care, i.e., more spending does not yield better outcome for the patient (e.g., see http://bit.ly/92Z0Y5 ).

Sadly, pay for performance (P4P)—in which providers receive a bonus for doing certain tests and procedures—does not take into account the cost-effectiveness of care delivered, thus does not promote high value care. In other words, we should be moving from P4P to Pay-for-Value (e.g., here are two more links about it - http://bit.ly/5xeQnn and http://bit.ly/36OXzn ).

Also, a paper in Health Affairs this month discussed evidence that “Value-Based Insurance” might be effective.

None of this means that our country is truly ready to focus seriously on value, but at least there are discussions taking place, which provides some hope. Nevertheless, if we fail to move in a value-driven direction, our bloated healthcare system will simply collapse under its own weight.

arnostginsberg said...

The health It is only useful if it increases the efficiency of health care of people.PCMH seems to be quite impressive.From my point of view it will gain maximum acceptance.

Mc Arthur said...

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Unknown said...

To the comment about costs having to go up because health patients means fewer visits.

Conversely, if a practice in said situation were to lower the charges for services, thus broadening their base of patients the income level would remain relatively stable and the country would have fewer people using the ER as their Primary Care Provider.

My cobra package recently expired and my cost to get seen by a GP to get a prescription for amoxicillin was $300 ( $260 for the GP with discount for paying cash and $40 for the amoxicillin). Any wonder under- and un-insured patients don't want to go to the doctor.

On the flip side, there is a 12 physician practice here in Austin that accepts only 2500 patients, which has a huge waiting list to join. The deal? $2500/per year and $25 co-pay per visit.
No insurance paper work, no deductible and a full range of services (gp through specialists). They do recommend that each patient additionally carry a high deductible policy for catastrophic care -- anything that would require surgery or hospitalization.

So no it doesn't have to be status, but you do have to get the legislative lobbying power away from the drug and insurance industries, because a healthy population means less profit for them.

Dr. Steve Beller said...

I appreciate the wonderful comments!

In response to Japher's last comment, legislation-lobbyist ties create all sorts of problems in many US industries, not only healthcare. Quid pro quo results in legislative favoritism for those giving campaign contributions. As I see it, our political-economic system is severely broken and we are becoming an oligarchy with disgustingly imbalance of wealth. I don’t blame any individuals for this, not the politicians, CEOs, corporate shareholders, healthcare clinicians … no one. It’s what happens when certain negative aspects of human nature (e.g., greed, ego and callous self-centeredness) go largely unconstrained. Any nation/culture is in trouble when profit trumps compassion, secret dealings obscure transparency/openness, “money makes the man,” the “good life” equals conspicuous consumption, read the “fine print” and “buyer beware” are the mantras of doing business, live for today without regard for tomorrow, value to the consumer is a low priority, etc.

I commend the Texan physician practice for their efforts. Catastrophic insurance is not great solution, however, since many people would avoid necessary care when the first $10K/yr. or so comes out of pocket, which would lead to greater expense when a person becomes more ill.

I suggest that it boils down to our nation’s priorities/values/virtues ... What would our country’s forefathers say about how the American Capitalism model has evolved (or should I say, “devolved”)?

seositeden.blogspot.com said...

This won't actually have success, I think so.