Here's an assignment for budding hacks: count all the weasel words in this post.

There's more on a related issue here, including this language that may or may not be in the latest version:

The utilization of an electronic health record for each person in the United States by 2014

While I agree with your argument, there are times when new treatments work but have yet to be proven. My wife was cured by an experimental treatment that only a few teaching hospitals were doing, and we had a devil of a time getting our HMO to cover it. It is now much more accepted, but I bet it wouldn't have been the government approved treatment when my wife had it done.

Wowe,
using this methodology just think how good we could do by having the feds also plugged into our grocery store,and they can approve or deny each product we attempt to buy since we know people waste huge amounts of resources on food that's not good for them.

Then we can also plug the feds into our restaurant meal choices and knock out those that are going to cause heart disease in the future.

Then the feds should monitor our television on/off and channel usage so they can deny coach potatoes rest time and make sure kids are watching stuff that's good for them. Imagine the time savings if the feds could manage our television time.

Then of course we need the feds monitoring our blog reading time which may cause eye strain or even heart attacks reading such drivel and they could ssave lives, etc.

What a brave new world you've discovered.

Ezra doesn't seem to grasp the difference between a person signing a private contract for a specific set of healthcare and doctors AGREEING TO THOSE SAME PRIVATE CONTRACTS.
And the use of a forced system where the government will be directly between the doctor and the patient at the time of care.

correction: "We NOW know that prescribing a swift kick in the head doesn't cure gout."

I think the smart thing to do is everyone just tell their doctor they want an abortion...see how quickly the liberals shutdown any government data gathering on that little procedure.

Looks like Judd Greeg got a good whiff of the head rot at the white house and ran for the hills..

And the use of a forced system where the government will be directly between the doctor and the patient at the time of care.

Posted by: Anonymous | February 12, 2009 4:34 PM

Eh, not really. Even if it was, so friggin' what? Right now I've got a team of soulless, faceless insurance bastards that have never met me who dictate my medical treatment from a company center hundreds of miles away. And they are well paid for this "service".

Oh come now Hairy Reed, we pay for your healthcare, why do you deserve better then the worst?

You've spent us trillions in debt, you lost the war, now you want us to pay for your airplane and the best healthcare money can buy?

I think the smart thing to do is everyone just tell their doctor they want an abortion...see how quickly the liberals shutdown any government data gathering on that little procedure.

Well, according to some estimates about one in three American women will have at least one abortion before she turns 45, so we're pretty close to that already. And abortions are VERY effective -- they end pregnancies almost every time. And they present lower risks to the mother than carrying a pregnancy to term. Sounds exactly like the kind of safe, common, cost-effective procedures any system would be wise to include.

Oh come now Hairy Reed, we pay for your healthcare, why do you deserve better then the worst?

You've spent us trillions in debt, you lost the war, now you want us to pay for your airplane and the best healthcare money can buy?

Posted by: Anonymous | February 12, 2009 4:48 PM

I have a disease related to pulmonary fibrosis. I have never smoked, but I have worked in some second hand smoke environments. Most people die from this illness in about 3 years. I've had it for 5 years, and I still work and spend loads of money on treatments and medicine that just prolong my life - there is no cure for the disease. The crappy employer insurance that I have is a textbook study in penny scraping profit maximizing, my pulmonary doctor and I fight them pretty much every step of the way. But what can I do, I certainly can't get insurance anywhere else now. I am not ready to give up and go on disability, but it would be a helluva lot easier.
Thank you for your kind, thoughtful reply. Also fuck you.

Mr. Klein,

You very correctly point out that EMRs and almost all health IT has the potential to bring enormous savings and improved quality to the American health system. Portability of both health insurance and one's medical history are keys to advancing the system. It is also fair to say that, though, that a very interventionist health care state COULD use these records to track physician compliance with recommended procedures and drop non-conformist doctors. Is that necessarily bad, though? Doctors in private practice can refuse to see any patients -- as many do with Medicaid today. If the government goes too far, this check (docs refusing to see those on gov't plans) will force the state to reconsider how much it wants to regulate on a micro-level.

While Ms. McCaughey's rhetoric of impending doom is unwarranted, it is not fair to completely discount her admonitions. She is jumping the gun on the assertions that our UK NICE equivalent will be used to dictate decisions at the bedside. One of lesson learned from the early days of HMOs was that utilization reviews (granted these are somewhat different from those) were extremely unpopular. It will depend on how much authority this body is given. In some countries, comparative effectiveness and health technology assessment (HTA) boards have broad power at the national level (e.g. Germany's HTA board). Some countries ban drugs and medical procedures (e.g. Australia on the latter) for the explicit purpose of rationing care. Others, like the Swiss HTA, only review "controversial" technologies. There is huge variation in the power these entities wield, and it is too early to tell how much power the American version within AHRQ will have.

I agree, though, that the pharmaceutical and biotech industries have much more to fear today than health practitioners. If the Obama Administration also pushes to open our market to foreign drugs and instruments, the sector will find itself looking for new direction and perhaps a new hoome. These measures will, though - without a doubt - save a tremendous amount of money.

And liberals would indeed welcome more data collection on abortion procedures. If in fact it did turn out that abortions killed half of all women who had them, or that a fetus aborted at 3 months would still be born at 9 months, I am pretty confident that liberals would roundly call for abortion to be ended as an unsafe procedure.

Of course, this is all hypothetical. I guess Anonymous really does want the option for forced anal sex to be prescribed by his doctor and funded by insurance.

Has Anonymous even looked at the graph posted? Do you have any response, or are you just shills for... hell, I don't know who you're shills for. More evidence-based medicine would be gladly taken up by insurance companies to reduce costs. Insurance companies even now regularly use it to not pay for treatments. What, exactly, is the change?

Is it really worth it to have health care costs continue to spiral out of control just so a doctor can prescribe mass doses of Vitamin C to cure TB?

Ezra,

The main opposition to a higher value, higher performing system will be the companies that stand to lose billions if we actually do cut down on waste and improper treatment.

Absolutely wrong. The main opposition will come from physicians and hospitals, which will lose their decision-making autonomy if there is a way of overseeing their treatment decisions. There are a multitide of ways for "companies" to address a cut down in waste-- 1) raise prices on products 2) focus investments more in areas that have greater unmet need and aren't wasteful-- the companies will be fine-- medicine as a profession will be changed forever.

Ezra, what you're confusing in your post is information use vs. information gap. A comparative effectiveness effort is about filling an information gap. Evidence-based medicine and the literature on 30% waste is about getting physicians to use the information what we already know.

That isn't about, as you say

Providing better information for doctors is the sort of policy that could attain consensus in American politics

A significant amount of information already exists. Its not being used because there is little transparency and clarity on quality of care. The fundamental policy question is: how do you drive quality and get more physicians to practice EBM? You could argue that government needs to be big brother. Or you could argue that market mechanisms could help drive patients to the "better" doctors which will drive better quality-- i.e. let consumers be big brother. None of that has to do with profits. Its about who should be the ones to force physicians to change how they practice.

You're way off on this one.

Sorry bud, but if you really think that the 30 percent waste can be solved by what we already know, you're just dead, dead wrong. We have a tremendous information gap. And that's what we're addressing with CER. And that's what manufacturers will fight. Action on information use will come later, if ever, and then, as you say, the hospitals and physicians will take the lead in opposition. But that's not the fight being engaged right now.

Shorter version:

There's less evidence than you might think around these treatments, and much less evidence than you might hope demonstrating how these treatments compare to alternatives.

You've got this wrong. Yes, there's a ton more data to collect. But physicians aren't using a lot of the data that we have today. The latter is the much tougher "getting physicians to change how they practice." The former allows folks to ignore the practice change part and instead spend time and money generating more data. We need greater accountability on quality. Its not about not knowing what "quality" is. When Berwick says that the right course of action is only followed 48% of the time, he's not guessing. He's use treatment guidelines based on data. We need to move the 48% figure up closer to 100%. That's the bigger win. The comparative effectiveness bit is about finding out when cheaper treatment options are more cost-effective. The 30% waste is heavily depending on the 48% issue, not the cheaper option issue.

Sorry bud, but if you really think that the 30 percent waste can be solved by what we already know, you're just dead, dead wrong. We have a tremendous information gap. And that's what we're addressing with CER. And that's what manufacturers will fight. Action on information use will come later, if ever, and then, as you say, the hospitals and physicians will take the lead in opposition. But that's not the fight being engaged right now.

Ezra,

Wennberg's point on variation of care has to with things like unnecessary hysterectomies-- the devices involved are a small part of the costs. The physicians and hospitals are making the money here. And the ones making the bad decisions. Based on information known today.

I don't know how much time you've actually spent reading primary sources on this stuff-- but you're plain wrong. Period. Spend some time reading Wennberg, Berwick, efforts on pay-for-performance initiatives. As I wrote before, there's clearly an information gap to be filled. But the larger gap is noncompliance with evidence-based guidelines that already exist.

You're out of your depths here, I've been doing this stuff for a living for a long time-- I'd back off until you've done a little more reading on the topic.

Houdini's Ghost,

Absolutely, Based on cost, the government would approve abortion vice birth everytime.

Since the government does not recognize a fetus as having any rights, why would any government ever pay for a live birth?

You look at the risk to the mothers health, the long term cost for the little blobs healthcare and its an easy call for any government healthcare system to only pay for abortions and not those pesky live births.

Well said Ezra.

I’d add a few things:

-Remember that having federal oversight review the medical decisions made by your doctor (though, of course, also remembering that no such action was proposed), is not necessarily a bad thing. There are bad doctors. There are terrible doctors who are out there and not practicing evidence-based medicine or staying current on the journals for their field. For example they now know that a $15 blood test can all but guarantee whether or not a patient’s kidneys would be harmed by the contrast used for MRI’s. Not all doctors know this yet. Not all radiology techs know this yet. There’s value in interceding sometimes. If anything, wisewon, this speaks to your point of doctors changing the way they practice. Doctors are used to hierarchy. The decisions that trickle down won’t come from the feds, but from physicians. And the physicians will have to defend their decisions not to bureaucrats, but to other doctors, just as they already do.

-McCaughey seems to be among those (like some of your commenters) who believe that her party doesn’t want universal health care. Three dozen Fortune 500 companies beg to differ. Safeway, Pepsi, General Mills, Kraft, CVS, sure, they want a market-based model for universal care, but they want it.

-Daschle talked a bit about ‘comparative effectiveness research’ in his book and it was admittedly one of his weaker points as it wasn’t really developed. If I had to guess I’d imagine it’d be some bolstering up of guideline.gov to be searchable by clinical outcomes or something like that, though, really, in my health policy wet dreams, it’d be searchable ‘best practices’ database. It’d be nice to be able to say, “ok, my public health agency has 2000 non-compliant diabetics and we can’t get them in the door, what have other agencies done?” and look it up. Or, “we’ve got a 50% no-show rate for Behavioral Health appointments, what have other plans done?” The real dearth of information in the public health world is on the operational side. Talking to patients about compliance and managing resources, this is all done through some sort of mishmash of folk wisdom and whatever-the-accrediting-body-tells-us-to-do. Sure, it could just be about clinical outcomes, but I’d like to see something broader.

And wisewon, sorry, you’re way off (I also do this). Doctors and hospitals want this. I’ve seen local models of shared ER admit data among hospitals and the users are ecstatic. It’s saving money and improving outcomes (to say nothing of flagging drug-seeking patients).

Though, in some ways, you are correct that a lot of waste could be reduced by sharing information that we already know, but the barrier is not, “little transparency and clarity on quality of care.” It’s about resources and operational obstacles. If the government comes in and builds the infrastructure, everyone will want to plug into it. Really. You’re also right that much of this information exists, but it’s not being ignored because physicians choose not to practice EBM, most of them do, but they don’t have access to it. They’re not using the information because the patient is in an ER and relevant test results that would help the doctor make better decisions are sitting in a paper file in a different city and not accessible at 3am.

Also, I don’t know if the GE Healthcare’s of the world will really be fighting this tooth and nail. I think they’ll be against it, but I suspect they’ll find an angle to make it work for themselves.

Its time to stand up Ezra and proclaim the Government should only pay for abortions based on risk and cost factors. If you want to take the added risk and cost of a live birth, pay for it yourself.!!

Doctors and hospitals want this.

Define "this"-- I'm talking about wasteful spending-- i.e. doctors are pursuing activities that aren't according to standard of care. Doctors and hospitals want to be told that they aren't practicing quality care? News to me.

You’re also right that much of this information exists, but it’s not being ignored because physicians choose not to practice EBM, most of them do, but they don’t have access to it.

They do have access to it. Its published in medical journals every month. They don't keep up with the field. There isn't anyone holding them accountable if they practice the standard of care they were taught 15 years ago, rather than the one that was updated last year. The data is available and they have access. If they were evaluated based on their adherence to EBM, they'd use it. But they're not paid based on quality, so they aren't incented to spend the time ensuring they're practicing quality. That's the issue.

You sound like a health IT guy-- there's no question new tools can help them do the job better. But it starts when docs wanting to do better. Which is about changing behavior. That's what I was getting at above.

Ahh yes, we were talking about slightly different things.

I'm not quite as cynical as you (and not an IT guy, quality guy, for the sake of being succinct), and I do think that if there were a way for a doctor to be seeing a patient, and a flag to pop up on a screen somewhere saying, 'needs a pap smear!' that the doctor would review the info and have no problem doing the pap smear. I think the barrier isn't so much laziness as it is time and information.

And I'm talking about patient-level quality information. Not peer-reviewed journals. Nationalized health records with some sort of clinical recommendation ability eases the information burden on the doctor and the doctor doesn't need to look at the patient's record, look at this month's JAMA, and put two and two together. The doctor looks at the patient's record, and a pop-up box appears (put there by someone else who read this month's JAMA) recommending that the doctor do some added step.

Of course, I could just be optimistic that that’s how it’d go down.

Also, in my personal experience at a previous job, pay for performance isn’t terrible. We once generated letters to all the PCP’s of non-compliant diabetics and told them how much they’d get if they brought every one of them in for check up and it sure worked.

The health debate also needs to shift to the consumers eventually. Someone, preferably the president, needs to say, “Stop going to the Emergency Room if it isn’t a frickin emergency, you’re costing the country billions!” But that’s another fight for another day.

Anonymous,
What point is it that you think you're making, exactly? At first you claimed that liberals would "shut down" any tracking of the prevalence of abortion because... I'm not really sure why. I pointed out that abortions are very common, and not a bad health care option for many women.

Now you're proposing some ludicrous idea that gov should only pay for abortion, not childbirth. That's very stupid. Nobody supports that, least of all pro-choice people. We believe the decision to have or not have a child should be a woman's choice. It's right there in the name: pro-choice. WTF are you even trying to say?

Also, would you mind picking a more specific pseudonym? It's hard to keep track of all the anonymouses around here. I'm curious how many different idiots are showing up here, or if it's all just you.

This is a loser argument.

80% of Americans believe we have the best quality healthcare in the world. You will not convince them quality sucks. Put down your powerpoint and walk away. Just walk away.

Stop trying to tell Americans we have to do something that MIGHT be rationing but really isn't rationing because we'll only cut the stuff they don't need.

Jesus, this is a dog of an argument. Why would I want to risk rationing to fix something that doesn't need fixing? You think your chart is reassuring? I'm fearful now.

The sane response to this is "Maybe, you know, we should just back off this whole healthcare reform thing. I don't want people with charts deciding what care is and isn't unnecessary."

If you want comparative effectiveness, use an argument other than "it will save money by scientifically proving all the pointless things your idiot doctor is doing."

But Jesus, let's not do 1994 all over again, where they scream "you're rationing" and our brilliant counter is: "yes, but we're rationing really, really smart!"

Ezra,

Two other final thoughts:

-- You're focused on the profits of manufacturers, which just doesn't make sense from a pure cash flow perspective. Physicians and hospitals account for $1.4 trillion of the total $2 trillion in health care spend. There's just no way to cut out 30% of health care waste and not have them be the biggest loser. They're responsible for 2/3 of the total spend. They have the most to economically lose under any reform.

-- Let me try to reconcile what are your beliefs based on who you're getting information from and our current disconnect. There's no question that you're right that the intent of CER proponents is to focus on the information gap. I also think, as you espoused, that many CER proponents in your neck of the woods do actually think that information gaps are the bigger problem, not information use (i.e. lack of EBM adherence to current data). What scares me is that youagree with this line of thinking, and you're relatively well-informed, for DC standards. The problem is that Democrats have demagogued about big company profits for so long on the stump, that they actually think that's the biggest problem with health care costs-- not having clear data about when expensive drugs aren't worth using-- rather than a focus on wasteful spending due to variation in care/lack of adherence with EBM. So I have no illusions that when your crowd is thinking about CER, they are looking at the reduced device and drug spend that will result from using cheaper but similarly effective products. But let's separate that from the actual data-- Berwick and Wennberg show variations in care and lack of adherence to quality based on elements on clinical practice, not drug/device spend. Its the latter that's driving the waste, higher cost drugs or devices is a significantly smaller element of the waste. So I'm not opposed to CER by any means-- that will drive value. But when CER policy implementation is getting in the way of the bigger cost savers-- changing clinical practice behavior-- because folks like you think the latter is the smaller issue, that's when I have a problem. And to put it simply, that's why I knock on DC types when I do, because all you realy have to do is read the literature from these guys, instead of just doing photo ops with them, and you'd see where we should be putting more of the focus.

Ezra,

Two other final thoughts:

-- You're focused on the profits of manufacturers, which just doesn't make sense from a pure cash flow perspective. Physicians and hospitals account for $1.4 trillion of the total $2 trillion in health care spend. There's just no way to cut out 30% of health care waste and not have them be the biggest loser. They're responsible for 2/3 of the total spend. They have the most to economically lose under any reform.

-- Let me try to reconcile what are your beliefs based on who you're getting information from and our current disconnect. There's no question that you're right that the intent of CER proponents is to focus on the information gap. I also think, as you espoused, that many CER proponents in your neck of the woods do actually think that information gaps are the bigger problem, not information use (i.e. lack of EBM adherence to current data). What scares me is that youagree with this line of thinking, and you're relatively well-informed, for DC standards. The problem is that Democrats have demagogued about big company profits for so long on the stump, that they actually think that's the biggest problem with health care costs-- not having clear data about when expensive drugs aren't worth using-- rather than a focus on wasteful spending due to variation in care/lack of adherence with EBM. So I have no illusions that when your crowd is thinking about CER, they are looking at the reduced device and drug spend that will result from using cheaper but similarly effective products. But let's separate that from the actual data-- Berwick and Wennberg show variations in care and lack of adherence to quality based on elements on clinical practice, not drug/device spend. Its the latter that's driving the waste, higher cost drugs or devices is a significantly smaller element of the waste. So I'm not opposed to CER by any means-- that will drive value. But when CER policy implementation is getting in the way of the bigger cost savers-- changing clinical practice behavior-- because folks like you think the latter is the smaller issue, that's when I have a problem. And to put it simply, that's why I knock on DC types when I do, because all you realy have to do is read the literature from these guys, instead of just doing photo ops with them, and you'd see where we should be putting more of the focus.

Houdini's Ghost.

I simply pointed out simple facts, the liberal democrats have opposed every attempt to gather health data on abortions.

Second, my point is that a simple cost/benefit analysis by a government office on birth versus abortion would always recommend abortion.
The point being how dumb it is to allow some government office determine anything for free people.

I think Ezra's trying - only somewhat successfully - to start taking on McCaughey, because someone has to. I think the problem is that Ezra's, still, preaching to the converted, and talking in ways that don't invite the average, not fully informed person into the discussion. Ezra discounts the idea of "McCaughey's populism", but that's the key to her success: no one else is talking, in plain terms, about the health care components of the stimulus in a way that talks to someone who comes to this without the background (and frankly, I think the GOP is getting plenty of mileage out of asking what this stuff is doing in the stimulus bill anyway). McCaughey explains what the bill says... and then explains what's wrong with it. To fight that, you really have to go back to square one. Or Minus one.

I also think there's a false choice argument raging - I don't think there's a dispute that EMRs will help improve care, or that improved care isn't everyone's goal here. Centralization and simplification of treatment information is bound to have a positive impact. I think that's different,as wisewon suggests, from the data that EMRs can help provide on best practices and cost control - things that doctors resist, because they see it as dictating kinds of allowable care, and that hospitals resist because it directly affects bottom line profits.

But for patients, all of this can seem really out in the weeds - they're going to want to know a) who can see their records, and b) what will they do with that info? I think it's long been the case that the sense of intrusion, and of the sense of personal confidential information being attached to health has been a driver of the resistance to EMR adoption, from the patient side. That's not the whole story - doctors are very slow adopters of computer based solutions, and that's a big part too - but privacy has clearly been a stumbling block. And I think any indication that EMRs will be available for "review" is going to fuel the privacy concerns. And a lot of actors who could care less about "privacy" (i.e. insurers and docs really don't share the privacy concerns), would happily let that fear play out if it helps them get their way.

Again, I think McCaughey is succeeding at scaring people because progressives don't have a well spoken, well aimed, response provider. We have a lot of people who do great jobs talking policy with other, like minded people from a policy perspective, but very few voices who lay out, in basic terms, what health care issues mean to the average person, why they should care, and why the proposed solutions - like EMRs - will help. We don't challenge patients enough to be better informed consumers, and we continue to let the "he's a doctor, he must know" type logic go unchallenged. All of those things lend credence to McCaughey, and others, who simply don't want to see the left prevail. They don't have a solution to healthcare, and they know the left can win on this issue... so they have to undercut it. But we're not fighting back, certainly not on the right turf. And that, more than defending the policy benefits of the legislation, is what we need.

You guys need to make up your mind on what you want. Higher quality or lower cost?

Pay for performance was tried in the UK and was a huge hit with doctors--they were so good at it in fact that their annual incomes shot up by 40%. Healthcare costs skyrocketed as a result.

The problem? There was absolutely no change in "quality." Turns out the pay for performance metrics did absolutely NOTHING to improve quality of healthcare.

So what they did is double the budget with no change in quality.

The problem with healthcare is not quality. All those studies showing that patients only get 50% of the healthcare they are supposed to get is absolute BS--it makes absolutely no difference in morbidity or mortality, as the UK "pay for performance" initiative exposed. Whether someone gets an ACE, beta blocker, and statin following an MI makes for nice theoretical improvements in quality, but when the rubber hits the road it makes not one iota of difference in morbidity/mortality.

The problem is cost, not access, not quality. Fix the COST problem and quit fucking around conflating issues that arent relevant.

AGAIN, FIX THE FUCKING PROBLEM, DONT MAKE THINGS WORSE BY GUESSING.

Health care, we know, is too expensive, and it's too expensive in part because we pay for lots of treatments that don't work.

Just as a PS to my comments, and wisewon's - Health care is too expensive because we pay for a lot of services, some of which are needed, and many of which aren't. The idea that we know which "treatments" work and which don't oversimplifies and understates the problems we have right now. And in health care coverage, driven by Medicare "fee for service", we pay for all sorts of things - tests, MRIs, CAT scans, PET scans, just for starters - many of which are not needed. They may have nothing to do with ultimate diagnosis or treatment. What they have to do with is practice which is why we talk about "best practices."

People don't realize, for instance, that phone triage is a great way to reduce waste; the availability of a pediatric nurse to answer new parent questions reduces taking a kid to the doc "just to check" if a fever is serious. Basic conditions - flus, colds, etc - can be addressed many places, don't need a doctor visit, and don't necessarily need a scrip or a shot. That's the kind of changes to practice that can reduce costs and simplify patient care. Docs resist it. Why? Because it reduces their ability to practice in the way they "know best", even if that way is expensive and doesn't lead to any better outcome. Hospitaks resist cutting back unnecessary tests. Why? Because those areas, and the expense of billing for tests, helps their bottom line. And on and on.

And we think patients would question some of these "best practices" but in fact they like them - often, a calm voice and the ability to put their problems in context is all that's needed. We'd like to stay out of the doc's office. We'd like to be able to handle the simple things ourselves. And we can. EMRs can help. But we do need a common language, and we do need to explain things clearly. Treatments are not service. And no one, I think, would question the need for proper treatment. But unnecessary services? That's aseparate issue, and we should be pushing to control them. Much more than we do.

great post, interesting comments (anonymous excepted --jeebus!).

Weboy and ThomasEN, I think are one the right track, along with Ezra.

Wisewon, I feel like Alvy Singer in Annie Hall- I want to pull out Don Berwick and Jack Wennberg from behind a corner and heve them both tell you that you don't know what you're talking about. Clealy you do have some knowledge, but clearly so do others on this blog. I'm a phsyician and I've been dealing with and teaching myself this stuff for many years as well, but I acknowledge deficincies in my knowledge base. But I think your views are a bit myopic.

BUT I have been wrong before. If you'd like to post some linke to the Wennberg and Berwick references that support your points, I would sincerely like to read them. They are two of my heroes, along with Uwe Reinhardt.

Cheers,

"They’re not using the information because the patient is in an ER and relevant test results that would help the doctor make better decisions are sitting in a paper file in a different city and not accessible at 3am."

Too me, this is the most frustrating thing about emergency care. When my mom had leukemia, she received treatment at four different hospitals at once. None of them shared the records. My mom had a lot of recurring symptoms. It would have been helpful if every hospital had access to the records about previous incidents, the treatments, and the effectiveness. But each hospital had their own records, and nothing else. An electronic database that can be accessed by any hospital would make a huge difference. Just saving an hour on diagnosis can be the difference between life and death. Combine that with a database of the general effectiveness of treatments, and that could be a very powerful.

cmhmd,

Below is a commentary signed by Berwick, Wennberg and Reinhardt. Its clear that they believe that pay-for-performance based on adherence to today's EBM standards should begin now. As I noted, as do they, there's clearly room for further improvement on standards via new data collection. But the call is clear-- we need physicians following the today's EBM guidelines based on today's information, with more to follow down the road. Using my terms: its information use #1, information gap #2. That was my point above. Contrary to their recommendation, we don't see significant shifts in payment reform as part of the Dems' package. There's signficantly more momentum for CER. Both are needed, but the Dems priorities are backwards.

The human and financial costs of medical error
and substandard care have been exhaustively documented. A robust inventory of
measures and standards for quality improvement has been developed and continues
to grow. The strategic concept of paying for performance—a bedrock principle
in most industries—has begun to emerge in health care in a variety of experiments
in both the private and public sectors.

You can read the full (along with many other articles by them) piece here:

http://www.safetyleaders.org/pdf/Paying_for_Performance_Medicare_Should_Lead_Berwick_Health_Affairs_11_03.pdf

PS I'd be honestly curious to hear what part of my posts above are wrong. I think its much more likely that its a miscommunication issue-- as I agree with 95% of what weboy and thomasen said.

Hairy Reed

"But what can I do, I certainly can't get insurance anywhere else now."

Ya it's not like the federal government passed some law called HIPAA expressly guaranteing my ability to buy insurance with no pre-existing conditions. Unless I pull my head completly out of my ass I'm stuck with this coverage. Can't go work someplace else, can't use HIPAA to change carriers, can't start my own business and get a guarantee issue plan in just about every state. Nope here I am stuck with my head up my ass and no options but to cry to strangers on the internet.

"And that's what manufacturers will fight."

Does anyone have any idea what Ezra is talking about? Does he share these numbers with anyone when he makes them up?

http://www.census.gov/compendia/statab/tables/09s0134.xls

Of 427 billion in spending only 8 billion was spent on DME and 51 billion on drugs. THe vast majority of payments went to providers. Your entire argument is BS. if you erased ALL SPENDING paid to manufactures and drug companies you would only save around 14%. Your math doesn't even begin to add up.

"If the government comes in and builds the infrastructure, everyone will want to plug into it. "

As illustrated when HIPAA mandated payors accept EDI claims from doctors years ago, overnight all the paper disappeared and doctors did al their billing electronically. Even when it is given to them for free and it's usage would save them money they don't adapt, this has been proven many times over.

OK, as a consumer with slightly better than average knowledge and intelligence, I must admit that while this stuff makes some sense in each argument, the field as a whole is still pretty muddled. Weboy has it right, most people don't really know or care who's fighting on what side of things. They believe we have awesome healthcare, and we need to show them that, frankly, we have the worst healthcare in the developed world.

While people do care in the abstract about privacy of medical records, what they want is for people to tell them that they're records are private. They don't currently know if there are electronic records being used, and probably assume that the information goes into a computer somewhere. People will vote based on propaganda about privacy, but they really don't know enough about how computers work to make an educated vote regarding it. I think that's an important distinction.

We do need to figure out how to engage a wide spectrum of fairly ignorant voters on this... I think that might be my next think project (much more useful than my last one of finding out what moves are considered awesome) since I'm currently unemployed...

Hairy Reed

"But what can I do, I certainly can't get insurance anywhere else now."

Ya it's not like the federal government passed some law called HIPAA expressly guaranteing my ability to buy insurance with no pre-existing conditions. Unless I pull my head completly out of my ass I'm stuck with this coverage. Can't go work someplace else, can't use HIPAA to change carriers, can't start my own business and get a guarantee issue plan in just about every state. Nope here I am stuck with my head up my ass and no options but to cry to strangers on the internet.

"And that's what manufacturers will fight."

Does anyone have any idea what Ezra is talking about? Does he share these numbers with anyone when he makes them up?

http://www.census.gov/compendia/statab/tables/09s0134.xls

Of 427 billion in spending only 8 billion was spent on DME and 51 billion on drugs. THe vast majority of payments went to providers. Your entire argument is BS. if you erased ALL SPENDING paid to manufactures and drug companies you would only save around 14%. Your math doesn't even begin to add up.

"If the government comes in and builds the infrastructure, everyone will want to plug into it. "

As illustrated when HIPAA mandated payors accept EDI claims from doctors years ago, overnight all the paper disappeared and doctors did al their billing electronically. Even when it is given to them for free and it's usage would save them money they don't adapt, this has been proven many times over.

You know what irritates me the most about regressives? They believe (With a passion.) that if they can just push a lie enough, sooner or later, it will be accepted as truth. "The markets will solve social problems"."We have no health care crisis in this country. Only those who are lazy are without access to the best system in the world!" "Ronald Reagan was a great president who ended the Cold War." Funny, but let's assess. If "the markets" were so great,and a laize faire attitude toward national commerce was the answer, why are we in this current situation? And if employer based, hit or miss, leave it to the private insurers, was the answer to making sure every citizen had access to quality health-care, then why are we in the situation we're in? And if Reagan's tax cut, military welfare philosophy was so great, why did he push the biggest tax INCREASE later in his term? And why is that every other country is not cowering in fear of the U.S.of A?

DME is NOT who gets reimbursed for advanced imaging scans. DME is wheelchairs, canes, oxygen supplies, special beds, etc.

In the table you provided, the advanced imaging fees would've been divided up between inpatient hospital, managed care, and physician fee schedule.

And HIPAA EDI worked just fine whenever a payer was strong enough to mandate that providers only submit via EDI (i.e., state medicaid plans).

Monkey. Don't quote tables you don't know how to read.

A am recommending “The Last Well Person: How to Stay Well Despite the Health-Care System” by Nortin M. Hadler to anyone interested in this subject.

Nassin Taleb is now talking about how little we get from healthcare. Robin Hanson and others have been saying the same for years.

Unless I pull my head completly out of my ass I'm stuck with this coverage. Can't go work someplace else, can't use HIPAA to change carriers, can't start my own business and get a guarantee issue plan in just about every state. Nope here I am stuck with my head up my ass and no options but to cry to strangers on the internet.
Posted by: Nate | February 12, 2009 11:31 PM (twice)

Hey, thanks Nate! Just as soon as a cure is developed for a disease that robs me of 60% of my lung capacity, yeah, absolutely, I will just go out and start my own business and insure myself. Of course the only effective treatment, which the FDA has stalled on for about six years, is so expensive I should probably forget it. Or maybe I could just live on the street for a couple of years after a $200,000 (low estimate) lung transplant that I somehow pay for. Christ, have you ever been seriously ill before?
Look, I am no expert, and apparently neither are you, but but I bust my ass to stay at work and to drive two hours to a decent research hospital for every appointment. It's hard - hard on the family, hard on the body. I am not "crying" for anything but mercy.
Thanks for all the awesome suggestions from wingnut land tho. Should come in handy when the angels arrive.

BTW this may not be the idea time to cut out wasteful healthcare spending.

People don't realize, for instance, that phone triage is a great way to reduce waste; the availability of a pediatric nurse to answer new parent questions reduces taking a kid to the doc "just to check" if a fever is serious. Basic conditions - flus, colds, etc - can be addressed many places, don't need a doctor visit, and don't necessarily need a scrip or a shot. That's the kind of changes to practice that can reduce costs and simplify patient care. Docs resist it. Why? Because it reduces their ability to practice in the way they "know best", even if that way is expensive and doesn't lead to any better outcome. Hospitaks resist cutting back unnecessary tests. Why? Because those areas, and the expense of billing for tests, helps their bottom line. And on and on.

As soon as you made this comment I realized you have never worked in a pediatrics clinic and have no clue what you are talking about. Peds clinics are ALL ABOUT TRIAGE NURSE PHONE LINES, in fact its virtually unheard of to find a clinic that DOESNT have one.

I am curious as to why my comments before are considered wrong

With the recent passage of the stimulus bill, and all of the provisions included in it, I agree with you that the government’s use of electronic health records (EHRs) to monitor successful treatment can do wonders for doctors, patients, and health care, at large. Conducting research can present countless logistical issues—one of which is the ability to obtain medical information about patients, even if they are used merely for statistical purposes and not referring to patients individually. The ability for these EHRs, which the stimulus bill is incentivizing, to be used to monitor cost-effective treatment is really quite an innovative concept. It has demonstrated out-of-the-box thinking that previous administrations and health care bills lacked. Moreover, it makes it more feasible for researchers to suggest treatment that will show better results at lower prices. This may lead to a model of health care quality and spending that is directly correlated suggesting that increased spending leads to greater quality of care. While this information will also be used to guide Medicare decisions in determining which procedures may be covered or not, a plan like this should have been in place from the beginning to prevent moral hazard.

I do worry that without proper ethical guidelines and legislative supervision, the information found through this system may infringe on a patients' right to privacy. As someone who will begin medical school in the Fall, I am also worried that it may further restrict pioneering therapy by physicians. Do you think this may make it more difficult for doctors to try "experimental treatments" as some transplants may be called? Overall, I do agree that this stipulation may lead to pharmaceutical companies and device manufacturers to ‘suffer’ financially because some of their expensive and unnecessary products will not be used or prescribed. However, will this inspire them to create more useful products at lower prices to stay competitive? Will physicians ignore government-suggested guidelines due to coercive dealings with pharmaceutical industries? While I do think that may be unlikely, it could present a problem for the patient.

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