Saturday, September 26, 2009

Congress expects physicians to implement EHR's when they can't post a PDF on the web?

Congress expects physicians to implement EHR's and review patient histories in detail, when they can't even review their own bills before acting, and post a PDF on the web?

This has to be the lamest, most inept, and/or most patronizing Congress in history (with approval ratings to match, 16% as of Sept. 25 according to Rasmussen):

Washington Examiner
Baucus claims it's too difficult to put health care bill online

A proposal by Sen. Jim Bunning, R-Ky., that would have required the Senate Finance Committee to post the final language of the $900 billion health care reform bill, as well as a Congressional Budget Office cost analysis, on the committee’s website for 72 hours prior to a vote was rejected 12-11.

... Chairman Max Baucus, D-Mont., himself admitted that “This probably sounds a little crazy to some people that we are voting on something before we have seen legislative language.” Indeed.

Baucus’ excuse - that it would take his committee staff two weeks to post the bill online – sounds a little crazy too.

This very same Congress is pushing physicians to implement EHR's under penalty of Medicare payment reductions, while they claim an inability to post a PDF or Word document online. Implementing EHR's is only several orders of magnitude more complex...

Or, perhaps the "inability" to post the text has to do with text that appears at pages 80-81 of the bill:

"Beginning in 2015, payment [under Medicare] would be reduced by five percent if an aggregation of the physician's resource use is at or above the 90th percentile of national utilization." Thus, in any year in which a particular doctor's average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor's payments by 5 percent."

As in the Washington Times:

This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked.

And because no doctor will know who falls in the top 10 percent until year's end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.

No metrics on quality of care, outcomes, patient satisfaction, or other aspects of the complex process of medical care are apparently involved. Just an "aggregation of the physician's resource use."

May I use the words "capricious and arbitrary" to describe this metric?

Now, we should ask:

  • Is this what our government means by "data driven healthcare?"
  • Do they realize the likely adverse consequences of such half-baked measures?
  • Are those who would propose such a bill friends of patients, and friends of physicians?

Where have I seen this before? (How about: biomedical dilettantes helping impair R&D at a pharmaceutical company, now in sale mode due to a poor pipeline of new drugs, through cutting drug discovery resources on the simplistic metric of "cost per user per database?")

Ultimately, this Medicare strategy is the end result of allowing medical dilettantes (no matter how well they've "self educated" themselves about medicine) to control the playing field. It is a poster example of a perverse incentive in direct conflict with the obligation of physicians to provide the best care.

In the end, patients and physicians get screwed.

-- SS


Anonymous said...

This is just more of the same policies of the past 2 decades that are the root cause of what are thought to be today's problems with health care.

Should stuff like this become law, medical care will be sure to deteriorate.

Francois said...

Once again, Mark Twain proves how smart (and timeless) his insights were:

"“All Congresses and Parliaments have a kindly feeling for idiots, and a compassion for them, on account of personal experience and heredity.”

“Suppose you were an idiot. And suppose you were a member of Congress. But then I repeat myself.”

“Fleas can be taught nearly anything that a Congressman can.”

"No citizen's assets are safe while Congress is in session."

Francois said...

About this provision in pages 80-81; is the story really that simple?

Francois said...

About this provision in pages 80-81. Is the story that simple?

Not so sure:

"What's more, the Times is wrong when it suggests the Finance Committee bill puts no focus on quality. In fact, it gives doctors incentives they don't have now, especially in the management of the chronic illnesses that have been such a factor in driving up health costs. This from former Clinton Administration health adviser Chris Jennings (via Ezra Klein):

... I choose to focus on a couple of other diamonds in the rough. The first would be the funding for prioritization and development of quality measures linked to aggressive reimbursement incentives to physicians for reporting on these measures. (These measures, developed by health professionals, are used to promote best practices for some of the most expensive chronic diseases, such as heart disease, cancer and diabetes). I have concluded that we will never really change the way we deliver health care without the buy-in of the medical profession, which can only be secured if they develop and apply measures that can be used to empower practitioners and hold them accountable through comparative outcomes with/by their peers.

A second, and related issue, is a Finance Committee provision which gives CMS the authority to develop pilot programs to test methods of reimbursing providers for chronic disease management, (including collaborations with the states and the dual eligible program). Today, the easiest course of medical intervention is to prescribe treatment plans that deal with the effects of the disease, high cholesterol, high blood pressure, etc., rather than spending time with patients to help motivate them to take control of their health and manage their own diseases through lifestyle changes. Only when patients begin to understand that they must be the focal point of any intervention to constrain or even reverse the course of expensive chronic illness and, ultimately, produce savings, will we have made progress. The most creative part of this policy is to allow the pilots to be constructed in a fashion that waive strict budget neutrality requirements (because this has killed ideas in the past) AND allows them to expand nationally automatically (without any other legislative action) IF they can prove budget neutrality or better in the budget window. We all know that chronic illness is the primary contributor to our nation's health-care tab – preventing and managing it is one of the absolute keys in getting the ultimate job done."

MedInformaticsMD said...

Either they're going to dock by aggregate data about top spenders, or they're not. Sadly, it's unclear which at this point. If so, despite other exploratory programs, this is a perverse incentive for the reasons mentioned.

In term of metrics, though, this from the WSJ today in a letter to the editor:

... An unnamed Sr. administration official told arms control analysts that "a ground based interceptor is generally about a $70 million-per-missile asset going after a $10-$15 million [Iranian] missile. The trade is not a good one economically. It's not a good one from a military strategy position." (from "Cost Concerns Propelled US Missile Pivot", World News, Sept. 19.)

And, of course, spending $200 for a toaster is a good deal compared to buying a Ferrari.

-- SS