Clinical Analytics and Healthcare Payment Reform

As the US healthcare system transitions from a pay-for-service model to pay-for-value through new arrangements including bundled payments and the Accountable Care Organization (ACO), healthcare organizations will require advanced analytics solutions to track, analyze and report on quality and cost across every care setting.

Allscripts and Humedica today announced their collaboration on a next-generation cloud-based clinical informatics platform that will help physicians and hospitals succeed in the coming era of value-based reimbursement, addressing a fundamental shift in the way healthcare providers are paid.

Provider organizations need robust operational and outcomes benchmarking and comparative analyses. The solution will enable organizations to manage quality and risk to drive improved outcomes in a complex environment - across all settings of care and even when they are using disparate clinical systems.

Humedica has been providing comprehensive clinical analytics to leading medical groups across the country through its long-term partnership with the American Medical Group Association and its medical informatics subsidiary, Anceta.

The Allscripts-Humedica collaboration will empower physician practices, hospitals, health systems, ACOs, and post-acute providers to:

• Gain insight into their clinical and operational performance
• Assess and identify their best clinical practices
• Identify the levers for clinical improvement
• Manage individual variations in clinical performance
• Improve compliance with care guidelines
• Perform predictive modeling to track high-cost and high-risk patient care in real-time, thereby reducing preventable complications and improving performance
• Prove the value of care delivered to payers through access to configurable performance benchmarks

SUPPORTING QUOTES:
"Having worked closely with both Allscripts and Humedica, we are excited that the two organizations are partnering," said C. Edward Brown, FACHE, Chief Executive Officer of The Iowa Clinic, the largest physician-owned multispecialty group in Central Iowa. "We have been extremely satisfied with both the Allscripts Electronic Health Record and the Humedica MinedShare® solution."

"To succeed in the era of payment reform, healthcare organizations need visibility into quality and cost across every care setting with the ability to track the performance of each provider, organization and at-risk patient in the care process," said Glen Tullman, Chief Executive Officer of Allscripts. "Our partnership with and strategic investment in Humedica augments our successful reporting and analytics solutions, with a cloud-based informatics engine that's fine-tuned to meet some of the most pressing challenges of payment reform. In addition, because some of our key clients already have adopted Humedica, we've had the opportunity to see how powerful the solution is and how much more we could do together to advance patient care. "

"Clinical insights gained through analyzing data in the Electronic Health Record and other applications can give healthcare organizations unprecedented visibility to the total clinical risk, true clinical performance and best practices necessary to optimize population health," said Michael Weintraub, President and Chief Executive Officer of Humedica. "Our partnership with Allscripts ultimately will enable healthcare organizations to translate analytics into actions that help them succeed in the era of healthcare reform."

"I have no doubt that many member organizations of the American Medical Group Association, like the Iowa Clinic, will benefit from the relationship between Humedica and Allscripts," said Donald W. Fisher, Ph.D., President and Chief Executive Officer of AMGA. "Multi-specialty medical groups need sophisticated informatics, including in-depth clinical analytics, to assume a leading role in transforming healthcare, through ACOs and other value-based payment models."

Disclosure
Rich Elmore, editor of Healthcare Technology News, is Vice President, Strategic Initiatives at Allscripts.

Tonal Recall

The health care reform debate hits a new low as Democrats insist that Republicans refer to health care reform as job-destroying, not job-killing.

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Tonal Recall
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Obama's Priorities for Reform

The intensifying debate over healthcare reform is forcing Barack Obama to reshape his arguments for reform. Why We Need Health Care Reform reflects Obama's latest talking points with an eye to capturing the support of mainstream voters, focusing on four key messages including 1) access to insurance, 2) cost savings, 3) efficiency and sustainability for Medicare and 4) consumer protections for health insurance:

• "First, if you don’t have health insurance, you will have a choice of high-quality, affordable coverage for yourself and your family — coverage that will stay with you whether you move, change your job or lose your job.
• Second, reform will finally bring skyrocketing health care costs under control, which will mean real savings for families, businesses and our government. We’ll cut hundreds of billions of dollars in waste and inefficiency in federal health programs like Medicare and Medicaid and in unwarranted subsidies to insurance companies that do nothing to improve care and everything to improve their profits.
• Third, by making Medicare more efficient, we’ll be able to ensure that more tax dollars go directly to caring for seniors instead of enriching insurance companies. This will not only help provide today’s seniors with the benefits they’ve been promised; it will also ensure the long-term health of Medicare for tomorrow’s seniors. And our reforms will also reduce the amount our seniors pay for their prescription drugs.
• Lastly, reform will provide every American with some basic consumer protections that will finally hold insurance companies accountable. A 2007 national survey actually shows that insurance companies discriminated against more than 12 million Americans in the previous three years because they had a pre-existing illness or condition. The companies either refused to cover the person, refused to cover a specific illness or condition or charged a higher premium."

Gone from the pitch? The public option and investment in health care information technology.

The public option is no longer included in the bill being negotiated by the Senate Finance committee. In his Friday Town Hall meeting in Montana, Obama mentioned Committee Chair Max Baucus by name some 8 times, - saying Baucus is "working tirelessly to make sure the American people get a fair deal" and is "committed to getting this done." The bi-partisan negotiators are getting heat from progressives, so "Obama’s embrace seemed designed to provide him some political cover to keep those bipartisan negotiations going in September."

And Health Information Technology? It's already funded through ARRA and incidental to the current debate.

The Senate's Gang of Six Stays Inside for Recess

While the rest of the Senate left town for their August recess, six Senators stayed behind. The bi-partisan Senate Finance Committee negotiators are reported to be making progress on their healthcare reform plan.

Max Baucus, the Finance Committee Chair has given the negotiators a September 15 deadline for completing their work. And Chuck Schumer has weighed in that “If they can’t do it by Sept. 15th, I think the overwhelming view on the Democratic side is going to be, then, they’re never going to get it done... And there’s always a worry that, you know, delay, delay, delay, you lose any momentum whatsoever.”

Douglas Elmendorf, CBO Director, has testified that other healthcare legislation in Congress would raise costs. Before the House Ways & Means Committee, he said that "we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significiant amount. And on the contrary, the legislation significantly expands the federal responsibility for health care costs." All of which raises the bar for the Senate negotiators to come up with a plan which bends the cost curve in the right direction.

Shailagh Murray and Lori Montgomery recently reported on the Senate negotiators' progress towards eventual coverage of 94 percent of Americans that "would expand Medicaid, crack down on insurers, abandon the government insurance option that President Obama is seeking and, for the first time, tax health-care benefits under the most generous plans." Excerpts of the negotiators' policy positions follow.

• "Seeking compromise on some of the most complex issues .. including how to compel employers to continue providing insurance to their workers; how to more fairly distribute government subsidies for coverage; and who and how many should be allowed to remain uninsured."
• "Limit (congressional) authority over Medicare by empowering an independent commission to extract savings from the program..."
  
• "Rejected a government-run health insurance plan in favor of a network of member-owned cooperatives..."
• "Outstanding issues include how to structure a Medicaid expansion to make it fair to individual states; how to establish subsidy levels to maximize assistance to the uninsured; and how to squeeze savings from Medicare without imposing an undue burden on seniors or compromising the quality of care. Another flashpoint is whether government insurance subsidies could be used to pay for abortions."
  
• "Agreed to about $500 billion in changes to existing federal health programs, including Medicare and Medicaid. For example, negotiators would require wealthier seniors to pay more for prescription drug coverage under Medicare, and they would charge co-payments for clinical lab procedures. The lab co-pays are potentially lucrative, raising about $20 billion over 10 years."
• "Other new sources of revenue include penalties on individuals who do not obtain health insurance, and a "free-rider" provision that would require employers that currently offer health insurance to continue to do so, or to reimburse the federal government for workers who switch to subsidized coverage through an insurance exchange. Both provisions could yield about $43 billion over 10 years."
• "The rest of the additional revenue -- about $250 billion -- would come from new taxes, primarily from an excise tax of up to 35 percent on insurance companies that sell extremely generous policies worth at least $21,000 a year for family coverage or $8,000 a year for individuals, according to aides involved in the discussions. About 7 percent of taxpayers hold such policies... Insurance companies are likely to pass the cost of such a tax to policyholders, raising the price of those plans. That would create a strong incentive for employers to stop offering them, thus driving down overall health-care costs. With employers paying less for insurance, tax analysts predict, they would pay workers more in wages, increasing income tax collections by as much as $180 billion over the next decade."
• "Smaller tax provisions (include) a $2,000 cap on flexible savings accounts -- which are currently unlimited -- and a plan to improve tax compliance by requiring businesses to tell the Internal Revenue Service when they pay corporations for services."
• "Studying a plan to fine insurance companies that do not pay providers electronically, a plan to reduce payments to providers to force them to increase efficiency and a plan to study the comparative effectiveness of various medical treatments."
• "Set a target for savings through those reforms. If the target is not met, they would create a panel, called the Medicare Preservation Commission, that would recommend ways to obtain additional savings."

It's doubtful that liberal democrats and conservative republicans will be able to endorse the resulting plan. However due to the Senate's key role in enabling any healthcare legislation, and the Senate Finance Committee's key role in funding healthcare reform, their recommendations are sure to be influential in this fall's debate.

Let's see whether Senate negotiators reconcile with key elements being touted by Obama in his "What's in it for me?" stage of the debate: "(1) ending the practice of denying insurance coverage to people with a pre-existing illness; (2) keeping people from losing their coverage if they get sick; and (3) protecting Americans who face high out-of-pocket medical costs." The Democratic National Committee released a new television ad today with the same message:

Grand Rounds

Welcome to this special edition of Grand Rounds, the Best of the Medical Blogosphere, focusing on Health Care Reform. The tapestry woven through these exceptional articles demonstrates the many dimensions of the health reform challenge.

Why Do We Need Reform? Patient and Consumer Perspective

Type 1 diabetic for over 22 years, blogger Kerri Sparling says it all in her post at Six Until Me:

"Why, Insurance Company, are you so against proactive care? Why do I need to pay more for a brace or a shot or an extra visit when you're more content paying for a several thousand dollar surgery instead? Not enough bang for your buck? Why do you fight me tooth and nail against coverage for a continuous glucose monitoring device? Is my life not worth the investment to keep my legs on instead of paying 100% to amputate them in a few decades? I know I'm expensive as a chronic disease patient, but I'm healthier than 85% of the people I know. I eat well, I exercise regularly, and I am on top of my disease. Yet you deny me life insurance, you won't let me purchase a private health insurance policy, and you would rather see me on an operating table than taking up a doctor's time in an office visit. (And it's not like I'm taking up more than 5 - 7 minutes of a doctor's time, because that's about all we get, on average. Pathetic.)"

Laurie Edwards at A Chronic Dose reviews "Are We Feeling Better Yet?" a collection of essays from prominent women writers that speak to challenges and contradictions in our current system. While she found that no, we aren't necessarily getting better yet, the stories show where we need to go. Edwards argues that the patient narrative deserves a place in the reform conversation.

Robin S at Survive the Journey details the challenges of access based on socioeconomic and racial factors. A Johns Hopkins study found that socioeconomic and racial factors are predictors to admission for pituitary adenoma patients to high-quality care centers. " The number of patients receiving care in the >$60,000/yr income-bracket was almost double the other income levels."

Jeffrey Seguritan at nuts for healthcare reports on quick hospital readmissions which constitute an estimated $17 billion in costs to Medicare, and may signal poor quality in terms of inpatient and outpatient follow-up care. The Obama administration is proposing to penalize hospitals for quick readmissions and bundle hospital reimbursements for inpatient and outpatient care - - they'll need to carefully consider both severity of illness and gaming of the system.

Providers, Prevention and Self-Management

Jane Sarasohn-Kahn at Health Populi lays out the costs of chronic disease and the key role of self-care.

Jolie Bookspan finds that a major overlooked part of health care reform is that many standard payments are for things that shouldn't need to be done in the first place. See her example - of how to Prevent Back Surgery.

Stacey Butterfield at ACP Internist finds that health care reform starts at home, as physicians at one conference practice what they preach when it comes to preventive medicine.

Nancy Brown at Teen Health 411 finds that primary care physicians could do more to screen for teen eating disorders to avoid hospitalizations.

Meaningful Use and Enabling Technology

John Halamka at Life as a Healthcare CIO describes the first meeting of the ARRA/HITECH mandated HIT Standards Committee which focused on the following key themes:
"a. We need a high level roadmap of milestones to ensure we meet our statuary deadlines for initial deliverables in time for the 12/31/09 interim rule.
b. We also need a roadmap which takes into account the other mandates/compliance requirements already imposed on healthcare stakeholders such as ICD-10 and X12 5010. We need to ensure our clinical work is in synch with administrative data exchange activities already in progress.
c. Although we should provide for the exchange of basic text, we should strive for semantic interoperability whenever possible, using controlled vocabularies which are foundational to decision support and quality reporting.
d. We should set the bar for interoperability higher than the status quo but also make it achievable, realizing that rural providers and small clinician offices have less capabilities than large academic health centers. We'll need to retrofit many existing systems - healthcare IT is not a greenfield and thus we need to be realistic about the capabilities of existing software, while also encouraging forward progress and innovation.
e. Meaningful use will change over time. Data exchange and the standards we select must evolve. To ensure successful adoption throughout the industry, our work must be continuous incremental progress with phased adoption of standards."

Barbara Olson at On Your Meds discusses what "meaningful use" may mean for medication safety. She advocates for making medication histories and profiles of patients accurate and readily accessible across the continuum of care are among the most important targets for “meaningful use” initiatives.

Mr. HIStalk reports on the ONC's plans to define “meaningful use”. "Translation: we haven’t figured out what we are doing yet and aren’t ready to commit to anything."

Wes Rishel at the Gartner found that the successful EHR implementations included health information exchange and used "implementation approaches that are more highly directive and more keyed to supporting the practices' complete workflow changes necessary to benefit from the EHR."

Health Business Blog's David Williams interviews EHR vendor Practice Fusion's CEO, Ryan Howard.

Laika Spoetnik's MedLibLog gives an example of a real successful application of web 2.0 in patient centered healthcare for Parkinson's disease. Health 2.0 represents "a new way of thinking in healthcare:

1. the patient becomes centric, care becomes collaborative: the patient is not passive, he is “equal” to the healthcare provider. It isn’t “he asks, we provide”, but the patient definitively has a voice (and choice) in his own healthcare.
2. coherent and transparent healthcare.
3. expertise (few experts, but with very specialized knowledge)."

Dollars and Sense

Consumers Union Blog reports that two thirds of Americans support a public health care plan. "Affording healthcare is still a major issue with nearly two-thirds expressing major or moderate concern about the ability to afford doctor visits in the future. Sixty percent of Americans said they were concerned about the possibility of bankruptcy because of a medical concern."

DrRich at the Covert Rationing Blog explains why the representatives of all the major healthcare interests threw in with President Obama's healthcare reform. DrRich believes that this time is different than the Clintons' attempt in '93. "The private concerns, this time, have shot their wad. They are entirely bereft of ideas. They know not what to do... And so, the last obstruction to healthcare reform has been removed."

Bob Laszewski at Healthcare Policy and Marketplace Review sends out an open letter to the Congressional Budget Office. "So, six months later lawmakers are sending one of these "cost containment lite" proposals after another over to the the CBO and the CBO is sending them back stamped, "insufficient funds." And there's lots of whining about it now going on atop the Hill where people are desperate to find easy money for health care reform. It will take more than $1.2 trillion to pay for health care reform and the Obama budget cuts have only identified about $300 billion toward that goal. We will not reform the health care system unless we really reform the health care system. The only thing standing between BS reform and real reform are the men and women--real men and real women--over at the CBO."

Jacob Goldstein at the Health Blog highlights OMB chief Peter Orszag's comments on the four steps to better cheaper care.

Louise at Colorado Health Insurance Insider describes the House pledge to have a sweeping health care reform bill on the floor by the end of July, and the details starting to come out about the direction they want to take. Requiring everyone to have health insurance coverage is one of the cornerstones of the reform.

Bob Vineyard at Insure Blog argues against the hidden costs of health care reform.

What's Working Elsewhere?

Alison Finney at Shoot Up or Put Up (Comatose and rotting toes - the lighter side of insulin dependency), was diagnosed with Type One Diabetes in 1983 at the age of 4. She gets her healthcare from the UK's National Health Service. While the British NHS may have it's faults, as a patient with a chronic disease she's a real fan.

Passing the Baton

Next week's Grand Rounds will be hosted by See First. Check out Evan Falchuk's See First article on the language of health care reform. Does it reveal a "deepening divide between how people talk about health care and what it really means to be sick"?

Check in at Get Better Health for the Grand Rounds schedule. Thanks to Val Jones and Colin Son for organizing Grand Rounds.

'What we call health care costs, they call income'

Health care industry groups met with President Obama yesterday to propose $2 trillion in reductions in the rate of growth of health care costs. They committed to reduce the growth in costs by 1.5% each year for ten years.

Insurance companies, hospitals, physicians, pharma and labor organizations are supporting this voluntary plan in the hopes of fending off legislation that controls costs. The groups include the American Hospital Association, the American Medical Association, America’s Health Insurance Plans, the Pharmaceutical Research and Manufacturers of America, the Advanced Medical Technology Association, and the Service Employees International Union.

According to Ricardo Alonso-Zaldivar and Philip Elliott, "it's unclear whether the proposed savings will prove decisive in pushing a health care overhaul through Congress. There's no detail on how the savings pledge would be enforced. And, critically, the promised savings in private health care costs would accrue to society as a whole, not just the federal government. That's a crucial distinction because specific federal savings are needed to help pay for the cost of expanding coverage."

President Obama's stated that "we cannot continue down the same dangerous road we've been traveling for so many years, with costs that are out of control, because reform is not a luxury that can be postponed, but a necessity that cannot wait... It is a recognition that the fictional television couple, Harry and Louise, who became the iconic faces of those who opposed health care reform in the ⿿90s, desperately need health care reform in 2009. And so does America... That is why these groups are voluntarily coming together to make an unprecedented commitment. Over the next ten years - from 2010 to 2019 - they are pledging to cut the growth rate of national health care spending by 1.5 percentage points each year - an amount that's equal to over $2 trillion."

Janet Adamy of The Wall Street Journal reports that "administration officials said, they do not have a way to enforce the commitment, other than by publicizing the performance of health care providers to hold them accountable. By offering to hold down costs voluntarily, providers said, they hope to stave off new government price constraints that might be imposed by Congress or a National Health Board of the kind favored by many Democrats."

Jeffrey Young at The Hill.com reported that this commitment would "translate into annual savings of $2,500 for a family of four after five years. Over time, slowing the growth of healthcare spending at this rate would 'virtually eliminate the nation’s long-term fiscal gap.'"

But will these trade associations still be on board with the Tom Daschle's view that "a public plan will reduce costs and improve access"? "Employer premiums could be substantially lowered with the choice of a public health-insurance plan; a typical American family could save nearly $1,000 a year in reduced premiums alone. If containing costs is one of our biggest goals, how can we not do this?"

Economist Paul Krugman at the New York Times urges caution and explains that there are reasons to be cynical of the industry's intentions. "Before we start celebrating, however, we have to ask the obvious question. Is this gift a Trojan horse? After all, several of the organizations that sent that letter have in the past been major villains when it comes to health care policy... The point is that there’s every reason to be cynical about these players’ motives. Remember that what the rest of us call health care costs, they call income... I still won’t count my health care chickens until they’re hatched. But this is some of the best policy news I’ve heard in a long time."