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Obama Asks Bloggers For Help With Health Care System Overhaul

July 23, 2009
by Joe Bormel
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Obama Asks Bloggers For Help With Health Care System Overhaul
Show me the quadrants

The politics of healthcare reform are dizzying. I, and probably most readers in the HCIT industry, have been focused on how to achieve goodness as defined by the ARRA-HITECH definitions. We're also mindful that significant payment reform, if it happens, will clearly lag our new cost implications. As much as we might want to be noble, a persistent negative cash flow is discordant with keeping the lights on.

But those issues have fallen off the public and media radar. They have been replaced by large policy issue, “Who is going to pay for healthcare reform?”

As if these issues are separate (clearly they are not), what do we get for our newly allocated dollars? Does this lead to new net costs or new net savings? Douglas Elmendorf of the CBO concluded, " the legislation significantly expands the federal responsibility for health-care costs." And that is consistent with many other CBO analyses. With limited dollars and a portfolio of spending opportunities, where is the dialogue on the economic impact of ARRA-HITECH? Not the rhetoric. Where is the empirically informed, quantitative modeled decision matrix?

What if the ARRA-HITECH Stimulus dollars led to 38 million fewer heart attacks through the use of EHRs? Suppose that led to downstream net savings over three years that dwarfed the new costs?

What if we had data that was convincing to the Congressional Budget Office on explicitly which initiative, Cholesterol or Blood Pressure management led to that net savings? And, over what timeframe? And, which one of the two was more likely to actually increased the national rate of healthcare expenditures, given what the Government knows about Medicare beneficiaries today and existing guidelines, with and without projections to 2025 and beyond?

Well, at the same conference that David Blumenthal spoke after the 2008 presidential election, the 2008 AMIA meeting, another doctor gave the plenary speech and addressed exactly those questions. That other doctor and his collaborators have studied these implications of guidelines. They have applied these modeling tools with payers and care delivery organizations. They've worked with several notable organizations that have substantially similar challenges being addressed by the Obama health-care plan. Those organizations include Kaiser-Permanente of Hawaii, the CDC, and an employer-based, white collar, 30,000 member corporate health plan. Robert Wood Johnson Foundation has funded over 15 million dollars to using their model-based approach. All of these organizations were intensely concerned with economics, that is, how to effectively spend money to save money on healthcare. With attention to quality, of course.

I'm talking about Dr. David Eddy's talk concerning the Archimedes model. There are a number of articles and recorded presentations by him and others that detail the econometrics that are clearly integral to using EHR technology effectively to save money and lives. And, per the first paragraph, where we're likely to achieve financial savings over the next five to ten years. And, where we're not.

There are other models that have relevant predictive power and utility other than Archimedes. The point here is not which model or modeler. The point is that EHRs are only a hammer, not a house. Healthcare legislation that focuses on nuances of the hammers is not going to get us the house that's being envisioned. That vision will be exemplified and evaluated using models like Archimedes.

In the example provided by Eddy at AMIA, Cholesterol management had improved quality of care, combined with net savings, for the population the model was applied to; blood pressure management had a clear net increased cost. Cholesterol management produces a quadrant one result in the Quality versus Cost matrix above, for the study population Archimedes was applied to in Eddy's example. If that result applied to relevant US populations, Where should the government direct the definition of meaningful use as a result?

Eddy also pointed out that it's possible to go even further toward the top left, i.e. more cost savings and higher quality, by focusing on higher risk people. Can we achieve such personalized guidelines and benefits in a practical way in the paper world? Are these savings the stuff the EHRs are being touted as delivering?

So, Mr Obama, thank you for inviting me to blog about how important it is for all of us to seize the day. I am undecided on the issue of who should pay. I am very decided, however, that it's possible, and in fact likely, that costs and quality will not improve without the kind of modeling described here. And it's resultant transparency. Let's not confuse quadrant one and four in the diagram above.

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Jack,
Thanks for your comment. Especially the part where you agreed with me!

I have to push back on the "take a little more time" part of your comment. Many political pundits on multiple sides* of the aisle believe that "Delay means Defeat, and Defeat is Victory [for legislation opponents]."

I've often said, and Shakespeare agrees with me:


[Brutus:]
There is a tide in the affairs of men.
Which, taken at the flood, leads on to fortune
Omitted, all the voyage of their life
Is bound in shallows and in miseries.
On such a full sea are we now afloat,
And we must take the current when it serves,
Or lose our ventures.

      - Julius Caesar Act 4, scene 3, 218—224


I think that's probably true for healthcare reform. It's been over a decade since significant reform has been attempted. As I ended my original post, the alternative of "no decision" is essentially no substantive reform. Douglas Elmendorf pointed out last week that we don't have a large enough, substantive option on the table that will reign in costs. I think the conclusion may be true with or without expansion of coverage.

Jack, I think you made the point in the subsequent paragraphs of your comment that current system and exemplars are not adequately attractive. I suspect you know a lot more about the topics you raised than I do, so I will not comment further here.

The net is, I believe that using a comprehensive model is a much better alternative than applying pure cost cutting approaches and hoping for the best. In industry, pure cost cutting strategies never lead to sustainable revenue growth, business viability, or net positive margins. The same concept applies to healthcare, whether constructed as a public sector, private sector, or hybrid "industry."


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* Regarding "multiple sides of the aisle" --- lest you thought there were two sides to an aisle, here are four:

(ref:  This comes from same issue of WSJ, the paper edition)



Richard,

You're welcome.

If memory serves, the CMS/Premier Hospital Quality Incentive Demonstration (HQID) also identified practices that drove down costs while improving clinical performance.

Large data set profiling is a pre-requisite to projecting cost savings. Take redundant testing for example. My dad recently had a carotid ultrasound for a history of TIA. The exact procedure was repeated by the neurovascular surgeon perhaps 3 weeks later. The initial test was order for defensive reasons (i.e. no new symptoms.) The extent of redundant testing and the economic range of cost savings is objective data.

Thanks again for the kind words.

(Feel free to send me a private email if you need other materials.)

Joe,
Really, I don't think we're that far apart on the big picture. In a subsequent comment, you state the need to be "explicit . . . in a debate of this magnitude.

I could not agree more. And that was exactly my original point.

Additionally, I agree with IA's comment, "Don't try to fix the existing shortcomings by doing the same thing we do now, but on a larger scale."

Much more succinct than my first comment, but certainly running a parallel course.

I like the quote from Shakespeare. Paraphrasing it for this particular situation, it might begin,


"There is a tide in the affairs of state,
which mistaken at the flood,
may lead to drowning the citizenry.

Shakespeare further wrote, "And we must take the current when it serves . . . "


Again, in the current state of affairs, may we and our representatives have the wisdom to know if this current serves us, or when it is more likely to do so later.

Jack

Joe,
I could not agree with you more that we need to look at the right model or models out there to help resolve the debate over the myriad of healthcare issues out there. That said, maybe the right thing to do is take a little more time to try to get things right.

Look at ARRA as a starting point. System "meaningful use" is muddy at best, and it doesn't appear things are going to improve soon. So how can the feds possibly have a guideline in place by December? And then there's the question of "meaningful use of what?"

The usefulness of systems overall is in question, and what we're hearing is that it's probably too difficult to set system standards because the technology from the vendors and the needs of individual hospitals varies greatly. Hello? I thought that's exactly what standards are supposed to solve! And what's happened to the issue of interoperability so that a national EHR can be implemented. It appears this challenge has completely slipped off the radar.

In the larger scheme of things, the debate over healthcare insurance and paying for universal healthcare one way or another is even more troubling. Arguments against the administration's initial proposal seen to more validity than first thought. I look at the deplorable way government has managed healthcare for Native Americans through the BIA and wonder is this the shape of things to come? Further, although managed healthcare at the VA has improved over the past decade or so, there are still many troubling things occurring periodically in that system, too. And what about the absurd deficiencies that have been publicized at military hospitals concerning the treatment provided for war injured service members? Nothing short of appalling!

From top to bottom, dealing with the healthcare issue at every level is at best perplexing and worrisome. That's why I think it's time to allow some cooler heads, whoever they may be, to take center stage and help flesh out the challenges before we make what could be judged in the not too distant future a series of catastrophic mistakes.

Jack

Joe,
Thanks for the excellent post. I think it is so important to understand that healthcare policy analysis must move beyond the CBO budget "score." I'm going to make a point to learn more about the Archimedes model. I hope President Obama and his advisors read your blog.

Ron,
Thanks for joining in the discussion. I share your concern that political and economic forces will distort the policy making. I also recognize that there is a moral/ethical implication of pluralism - specifically, protecting people's rights to live and behave the way we wish, so long as it doesn't translate into harm or un-fairness for everyone else.  (This is elaborated in: Jonathan Haidt on the moral roots of liberals and conservatives)

It would be wonderful if we could draw clear lines between lifestyle, health, and healthcare. As you've pointed out, that's not so easy.

Personally, I'm relatively comfortable with taxing cigarettes. Although I don't drink high calorie beverages, or eat candy-bars, and much junk food, I'm not yet comfortable with taxing them.

To close on the theme of this blog post, I know that healthcare cost generation can be modeled. The models can be tested against actual experience and proposed reforms. Consumer experience and costs can be improved as a result. The large payers and plans have been and are doing this as I've outlined. It's hard to find, for example in the CBO reports, a reference to a saving accrual model that incorporates current expenditures and projections for the interventions proposed that are adequately stratified.

We also need a comprehensive model to capture and address the interaction of initiatives like Medical Home as a post-acute care mechanism and reducing reimbursement to hospitals for re-admissions.  There's very good logic as well as some data that these may directly linked.  

Perhaps it's too political, for example, to call out the financial implications of the call for generic medications in the current meaningful use matrix. That kind of transparency is necessary, if we are to achieve the quality and cost improvements we need.

Comments elaborating or refuting these points are welcome.

For your consideration, from a half-page advertisement, WSJ, 9/1/2009, page A10: http://www.healthways.com/trillions/

Although the details on comparative interventions was weak, the actuarial details seemed very credible. The entire paper is only about a dozen pages and is summarized on page 3. Worth a look.

IA, thanks for your comment. Yes, it would seem that being explicit about objectives, constraints, and other assumptions would be necessary statements in a debate of this magnitude.

Regarding Hammers and Houses:

The idea here is that vision and clarity on vision are extremely important. If your vision is to have a new house, and you go to the store and buy a tool (like a hammer) to help you achieve your vision (the house), you need to realize that you need a few other things beyond the tool to achieve the vision. In this metaphor, you'll at least need a plan, nails, lumber, and, oh yeah, a foundation, land, possibly a mortgage, etc.

It's a little bit bizarre to look at the hammer and, in anger, bemoan the fact that it's not the house that you really wanted.

Same concept applies to writing. If you buy a word processor and you weren't previously a writer, you're still not a writer.

In our industry, licensing software is a far cry from the vision - installing, implementing, training, deploying and utilizing the software.

Glaser puts this succinctly: "You cannot buy ROI, you must manager to it."

Readers of this blog all know that. Often, our superiors and subordinates are unclear on the those details. Job security of us!

So, in summary, "A Hammer is not a House" is an allusion to that concept.

Thanks for giving me the opportunity to expand on that.

All,

I am not at your level but as an average worker in a healthcare system and a user of healthcare I see a need for perspective. Do we let the politician's just make a choice for us? Do we let them exclude themselves?

Our government is not going to do any better than they typically do unless they do get a lot of "outside" help. I also see an opportunity for these government people to use your knowledge versus a few people with special interests. If we get a healthcare plan it needs to function and help address healthcare issues and coverage.

Personally I am skeptical as to if this change may ever come to pass. We all have our own special interests. The best plan the government could come up with would be one where they also have to live by it and use the same plan. If a Senator had to use the same process as you or I then the plan would be the better for it.

Just as they did with the credit card reform and bankruptcy law reform a few years back I fear interests from outside influence will take precedence. Insurance companies may write the new healthcare plan. Or have a heavy hand in it.

In an age where we like our freedoms we also like to let others do the hard work. If you really want a plan get it to also do this - outlaw drive through at fast food restaurants completely except for handicap customers. Tax low food value foods that are unhealthy. Similar thought to raising costs of gasoline or cigarettes.

If we did that you have already cut down on greenhouse gases from cars because a lot of people are too lazy to get out of the car to go in and get the supersized burger, fries and 32 ounce drink of sugar. And of the cost of those high calorie low food value foods was higher by about 5 dollars people would buy it a lot less often. Means less beef sold and another lowering of greenhouse gases.

Fixing obesity would cure a lot of issues the above could be a step. Of course it will not happen. Instead insurance companies will ensure what ever the outcome, they make money. If you do not influence even more than they do.

Do insurance companies like bariatric surgery for example? Typically no. Like was mentioned above they do not analyze properly. Due to this probably a good idea to NOT let them write your new healthcare reform. Needs more help at your level outside of blogging. They (your congressman) may need a boot upside the head to figure it out.

Joe,

Good blog.

Several home runs in there:
Do the modeling! Several of the commentators after the Obama prime time speech this week pointed out how vague the proposals still are so the price tags people are assigning to the proposals are meaningless.

Set some concrete goals and milestones.

Don't try to fix the existing shortcomings by doing the same thing we do now, but on a larger scale.


The hammer and house allusion required some frame of reference I didn't have presume it was in one of your earlier blogs.


Keep it up.

In my original post above, I point out that, at least in one population of healthcare benefit recipients, Cholesterol management had a clear, early, net total saving impact. The Archimedes model, as described by Dr. Eddy at AMIA 2008 made that clear.

Today (Friday 7/24/2009), I read in the WSJ "Obama's Health Expert Gets Political" that Peter Orszag, "President Obama's point man on controlling healthcare spend" and former CBO director, personally lived exactly that same decision analysis:
Peter Orszag


For his own health care, he was relying on a doctor sent by his life-insurance company. As an economist, he figured that the insurer had a financial incentive to be sure he was healthy. "I figured they'd be really rigorous," he says.

But a friend pointed out various things the checkups skipped, such as cholesterol testing. It turned out that Mr. Orszag, then in his mid-30s, had dangerously high cholesterol. He changed his diet and began running, eventually competing in marathons. He also started studying up on health policy.  (ref:  same WSJ here)


This clipping almost needs no elaboration. So, here it is (sic).   He learned that the life-insurance company was not using decision analysis to inform its recommendations to him. The information was clearly available, since he found it, on his own, at that time.

The cost savings critical to making healthcare reform work come from identifying opportunity and waste (defensive medicine and pay-for-procedures, independent of value.) The single, largest, immediate clinical opportunity for healthcare providers to impact costs is to identify high risk profiles, like Orszag's, and mitigate the downstream cost implications of untreated high cholesterol.

[I worded that last paragraph to exclude the larger avoidable costs associated with behavioral issues, including diet, exercise, education, smoking, etc.]

If ever there was a stronger, more relevant case for modeling over relatively blind, pure immediate cost cutting without regard for downstream effects, there it is.

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Joe Bormel

Healthcare IT Consutant

Joe Bormel

@jbormel

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