Healthcare reform

werehippy

The first salvo in the legislative fight for the next Congress has just been fired. Max Baucus (D – Montana) is the chair of the Senate Finance Committee, and given that this committee controls the money coming into the government and half of the money going out gives him enormous control over social policy. The fight over healthcare will happen there, so it’s well worth reading Ezra Klein’s profile of Baucus in general, but especially if you want to get into the nuts and bolts of healthcare.

In general Baucus hasn’t been an especially inspiring Democrat, but he really seems to have his game face on here. He’s been holding public hearings (9 of them at last count) and has been meeting privately with Kennedey and others. And to formally kick of the policy fight, and more importantly frame the debate, Baucus has released a white paper laying out his positions.

There’s a lot of the Obama plan in there, though he adds quite a bit including an individual mandate. The plan runs just shy of 100 pages, and I don’t’ think anyone has read the whole thing yet, but the quick and dirty summary paragraphs from the executive summary are:

Like a sturdy stool, the Call to Action has three equally important legs: (1) a policy that ensures meaningful coverage and care to all Americans; (2) an insistence that any such expansion be coupled with an emphasis on higher quality, greater value, and — over time — less costly care; and (3) an absolute commitment to weed out waste, eliminate overpayments, and design a sustainable financing system that works for taxpayers as well as for the nation’s recipients and providers of health care.

....

Beyond measures to refocus the system on primary care, reward quality care, and invest in critical research and technology, the Baucus plan would endorse direct steps in five additional areas to curb excess health care spending. The plan would invest more to detect and eliminate fraud, waste, and abuse in public programs. The plan would address overpayments to private insurers in the Medicare Advantage program. The plan would increase transparency of cost and quality information and would require disclosure of
payments and incentives to providers by drug or device makers that may lead to biased
decision-making. The plan also considers careful reforms of medical malpractice laws that could lower administrative costs and health spending throughout the system, while ensuring that injured patients are compensated fairly for their losses.

The full executive summary follows below. There's a lot of good stuff here, though right off the bat I'm somewhat dubious about any talk of malpractice lawsuit reform (though it's certainly debatable). The points about reducing cost either seem glossed over or of questionable value, which I think could be a big issue both legislatively and with the real world application. Besides making it palatable, we do need to rein in costs and improve care, and ramping up access, though important, is only a first step.

werehippy

The executive summary:

The link between health care costs and the economy is undeniable. Reforming the health care system is essential to restoring America’s overall economy and the financial security of our working families.

The case for reform is strong. The U.S. is the only developed country that does not guarantee health coverage for all its citizens, with 46 million uninsured and another 25 million underinsured. As a result, families are struggling to keep up with out-of-pocket costs for medical care. American businesses are straining to absorb rising health care costs while staying competitive at home and around the world. Despite high levels of spending on health care, research documents poor quality of care received by patients in the U.S. Studies show, for example, that adults receive recommended care for many illnesses only 55 percent of the time. Children fare even worse.

Americans are acutely aware of problems in the country’s health care system, and they are ready for change. They are not alone. The nation’s health care stakeholders — consumers, businesses, labor, providers, plans, manufacturers, and state and local governments — are signaling that they are ready and willing to engage in serious and comprehensive reform of a health system in crisis. They recognize that the status quo of high costs, unacceptable numbers of the uninsured and underinsured Americans, and far less than optimal quality and value is unsustainable and intolerable. And, notably, the nation’s economists concur that system reform is not only necessary to rationalize our health care system, but to sustain our economy, our ability to compete internationally and, over the long haul, to deal with our long-term fiscal challenges.

A high-performing health care system would guarantee all Americans affordable, quality coverage no matter their age, health status, or medical history. Today, the costs of care for the uninsured are largely borne by those with insurance; providers charge higher prices to patients with private coverage to make up for uncompensated care, and these costs are passed on to consumers in the form of increased premiums. Requiring all Americans to have health insurance will help end the shifting of costs from the uninsured to the insured.

Covering all Americans would also ensure that the insurance market functions effectively. Insurance works because policyholders pay into their plans when healthy, and have their medical bills paid when they are sick. If a significant portion of Americans does not purchase coverage until sick, then premiums for all enrollees will increase to cover insurer outlays, and the problem of unaffordable coverage will persist. Finally, covering all Americans is essential to effective prevention and wellness efforts and managing chronic illnesses. Efforts to guard against and better manage illness are an effective tool to improve health and contain costs but, without every American in the system, those efforts will fall short of their full potential.

In a high-performing health care system, employers, individuals, health providers and plans, as well as government would all bear responsibility and contribute to fulfilling the goal of covering all Americans. Wellness and prevention would be prioritized. And increased quality would result in lower costs so that employers could afford to continue to offer health coverage and still compete in a global marketplace. Our public health programs would be on a more fiscally sustainable path. Ensuring that every American has
coverage would make health care truly portable, so that Americans are no longer locked into a job based on a need to retain their health coverage. This Call to Action outlines a vision for creating that high-performing health care system.

Like a sturdy stool, the Call to Action has three equally important legs: (1) a policy that ensures meaningful coverage and care to all Americans; (2) an insistence that any such expansion be coupled with an emphasis on higher quality, greater value, and — over time — less costly care; and (3) an absolute commitment to weed out waste, eliminate overpayments, and design a sustainable financing system that works for taxpayers as well as for the nation’s recipients and providers of health care.

Ensuring Health Coverage for All Americans.
The Baucus plan would ensure that every individual can access affordable coverage by creating a nationwide insurance pool called the Health Insurance Exchange. Those who already have health coverage could keep what they have. But for those who need affordable, guaranteed coverage, the Exchange would be a marketplace where Americans could easily compare and purchase the plans of their choice. Private insurers offering coverage through the Exchange would
be precluded from discrimination based on pre-existing conditions. Premium subsidies would be available to qualifying families and small businesses. By making health care more affordable and universally available to all Americans, the Baucus plan would take a major step toward eliminating racial and ethnic health disparities.

While the Exchange is being created, the Baucus plan would make health care coverage immediately available to Americans aged 55 to 64 through a Medicare buy-in, and it would begin to phase-out the current two-year waiting period for Medicare coverage for individuals with disabilities. The plan would provide every American living below the poverty level with access to Medicaid. This policy is consistent with the original intent of Medicaid, and it is the quickest and most cost-effective way to cover every American
living in poverty. The Baucus plan would also ensure that all states use the State Children’s Health Insurance Program (CHIP) to cover children at or below 250 percent of the Federal poverty level, putting help within reach for more needy children. Finally, recognizing that America cannot keep its promise to provide care to Native Americans and Alaska Natives with the current level of Indian Health Service (IHS) funding, the Baucus plan calls for additional funding for IHS.

Once affordable, high-quality, and meaningful health insurance options are available to all Americans through their employers or through the Exchange, individuals would have a responsibility to have health coverage. This step is necessary for insurance market reforms to function properly and to end the cost shifting that occurs within the system. It is expected that the vast majority of American employers would continue to provide coverage as a competitive benefit to attract employees. Except for small firms, employers that choose otherwise must contribute to a fund that would help cover those who remain
uninsured.

The Baucus plan would immediately refocus our health care system toward prevention and wellness, rather than on illness and treatment. Those who are uninsured ― and therefore less likely to receive preventive care and treatment for major conditions ― would be given a “RightChoices” card that guarantees access to recommended preventive care, including services like a health risk assessment, physical exam, immunizations, and age and gender appropriate cancer screenings recommended by the U.S. Preventive Services Task Force. Individuals without private coverage and not eligible or enrolled in a public health coverage program, but whose RightChoices screening detected and diagnosed one or more of the most common, costly chronic conditions, would qualify to receive treatment on a temporary basis until viable coverage options are available under the Health Insurance Exchange. Current Medicare, Medicaid, and CHIP beneficiaries would receive recommended preventive services with little or no co-payment. Preventive services would be covered by all insurance options offered through the Health Insurance Exchange.

Improving Health Care Quality and Value.
Recognizing that any attempt to cover the uninsured and reduce health care spending must address the perverse incentives fostered by current payment systems, the Baucus plan includes delivery system reforms that would improve quality and, over time, lower costs. The plan strengthens the role of primary care and chronic care management. Primary care is the keystone of a high-performing health care system. Increasing the supply and availability of primary care practitioners by improving the value placed on their work is a necessary step toward meaningful reform.

The plan would refocus payment incentives toward quality and value. Today’s payment systems reward providers for delivering more care rather than better care. A redefined health system would realign payment incentives toward improving the quality of care delivered to patients. Fixing the unstable and unsustainable Medicare physician payment formula is a necessary step in this process. The plan would promote accountability and coordination among providers by encouraging providers in different settings — physician offices, inpatient hospitals, post-acute care settings, and others — to collaborate and provide patient-centered care in a way that would improve quality and save money.

To facilitate the proposed delivery system reforms, the Baucus plan would improve the health care infrastructure by investing in new comparative effectiveness research and health information technology (IT). Health IT is needed for quality reporting and improvement and to give providers ready access to better evidence and other clinical decision-support tools. Reinvesting in the training of a twenty-first century health care workforce is necessary for many delivery system reform goals to be realized.

Achieving Greater Efficiency and Sustainable Financing.
The U.S. spends $2.3 trillion per year on health care, and economists warn that rising health care costs represent a serious threat to our long-term fiscal security. According to the Congressional Budget Office, up to one-third of that spending — more than $700 billion — does not improve Americans’ health outcomes. Excess spending must be eliminated and dollars put to better use, not only to correct the imbalances of the current health care system, but to offset the high costs of much-needed comprehensive reform.

Beyond measures to refocus the system on primary care, reward quality care, and invest in critical research and technology, the Baucus plan would endorse direct steps in five additional areas to curb excess health care spending. The plan would invest more to detect and eliminate fraud, waste, and abuse in public programs. The plan would address overpayments to private insurers in the Medicare Advantage program. The plan would increase transparency of cost and quality information and would require disclosure of
payments and incentives to providers by drug or device makers that may lead to biased decision-making. The plan also considers careful reforms of medical malpractice laws that could lower administrative costs and health spending throughout the system, while ensuring that injured patients are compensated fairly for their losses.

Long-term care services and supports are both a significant share of national health expenditures and a driver of cost. Considering policies to shift the focus from institutional care to services provided in the home and community could improve the quality of care delivered and reduce costs. Finally, the plan would explore targeted reforms of the tax code to make incentives more efficient, distribute benefits more fairly, and promote smarter spending of health care dollars by consumers themselves.

Conclusion.
I believe it is the duty of the next Congress to reform America’s health care system. In 2009, Congress must take up and act on meaningful health reform legislation that achieves coverage for all Americans while also addressing the underlying problems in our health system. The urgency of this task has become undeniable.

In the short term, health care reform would cost taxpayers more than the government can achieve in savings from all reforms and financing changes. Congressional leaders and the public must be realistic about the timeframe in which the fiscal success of reform is measured. If we fail to act, however, we will double our current national expenditure on health care from $2 trillion to $4 trillion, continue to witness the plight of tens of millions of our citizens without health insurance cost shifting to those who do, continue to tolerate poor quality that leads to nearly 100,000 deaths a year, and watch our businesses become
less competitive and our nation go further into debt. In short, we all must realize that the costs of inaction, both in human and financial terms, will eventually be far greater than any initial outlays. We must choose to invest now in a health care system that will richly repay the nation with greater health and economic stability in the long term.

AngelHedgie

To give you a hint as to which way Max will go on this, we passed I-155, the MTCHIP authorization and expansion initiative, with 70% of the vote. Baucus may be many things, but stupid isn't one of them. People tend to forget that MT has a progressive streak.

In addition, as Klein's article points out, MT politics have shifted significantly. I've joked that the MTGOP selected the people running against both Baucus and Schweitzer were picked by drawing straws - with the guys drawing the short ones getting the job of being the electoral sacrificial lambs. This means that it's going to be hard to pressure him from the right.

Dalboz

Healthcare reform won't happen. The reason is simple: The insurance and pharmaceutical lobbies have their claws so deep in Congress that they won't allow it to pass. At best, what you'll get is some kind of token bill passed that gives a minimal tax credit, and at most you'll get bill passed that makes it illegal to not have health insurance, forcing everyone to buy their own. Then the Democratic Congress can go strutting around saying "See, we passed a healthcare reform bill." This would happen regardless of who was in control.

werehippy

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

I do have some reservations about the ability of any plan to reform the current structure and be sustainable, as opposed to just ripping everything out and starting from scratch, but given reality I'm feeling good about this. I also worry about funding, because even if everyone overall comes out ahead when you compare the amount they currently pay versus the revenue the government will have to collect to maintain the system it's a pretty potent potential cudgel for the Republican's to use.

Derrick

You see, the thing is though, the President Elect is for meaningful reform, the democrats in congress are, and the people are.

Who else is (or should be)? EVERY OTHER INDUSTRY THAT IS STUCK WITH THIS ALBATROSS.

Pharma is a powerful lobby, but hot damn you would think Big Business would throw their hat into the ring on this one. They can only win.

ElJeffe

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

werehippy

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Last paragraph of improving healthcare quality and value

To facilitate the proposed delivery system reforms, the Baucus plan would improve the health care infrastructure by investing in new comparative effectiveness research and health information technology (IT). Health IT is needed for quality reporting and improvement and to give providers ready access to better evidence and other clinical decision-support tools. Reinvesting in the training of a twenty-first century health care workforce is necessary for many delivery system reform goals to be realized.

edit2: Though I'm personally dubious about it's cost savings value. It's fairly pricey to implement (currently prohibitively so in small practices) and you aren't talking a huge savings in personnel expenses to move from a large staff of lower skilled workers to a smaller staff of skilled IT support. I'm sure there are relevant studies out there that get more specific, but I don't think the front end savings are all that appreciable.

Now in terms of improving quality of care and moving healthcare to a more evidence based and standardized model, I can't rave about electronic records enough. The kind of shit that slips by currently would scare the hell out of you, and IT can be a huge help there.

durandal4532

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

Oh holy yes.

Just looking at my father's office, and the offices in Miriam Hospital, makes me want to cry. Endless reams of yellowing, barely-readable paper. Digitizing would go at least a short distance towards making it easier on everyone to actually communicate.

About cost-saving, yeah it would probably be minimal if at all, but damn it would be worth it.

ElJeffe

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

werehippy

ElJeffe wrote: »

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

The thing is in most modern hospitals or major clinics that's done by either unpaid volunteers or low paid secretarial staff. And you have to balance that against a pricey implementation and ongoing IT hardware and staff costs. There are some savings, and the actual benefits to care can't be overstated, but it's not currently a money maker.

Now, if the government started throwing tax incentives around, or some more of the current plan for e-perscribing (percent bonuses to all medicare/medicaid payments if you use it, gradually decreasing and turning into a penalty after a certain number of years) all that math might change.

kdrudy

ElJeffe wrote: »

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

I work on the side where the claims have to go out to be paid, and dealing with paper claims uses up not just more time having them keyed in to be sent electronically to insurance companies, but there is a much higher rate of error that leads to rejected claims when things are sourced on paper which takes even more time to straighten out. We might not make as much off of health claims that come to us electronically, but they move through the system so much easier.

goobers

Is this plan expecting that businesses will drop their health care plans, or assuming that they'll keep running them? I saw that people could 'choose to keep their current plans,' but it seems likely that man businesses would phase plans out unless the subsidies/tax breaks are large, which doesn't make much sense.

Dalboz

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

enlightenedbum

Dalboz wrote: »

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

The Clintons went out of their way pissing off all kinds of Congresscritters when they were trying to do this, which isn't exactly comparable to having the chair of the Senate Finance Committee introducing the damn thing and it having the moral force of Ted Kennedy's legacy project behind it.

ElJeffe

enlightenedbum wrote: »

Dalboz wrote: »

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

The Clintons went out of their way pissing off all kinds of Congresscritters when they were trying to do this, which isn't exactly comparable to having the chair of the Senate Finance Committee introducing the damn thing and it having the moral force of Ted Kennedy's legacy project behind it.

Also, there was less public outcry for a solution to the health care crisis. It's now more expensive and more people are going without it. A lot of the free market uber alles crowd are currently sitting around unemployed with no health care benefits and a stark fear of contracting terminal ass cancer. That tends to move hearts and minds.

Dalboz

ElJeffe wrote: »

enlightenedbum wrote: »

Dalboz wrote: »

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

The Clintons went out of their way pissing off all kinds of Congresscritters when they were trying to do this, which isn't exactly comparable to having the chair of the Senate Finance Committee introducing the damn thing and it having the moral force of Ted Kennedy's legacy project behind it.

Also, there was less public outcry for a solution to the health care crisis. It's now more expensive and more people are going without it. A lot of the free market uber alles crowd are currently sitting around unemployed with no health care benefits and a stark fear of contracting terminal ass cancer. That tends to move hearts and minds.

Like I said, this is why they will possibly let it go to committee, then let it languish there indefinitely. I gives the appearance that they're working on it, without actually passing anything. The insurance lobby will pretty much devote themselves to destroying any congressman or senator that votes for such a bill in the next election.

enlightenedbum

Dalboz wrote: »

ElJeffe wrote: »

enlightenedbum wrote: »

Dalboz wrote: »

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

The Clintons went out of their way pissing off all kinds of Congresscritters when they were trying to do this, which isn't exactly comparable to having the chair of the Senate Finance Committee introducing the damn thing and it having the moral force of Ted Kennedy's legacy project behind it.

Also, there was less public outcry for a solution to the health care crisis. It's now more expensive and more people are going without it. A lot of the free market uber alles crowd are currently sitting around unemployed with no health care benefits and a stark fear of contracting terminal ass cancer. That tends to move hearts and minds.

Like I said, this is why they will possibly let it go to committee, then let it languish there indefinitely. I gives the appearance that they're working on it, without actually passing anything. The insurance lobby will pretty much devote themselves to destroying any congressman or senator that votes for such a bill in the next election.

Ah, so you're a cynic who thinks Washington is broken and there is no hope.

Dalboz

enlightenedbum wrote: »

Dalboz wrote: »

ElJeffe wrote: »

enlightenedbum wrote: »

Dalboz wrote: »

werehippy wrote: »

Except that Obama has explicitly made it one of his top three priorities, it's overwhelmingly popular, and we've got the key player in Congress, a traditionally centrist (if not outright DINO in certain cases) Democrat leading the charge months before the appropriate session even opens.

So did Clinton. Look where that went, and the insurance is even more powerful now than they were then.

I entirely anticipate that the whole thing will be stuck in committee indefinitely, if even that. The answer we'll get is "Yeah, we need reform, but 'they' (obscure 'they') won't agree on what needs to or can be done." It makes it look like they're trying to do something, and an unnamed "they" are blocking it (likely to be blamed on the Republicans, but the block will come from both sides).

The Clintons went out of their way pissing off all kinds of Congresscritters when they were trying to do this, which isn't exactly comparable to having the chair of the Senate Finance Committee introducing the damn thing and it having the moral force of Ted Kennedy's legacy project behind it.

Also, there was less public outcry for a solution to the health care crisis. It's now more expensive and more people are going without it. A lot of the free market uber alles crowd are currently sitting around unemployed with no health care benefits and a stark fear of contracting terminal ass cancer. That tends to move hearts and minds.

Like I said, this is why they will possibly let it go to committee, then let it languish there indefinitely. I gives the appearance that they're working on it, without actually passing anything. The insurance lobby will pretty much devote themselves to destroying any congressman or senator that votes for such a bill in the next election.

Ah, so you're a cynic who thinks Washington is broken and there is no hope.

Realistic based on experience, rather than hopeful based on...uh, hope?

Believe me, nothing would please me more than to actually see it work and genuine progress be made, but because of past experiences, I can't reasonably have faith that it'll happen.

Alistair Hutton

ElJeffe wrote: »

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

The big problem is what happens when two systems collide. If someone from North Carolina is over in California when they fall ill and NC and Cali use different computer systems for storing patient records there's a non-trivial data interchange problem. The history of IT projects in the British NHS is one of near constant failures and massive cost overruns, and we're a pretty compact nations with a sixth of the population of the USA.

Speaker

ElJeffe wrote: »

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

I've had at least four sets of dental x-rays done unnecessarily because I move around a lot and each new dentist would rather x-ray than wait for the previous x-rays to be mailed.

Nibble

Why wouldn't you have a unified national records system? That seems to be the exact opposite of good software engineering.

Speaker

Nibble wrote: »

Why wouldn't you have a unified national records system? That seems to be the exact opposite of good software engineering.

Privacy concerns.

werehippy

Alistair Hutton wrote: »

ElJeffe wrote: »

werehippy wrote: »

ElJeffe wrote: »

I am disappointed by the lack of mention of digitizing medical records to rein in the overhead of record-keeping.

It's in there. I was especially glad to see it, since it guarantees me a lucrative career through the next decade

Ah, I skimmed right over that somehow. Awesomesauce. :^:

I'm skeptical that it wouldn't save money, though. How many man-hours would be saved in not having to physically dig through file cabinets for this shit, through not having to fuck with a fax machine to send records, through not having to physically cart these things around the building, through not having to recreate the form you just lost because you put it down somewhere en route to the cafeteria?

The big problem is what happens when two systems collide. If someone from North Carolina is over in California when they fall ill and NC and Cali use different computer systems for storing patient records there's a non-trivial data interchange problem. The history of IT projects in the British NHS is one of near constant failures and massive cost overruns, and we're a pretty compact nations with a sixth of the population of the USA.

That's the kind of thing you just need to impose through regulation, especially if you're going to mandate usage. There are already at least nominally a couple of regulatory boards devoted to ensuring interoperability. There's also HL7, which sets international standards for formatting and data exchange of medical information that is probably where the solution lies. You and I might have wildly different systems, but as long as we're both required to have at least some minimum set of data for every possible record and we have to send the data in constant, discrete ways you can set up interfaces between any two systems.

The wikis are actually a pretty decent overview for Electronic records and HL7.

Unknown

This content has been removed.

Nibble

electricitylikesme wrote: »

Speaker wrote: »

Nibble wrote: »

Why wouldn't you have a unified national records system? That seems to be the exact opposite of good software engineering.

Privacy concerns.

Doctors are pretty defensive about who can just get their records as well.

Why wouldn't you want other doctors and hospitals to have access to your patients' records?

|EDIT| And it's not like you'd have to actually store the data in a centralized location; just make sure everyone is using the same program so that when they do want to exchange information, they can do so quickly and easily.

Dajian

Speaker wrote: »

Nibble wrote: »

Why wouldn't you have a unified national records system? That seems to be the exact opposite of good software engineering.

Privacy concerns.

You don’t need a centralized data warehouse you just need a standardized schema. Create a national health care storage standard and mandate that all systems conform (can import and export) to the standard so you can have distributed data stores and even different competing software manufacturers but they can all share data.

EDIT: Werehipppy got there first and with an existing schema.

ElJeffe

Is there a reason that records couldn't be created using an off-the-shelf database app? Just require that all records be exportable using some file format that most major database apps can recognize, and then leave it at that. Or is there some reason why medical records would need to be created using custom apps?

Dajian

ElJeffe wrote: »

Is there a reason that records couldn't be created using an off-the-shelf database app? Just require that all records be exportable using some file format that most major database apps can recognize, and then leave it at that. Or is there some reason why medical records would need to be created using custom apps?

My guess is that if healthcare institutions are going to be mandated to go digital and they are spending money to do it they are going to want to get more bang for their buck.

By this I mean if I own my own practice and I am mandated to become digital. Let's say I have a couple of options. A) Barebones solution that just stores and distributes the data law requires or a system that lets me do other things my practice handles like appointment scheduling and billing in addition to the government required digitization of records.

So long as option B is proportionally priced to option A then I think there would be a competitive market for it.

Point being that while the government will mandate the digitization they won’t be providing the software or hardware to do it (maybe a tax credit at most) so that means private industry will step in to fill that role. The thing that I think needs to be mandated is the format that the data is required to be (transmitted not necessarily stored) in.

Speaker

Dajian wrote: »

Speaker wrote: »

Nibble wrote: »

Why wouldn't you have a unified national records system? That seems to be the exact opposite of good software engineering.

Privacy concerns.

You don’t need a centralized data warehouse you just need a standardized schema. Create a national health care storage standard and mandate that all systems conform (can import and export) to the standard so you can have distributed data stores and even different competing software manufacturers but they can all share data.

EDIT: Werehipppy got there first and with an existing schema.

I defer to the superior technological expertise of just about everyone else on the forum.

werehippy

ElJeffe wrote: »

Is there a reason that records couldn't be created using an off-the-shelf database app? Just require that all records be exportable using some file format that most major database apps can recognize, and then leave it at that. Or is there some reason why medical records would need to be created using custom apps?

In theory, there's nothing wrong with it.

The front end would need a ton of work to be usable, and then on top of that you'd want to build a lot of logic to do safety checks (are you sure you want to give 1000x the lethal dosage of that med? or are you sure you want to cause that fatal drug interaction? are good questions), best practice suggestions (are you sure you don't want the recommended drug for this symptom or are sure you don't want a CT scan for that head trauma?), and then if you're feeling fancy you put in stuff like Medicare requirements or standard practices (your 60 year old female patient hasn't had a mammogram, you've ordered a MRI for a runny nose, the patient has already had a CMP this month, and so on). At the end of the day, that's what all the major systems are, they just all have different implementations of the front end, different structures to store the data on the back end, and most of them are using archaic database languages because they've been in production for 3 decades (the only places on either that use MUMPS are banks and hospitals).

HL7 is basically what you suggested for a file format to transfer information. A whatever (patient admission, results, medical notes, what have you) being transferred is sent (sent being actual direct transmission or loading from a file) as a set string of data, and each discrete chunk is separate by a standard character, and each chunk is a specific predefined piece of information. That lets anyone get the stream of data and their application should have a systematic way to take each chunk and then put it in the appropriate place to recreate the records in the their system.

Xandar

I work for a medical records software company. HL7 does achive this but getting 2 systems to communicate even using this protocal can be tricky as there can be much variation in what is acutally sent. It will alwyas be faster to just fax records to another hospital as each hosital would have to have conenction information for the patient interface. Our software allows userrs to fax patient inforation directly out to another fax number, if that number happened to also be a fax line to a hopital with our software it would go directly to electronic format, however it still would require a 'human'/user to index that infoarmation a a patients account. Obviously there could be further improvement here using OCR ect. to determine what patient the documents are referring to, but MRN/visit infoamation would never be the same between hosppitals and when you have 100's of thousands of paitnets, even first last name is not helpful. SSN information is not relaibly on a document so even then OCR would not be of help.

Mandating 1 software program would essientally cut out business for the companies, who do you pick? Epic? IDX/GE? McKession? All of these compainies and their products, while similar have particular strengths and weaknesses that allow them to have market share.

I can say that companies would likely welcome some further govt. regualtion on how to do e-records, but I do not see how congressmen/women would be qualified to lay out technical specifications for such a thing.

There is a push to a 'universal' patient identifier/number, but I don't have a lot of detail on it to share at this time.

This was so interesting to me I had to regeister and break my usual lurk/silience ruels for large forums. I'd rather not share which company I work for as I am not 'authorized' to be an offical representativebut would be happy to give some perspective as to how daunting a problem this really is. We have customers across the US and no two sites are the same or even all that similar....

ElJeffe

It seems like having to fax paper records everywhere is still a giant pain in the ass and kills a lot of the advantage of a digital system. Shouldn't we aim for as paperless a system as possible?

What would be the problem with requiring a format for the data supported by off-the-shelf products, when any hospital could still pay to have someone custom-build a package that used that format? To use an example I actually know something about, let's say the data had to be in a simple spreadsheet. You require that all data be exportable in a comma-delimited text format. So if someone wants to just go pick up Excel, they can do that. If someone wants to create a robust management system that handles all manner of tasks, they can do that, and just ensure that it can export in a comma-delimited text format. Each place can spend as much or as little as they want on the solution, and you'd likely have a huge boom in the software industry as hospitals nationwide start demanding custom management and record-keeping apps.

Seems win-win to me. Am I missing something?

tsmvengy

Xandar wrote: »

I work for a medical records software company. HL7 does achive this but getting 2 systems to communicate even using this protocal can be tricky as there can be much variation in what is acutally sent. It will alwyas be faster to just fax records to another hospital as each hosital would have to have conenction information for the patient interface. Our software allows userrs to fax patient inforation directly out to another fax number, if that number happened to also be a fax line to a hopital with our software it would go directly to electronic format, however it still would require a 'human'/user to index that infoarmation a a patients account. Obviously there could be further improvement here using OCR ect. to determine what patient the documents are referring to, but MRN/visit infoamation would never be the same between hosppitals and when you have 100's of thousands of paitnets, even first last name is not helpful. SSN information is not relaibly on a document so even then OCR would not be of help.

Mandating 1 software program would essientally cut out business for the companies, who do you pick? Epic? IDX/GE? McKession? All of these compainies and their products, while similar have particular strengths and weaknesses that allow them to have market share.

I can say that companies would likely welcome some further govt. regualtion on how to do e-records, but I do not see how congressmen/women would be qualified to lay out technical specifications for such a thing.

There is a push to a 'universal' patient identifier/number, but I don't have a lot of detail on it to share at this time.

This was so interesting to me I had to regeister and break my usual lurk/silience ruels for large forums. I'd rather not share which company I work for as I am not 'authorized' to be an offical representativebut would be happy to give some perspective as to how daunting a problem this really is. We have customers across the US and no two sites are the same or even all that similar....

This is why the people in our government would talk to "evil special interests" (read: experts) about how to design legislation that would outline the requirements for such a format.

I think the difference between this time and last on health care reform is that Obama is going to be better at bringing everyone together, and the general public is clamoring for a solution to high health care costs.

Lord Yod

I work on cars. Modern cars are required to use a specific type of command and control system called Controller Area Network (CAN), which governs exactly what information is transmitted between various electronic components on the vehicle, and what format it is transmitted in. It mandates exactly what sort of diagnostic information is exported via the vehicle's diagnostic linkup connector and exactly what sort of hardware/software you need to include in any device meant to read that data.

The system works really well. Using this information I can plug my equipment into any modern car and do a thorough diagnosis of the vehicle's engine management, emission controls, safety equipment, air conditioning, radio, or any of a number of other standard pieces of equipment using one scan tool.

The equipment on the vehicle is manufactured by whoever the auto manufacturer chooses to use. GM has its own company that does this, most European cars use Bosch, Japanese cars tend to use Nippon-Denso, etc. The equipment used to plug into the car can be made by anyone such as Snap-On, Mac, Matco, etc.

What I'm getting at is, these systems work really well, have standard data sets used for control and diagnosis, can be transmitted easily, and have standardized regulations for equipment manufacturers. Why on earth can't we do something just like this for medical records?

werehippy

ElJeffe, that's basically where it's headed and and communications are going to become standard as time goes on, especially if there's a real push towards making electronic records mandatory or at the very least much more common. To date all the systems have grown pretty much independently, and considering market share has been extremely low (10% of hospitals and 16% of primary care providers as of the last few years) there hasn't been a whole lot of incentive for any one system to polish up their incoming or outgoing connections to external systems or any one site to tweak their system to make things run more smoothly.

HL7 does exactly what your example does, with the added caveat that the order of the coma delineated data is set (so for example first bit of data is last name, then a comma, then first name, coma, middle name, etc).

Xandar is right that it's currently a beast getting two systems to talk to each other, but I'm of the opinion that's just because it hasn't previously been worth it. When there were 50 hospitals in the US that used an electronic system why spend all the time, effort, and money required to take electronic transfers of information when you can just route that stuff through the same paper based channels you have to maintain for the thousands of non-electronic record sites. As systems spread there's more incentive to take advantage of the the benefits of speeding up and automating information exchanges.

You're still likely to always have some issues (look at all the trouble making matches between different systems we currently have, like social security and voter registration rolls) but it's going to get much much closer to a true pure electronic record system in the near to mid future. Something like 50-60% of healthcare systems supposedly have some sort of electronic record budgeted for implementation to start over the next few years, though it take a few years to get a system up and an economic downturn is going to put the breaks on discretionary capital investments.

Dajian

ElJeffe wrote: »

It seems like having to fax paper records everywhere is still a giant pain in the ass and kills a lot of the advantage of a digital system. Shouldn't we aim for as paperless a system as possible?

What would be the problem with requiring a format for the data supported by off-the-shelf products, when any hospital could still pay to have someone custom-build a package that used that format? To use an example I actually know something about, let's say the data had to be in a simple spreadsheet. You require that all data be exportable in a comma-delimited text format. So if someone wants to just go pick up Excel, they can do that. If someone wants to create a robust management system that handles all manner of tasks, they can do that, and just ensure that it can export in a comma-delimited text format. Each place can spend as much or as little as they want on the solution, and you'd likely have a huge boom in the software industry as hospitals nationwide start demanding custom management and record-keeping apps.

Seems win-win to me. Am I missing something?

Even if there is a comma-delimited format someone still has to set that format and ensure that everyone uses it the same way. So, if there is going to be a standardized format why not use an XML Schema Definition or some other technology that can be used to verify format compatibility. You would want to ensure that the system you are using will always reliably created the agreed schema.

If there is a mandate to move to electronic documents then there should be an agreed upon industry standard format for keeping and transmitting the information. Any software that claims to be compliant should get a government certification that it can handle the format.

There is no reason Microsoft or any other company cannot add this output type to their product and get it certified though.

Xandar

ElJeffe wrote: »

It seems like having to fax paper records everywhere is still a giant pain in the ass and kills a lot of the advantage of a digital system. Shouldn't we aim for as paperless a system as possible?

What would be the problem with requiring a format for the data supported by off-the-shelf products, when any hospital could still pay to have someone custom-build a package that used that format? To use an example I actually know something about, let's say the data had to be in a simple spreadsheet. You require that all data be exportable in a comma-delimited text format. So if someone wants to just go pick up Excel, they can do that. If someone wants to create a robust management system that handles all manner of tasks, they can do that, and just ensure that it can export in a comma-delimited text format. Each place can spend as much or as little as they want on the solution, and you'd likely have a huge boom in the software industry as hospitals nationwide start demanding custom management and record-keeping apps.

Seems win-win to me. Am I missing something?

No, in essense this is the 'right' idea, and to some degree is what HL7 is (http://en.wikipedia.org/wiki/HL7) However it is a 'framework' and there can and will be some variation in how any given hopital uses it. Is most usful for getting ADT information between disparate systems (Admissions / Discharge / Transfer ). You mediacal record though is likely to be more then that. A lot of information is going to be images as well and can be in lots of dirrerent formats (JPEG, tif ect.) for just 'paper' documents that have been digitized. Actual diagnotic images has many many different formats (for example see
http://www.dclunie.com/medical-image-faq/html/) How many formats would a given 'viewing' application need to support, what about licesnsing for all those systems as some formats are proprietary?)

The best analogy I can come up with offhand is similar to your suggestion of using CSV for DB information, while thats a useful starting point, you can quickly run into issues. What if system 'a' has 7 columns of information and system 'b' uses 6? Or take the example of convertnig an WORD document to RTF and then importing into another word processor program. Sure you will get ;most' of the information correct, but some information may not be just right or formatted oddly, a minor PITA when trying to collaberate on a school/wrok project, potentially deadly when dealing with health records.


I'm all for the govt. laying down a more strict set of standards to allow basic communication between facilities, but its a duanting project and there will be lots of competing intrests looking to get 'their' way recognized as correct. Remmeber as well many hospitals still use mainframe/as400 for admitting/registration ect. how to rewrite all that code in a cost effective manner?


The best thing patients can do is get a complete copy of their medical records in some format (pdf say...) and store it on a jump drive when travelling. Worst case the hospital can print off a hard copy and give to the Dr.

werehippy

Dajian wrote: »

Even if there is a comma-delimited format someone still has to set that format and ensure that everyone uses it the same way. So, if there is going to be a standardized format why not use an XML Schema Definition or some other technology that can be used to verify format compatibility. You would want to ensure that the system you are using will always reliably created the agreed schema.

If there is a mandate to move to electronic documents then there should be an agreed upon industry standard format for keeping and transmitting the information. Any software that claims to be compliant should get a government certification that it can handle the format.

There is no reason Microsoft or any other company cannot add this output type to their product and get it certified though.

I think this keeps getting buried in my other replies, but this standard basically already exists. It's called HL7, and it's universally accepted. It's just each individual healthcare system hasn't had any reason to bother to implement connections to other individual systems (as opposed to different internal systems that one healthcare system may use) because there was no upside for them. They would need to buy and maintain secure external links and modify the incoming data to properly file to their own customized version of whatever system they are using, all for the extremely few cases where they'd be getting patients from another healthcare system that used an electronic record.

There just weren't enough places using EMRs to make it worth it. As the usage ramps up, the interest in making systems talk to each other will increase and people will implement what's already available.

werehippy

To loop back to the more general idea of healthcare reform here's a pretty decent overview of the two schools of though.

Basically, to outright steal from the group that focuses on reforming healthcare (control costs, improve care through IT and research on effectiveness, etc) and the group that focuses on expanding healthcare (there are 46 million without any coverage, get them on board first).

The Obama plan clearly caters to both, and all signs are that this is going to happen, but it's worth keeping an eye on where people are coming from when they advocate for various things.

templewulf

As a(nother) medical software programmer, I can tell you that hospitals are large, slow, stupid, and demand backwards compatibility. Our software uses an infuriatingly retarded tree structure to store data. It is programmed on an OS invented by the company for the purposes of running our software.

Basically, a lot of medical software companies have "Not Invented Here" syndrome, and hospitals want it backwards compatible with retard-o formats.

Beyond that, it actually already is happening. Just not universally across all systems. I'm pretty sure we're going to need further government mandates for this to happen any faster.

Also, I can't show you what the exported text files look like, but let me assure you they are as retarded as you can imagine. Imagine an .ini file with no labels to identify one thing from another, mixed up together with no whitespace, but in a very specific order such that if you transpose two fields, the hospital is suddenly missing $10,000.