Wednesday, March 31, 2010

Meaningful Use

There are two ways for organizations to make use of information technology. One is to conceive of a better way of doing something that it makes possible and then use the technology to do it. The other is to apply the technology to what is being done in the hope that something good will come from it.

Hospitals and doctors seem to have opted for the ‘hope’ approach.

The federal economic stimulus package included a big slug of money to support the application of information technology in the health field with particular emphasis on the development of the electronic medical record. Those responsible for awarding grants apparently are concerned that the ‘hope’ concept will prevail because they are requiring applicants to show that the computer applications to be funded will be put to what they call a “meaningful use” and have gone on to define what they mean by that.

One might suppose that hospitals would be embarrassed by the need for such a policy, implying, as it does, that they would take public money and use it to develop expensive computer systems that were not ‘meaningfully useful.’ But they are not. Instead, they are complaining that the definition is too strict.

It is something of a commentary on the state of management in health care that it cannot be counted on to make use of information technology, an expensive and powerful administrative tool, in a responsible way.

When the country gets serious about health care reform, it will insist that something be done about that.

Thursday, March 25, 2010

A Political Speculation

Like millions of others, I voted for Barak Obama with unrealistic expectations. That may explain my disappointment with how he has dealt with the issue of health care reform.

Listening to his remarks during the campaign and the first months of his presidency, I came to hope that with his eloquence and ability to deal with complex issues, he would lead the American people through the urgent and conflicting issues of cost and coverage. I thought he might have been able to help people to understand the relationship between the two and the importance of dealing with both of them, even though that might involve some unpleasantness, even sacrifice.

I was then chagrined to see him abandon the cost issue almost altogether and take a demagogic approach to coverage by demonizing health insurance companies. The result is a hodge-podge piece of legislation that promises more than it probably will be able to deliver and is more likely to exacerbate the cost issue rather than to alleviate it.

Then I read a long article about Secretary of the Treasury Timothy Geithner in the most recent Atlantic magazine. It described the unpopular but successful way in which the Obama administration dealt in its beginning days with the financial crisis it inherited. The policies followed offended both the left and the right wings of the political spectrum and used up a large chunk of the political capital Obama had accumulated in the election.

So perhaps the President decided he didn’t have enough left to take the high road in health care reform but that instead he would use that issue to restore some of it.

That is pure speculation, but there may be something to it.

Wednesday, March 24, 2010

Health Insurance Embellishments

A year ago, the talk was about health care reform. Then as the legislative process got under way and politics took over, the subject morphed into health insurance reform.

More recently, there has been increasing reference to health care overhaul.

Yesterday The Boston Globe published a list of the subjects covered in the legislation adopted by the US Congress last Sunday. .

The list consists of twenty-three loosely related provisions directed at prohibiting certain objectionable insurance practices, remedying perceived inadequacies, implementing improvements, and expanding benefits. The list also includes financial measures that purport to raise revenues to cover the cost of the program.

The one major change is the requirement that everybody (well, almost everybody) have health insurance or pay a penalty. But that does not take effect until 2014, two congressional and one presidential elections away and goodness knows what will happen between now and then.

I think of reform as being a basic revamping. I think of overhaul as a replacement of worn and broken parts. The Globe list did not seem to me to warrant being characterized as either.

I think a more appropriate title for the bill would be the Health Insurance Embellishment Act of 2010.

Thursday, March 18, 2010

Europeans and Single Payer

Advocates of single payer frequently point out that the people of Europe seem to like their universal coverage systems and ask why it is that we can’t have one as well.

I think I have the answer to that. Europeans think their systems are better than what existed before but insured Americans aren’t convinced that single payer would be better than what they have.

In this country Medicare - a single payer, universal coverage system for seniors -is popular. Despite its taint of “socialism”, it is thought to be an improvement over the situation that existed during the early 1960’s when costs had risen beyond the ability of most seniors to pay out of pocket when they got sick, or to afford expensive health insurance.

However, when Medicare was amended during the Reagan administration to provide for catastrophic coverage, it was not seen as an improvement. There were vigorous objections and the program was repealed before it had a chance to get started.

Thanks in large part to our generous level of spending, most insured Americans are satisfied with what they have. They do not see how a governmental system of health insurance would be better for them and suspect it might be not as good. Furthermore, somebody would have to pay the added cost of a single payer system and the already insured people suspect it could be them.

That leaves the humanitarian argument; i.e., that we ought to be helping the people who can’t get health insurance or can’t afford it. For reasons pointed out in an earlier posting, that argument has so far not proved effective enough to carry the day for single payer or universal coverage – at least not at the national level.

If Americans with health insurance thought that they would be better off with single payer, we’d probably have it by now. But they don’t, and so the European comparison does not apply.

Thursday, March 04, 2010

Just Say No

Should a physician be allowed to prescribe a test or treatment, provide it, and then collect for it?

That question first came up with drugs and the answer was, and remains, a clear no. The idea is that when making decisions about prescribing medications, the doctor should not be tempted to make money by prescribing inappropriately.

But over the years the issue has gotten fuzzed up, perhaps starting with the country doctor who bought a large house and turned it into a hospital. The doctor then charged for the hospital’s services but founding a needed hospital was seen as a public service and there was little worry that the doctor would admit patients unnecessarily in order to generate personal income.

As time has gone on, more and more diagnostic and therapeutic services have come to be provided and charged for by the physicians who prescribe them, even to the extent of a resurgent trend in physician-owned hospitals.

The issue has reached the federal level. Congressman Stark of California has made something of a reputation for himself by sponsoring legislation to prohibit, or at least restrain, what has come to be known as self-referrals.

The issue came up in a February 26 New York Times story about the Melbourne Internal Medicine Associates, a group practice in Florida. MIMA operates a radiation therapy service and is under investigation for billing for the services of physicians who were out of the country when the service was rendered and for prescribing more expensive radiation treatments when less expensive treatments would be adequate.

The MIMA case may be mostly about fraudulent billing, but underlying it all is the self-referral question.

In politics, nothing is simple, but to me the question is not complicated. If it were mine to decide, I’d just say no.

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