reform

HealthsystemCIO.com–a few thoughts

Posted by

1

These are my comments to the post by Steve Huffman, VP & CIO, Memorial Health System.

Well written Steve. I think part of what is being missed by Washington is that in their effort to mandate providers move to facilitate a nationalized healthcare model; they have overlooked a few things. For starters, I think the EHR discussion has shrouded the fact that EHR is voluntary. Unfortunately, very few providers look at EHR as a decision they should evaluate—do I or do I not do EHR. Instead, they eschew that question, and view the need to do EHR as a decision that was made for them.

• Two business models are in play, a national model and the one used by providers. In the end game, even though it is only mentioned in the privacy of their own policy rooms—and not streamed on CSPAN—the national model is ultimately being designed to connect every doctor to every patient—one big hospital under thousands of roofs. The other model is the provider’s singular business model. It’s a patient-centric model (the healthcare business) and a business model (the business of healthcare). The two models have different goals and different requirements.

• If the model Washington is pushing were attractive, providers would be knocking one another down tying to be first in line to implement it. Clearly, that is not happening. Instead, Washington is offering billions in rebates, and there are still few takers.

• There is no viable plan on how to get from here to there—none, nada, zip. Instead of a coherent plan coming from them, they have put the monkey on the back of the providers, guiding them with carrots and sticks. Washington launched this idea without a much of a plan, and after the fact saddled the providers with three innocuous stages of rules—two of which remain undefined. They have yet to convince providers that they have a way to make sense out of having 400 different EHR vendors, no set of standards, hundreds of unique HIEs—I know you can’t have hundreds of anything and label it as unique—which bespeaks–the problem–and realistically expect it to work.

Why change your business rules and work flows to try to meet a plan that has stability of having been drafted on an Etch-A-Sketch? There are plenty of valid business reasons to evaluate changing the way providers work. There are huge potential gains in safety, care, efficiency, and effectiveness. These gains vary by organization. They vary based on the unique requirements of each organization. Properly planned and implemented, and EHR program with change management on workflow improvement can facilitate taking the business of healthcare from an 0.2 model to a 2.0 model.
Done poorly, and EHR will prove to be nothing more than a multi-million dollar scanner.

That being the case, you may want to use Steve’s methodology and ask him where you can go to buy a supply of the Composition books he uses.

I am Stupified

Posted by

0

Got the T-shirt.

Did you know AIG got $79 billion?  There’s also our friends at Goldman.  This got me thinking—some would argue that it in itself is noteworthy.  There’s a reason nobody shed tears for these guys, and that is the average person has no connection to them other than what they hear on the evening news.  We never got a car loan or a mortgage from them, so when they were dangling over the precipice we wouldn’t have lost any sleep had they been allowed to fail.  Unfortunately, the reports of their death were greatly exaggerated.

American poet John Godfrey Saxe based the poem The Blind Men and the Elephant on a fable told in India many years ago.  The poem is about blind men trying to describe the elephant solely on what they are able to feel.  As they are all feeling a different part, they each think the elephant is something different from what it is and from what the other believes.

It feels like the reform effort involves an equally obtuse process—dozens of people in separate rooms, each with their own pad of paper and box of Crayolas. When they finished creating their vision of reform, the person with the biggest office stapled all the pages together with the big red stapler like the one they used in the movie Office Space.

Here’s how this all ties together—don’t blink or you may miss it.  People weren’t vocal about AIG and Goldman because we weren’t connected, because it wasn’t personal.  The opposite is true about healthcare reform.  We are connected.  It is personal.  This is what Washington doesn’t get.  If they don’t demonstrate that they get it, it will fail.

Nancy Pelosi has been the poster child for the reform effort.  Her unfavorable ratings are at two to one.  Sixty percent of Americans, also known as voters, are against the reform.  I’d wager that nearly one hundred percent of those people have insurance, and rightly or wrongly, they believe that reform will take that from them.  There is a small but important distinction here.  They are not against reform per se; they are against the reform as is being discussed.  Moreover, the snowball rolling down hill that Washington–and most of the east coast–can’t stop is that nobody can accurately describe what it is they’re against.

How can the average person know if reform will work?  If reform can’t be explained clearly on a single page, Washington will lose the voter–they have.  The opponents of reform had their message down to a page; the one bullet point is “change the bill.”

Is wellness being overlooked?

Posted by

1

The following are my comments to Sue Schick’s blog, Are you ready to commit to a wellness program?

With all of the pronouncements coming from Washington about healthcare reform, it is easy to be waylaid by Gossamer eddies and side currents that pay little attention to one key area—health. There is plenty of discussion about insuring the uninsured, covering pre-existing conditions, and the rollout of a national healthcare model under the guise of healthcare information technology and facilitating the transport of electronic medical records.

I think Sue’s words are spot-on and timely. Even if nobody is going to pay for it, with so many Americans participating in the healthcare conversation, an entire industry being re-engineered, and a trillion dollars to fund the transformation, should not there be more attention paid to wellness, to proactively making one responsible for one’s own health?

Unfortunately, my perspective on this issue is shaped from having been there, done that, got the T-shirt—a heart attack at the age of forty-six. I’ve transformed myself from someone who took twenty-four years off between workouts to barely taking twenty-four hours off between workouts. I didn’t need an employer to sponsor a wellness program; all I needed was a ride in an ambulance.

There may be a lot of different ways to get someone’s attention around wellness, around being responsible. Those who want to be well will have to make that decision for themselves. No company can do it for you, but companies certainly can be supportive of your efforts to help yourself.

There has been a lot of conversation in the healthcare debate about what role the insurance companies have played in driving reform. Right or wrong, a number of stakeholders view payors as bad actors, as the raison d’être of reform.

Wellness seems to offer payors a way to put on the white hat, to be proactive. Patients understand that they do not pay their providers for their healthcare. In the event patients need a provider, patients pay the insurers, cross their fingers, and hope the insurers agree to cover the expense.

I am somewhat of a dilettante to the insurance side of the healthcare model, so I apologize in advance if I misspeak. Here’s my take as to the white hat opportunity, a way to take a leadership role in the matter of wellness. When you apply for insurance, you receive negative ratings for unhealthy and unsafe behaviors; smoking, health history, sky diving. However, if you run five days a week, maintain your weight, eat fish and refrain from drinking, you accrue no points for good behavior. In fact, you are rated as though you made no proactive attempts to manage your own health.

Auto insurance companies raise your rates for certain bad behaviors, and they lower them for certain good behaviors. No accidents for two years—the rate goes down. No traffic violations—the rate goes down. Behavior modification. I am aware of it and I manage my behavior to get lower rates.

Can a similar model work for health insurance? What would it take for payors to offer an incentive model for rewarding good behaviors?

My 1st post on HealthsystemCIO.com

Posted by

1

The following is my first guest post on Anthony Guerra’s new site, HealthsystemCIO.com.

If you haven’t begun the process of selecting and implementing an EHR, Meaningful Use may not be something with which to concern yourself. The reason, you probably will not be done in time to collect the incentive money. How can I state that with such assurance? One of my clients has already implemented EHR and CPOE—already done the heavy lifting—and they will have to divert most of their resources just to meet the Stage 1 requirements.

If you haven’t begun, there may be no rush to acquire a vendor, although the vendors will not tell you that. Rushing may lead to a bad selection. Don’t cost yourself tens of millions get to have a chance at a few. By the way, did any of the vendors with whom you are speaking mention that they have no clue if their system will meet any of the Stage 2 and 3 requirements? Right now, it’s like the vendors are selling cars without knowing whether it will need to run on gas or Hydrogen.

I think the Meaningful Use dates will be pushed back. Why? Because few if any of the providers will be in a position to apply for the incentive money. Washington created a $40 billion lottery and they are having trouble finding anyone able to purchase tickets.

Now for those whose EHR implementation is well underway or up and running — should you try for the incentive money? That’s a valid question. Just because someone is offering you a check doesn’t mean you have to take the money. Here are some questions you ought to be able to answer prior to deciding if Meaningful Use is meaningful to you.

  • Meeting MU requires a shift in your direction; you take on the MU tasks and sacrifice some of what you were going to do
  • What are those tasks, what resources will they consume
  • What year is the best year for you to meet MU; 2011-2015?
  • Did you know you can still maximize incentive dollars if you pass MU in 2013?
    • That gives you very little time to react to Stage 2 & 3 requirements

Meaningful Use is a binary contest — you make it or you don’t. The decision to meet Meaningful Use does not have to be binary. There is no way to collect for meeting 90 percent of the requirements. How might you financially calculate the probability of obtaining the incentives? Let’s begin with Stage 1—the easy one.

  • Calculate the maximum incentive you could receive
  • Multiply that figure by the degree of certainty you have that your plan will be completed on time — a number less than 1
  • Then multiply it by the probability you think exists for passing the audit, another number less than 1
  • Calculate your cost to complete Stage 1, then figure out your ROI — not much is it?I’ve seen one provider whose ROI is negative.
  • This makes evaluating Stage 2 & 3 calculations seem rather superficial. Want my advice for calculating an ROI out of requirements that don’t exist? I’d use a placeholder of six zeros preceded by a number greater than five for each Stage.

So take time to evaluate your options. The only people who will look foolish are those who don’t know what questions to ask.

How will reform impact Payors?

Posted by

0

I have developed quite a fondness for children’s books, particularly those with a well disguised allegory.  Long favorites of mine include the short stories, Uncle Remus, written by Joel Chandler Harris.  Br’er Rabbit (“Brother Rabbit”) is the main character in each of the stories, a likable troublemaker and prone to tricks.

His opposition is usually Br’er Fox Br’er Bear. In one tale, Br’er Fox and Br’er Bear hope to capture Br’er Rabbit.  Fox constructs a lump of tar and puts clothing on it. When Br’er Rabbit comes along he addresses the “tar baby” amiably, but receives no response.  Br’er Rabbit becomes offended by what he perceives as Tar Baby’s lack of manners, punches it, and becomes stuck. Now that Br’er Rabbit is stuck, Fox and Bear ponder how to dispose of Br’er Rabbit.

With each idea suggested for his demise, Rabbit has no complaints, however the helpless, but cunning, Br’er Rabbit always pleads, “Do with me what you will, but please don’t throw me in to that briar patch.”  Finally catching on to how “frightened” Br’er Rabbit is if the briar patch, Fox, believing he has the upper hand, throws Rabbit into the briars.  As rabbits are at home in thickets, the resourceful Br’er Rabbit convinces his enemies to do what he wanted them to do all along.

Sound familiar?  It should.  Br’er President and Br’er Congress.  The contest is how do they capture Br’er Payor and get Payor to play nicely.

“Let’s put caps on Br’er Payor’s rates,” suggested Br’er Congress.

“Do with me what you will,” pleads Br’er Payor.  “Cap my rates, but please don’t make us cover the uninsured.”

“Why not make Payor cover pre-existing conditions?”  Asked Br’er President.

“Do that,” chided Br’er Payor.  “We’ll even cover hangnails.  But please don’t make us cover the uninsured.”

“You know Br’er President,” said Br’er Congress, “Br’er Payor seems awfully afraid that we will make them cover all of the uninsured.   Let’s do that, let’s hit Payor where it will hurt the most.”

And so they did—made Br’er Payor cover the uninsured—threw them right into the briar patch.  Right where Br’er Payor wanted to be all along.  Thirty-one million new customers—how awful.  Smack dab in the middle of a recession, payor is handed a windfall of new customers.  Premiums.  Times twelve—twelve months.  Let’s estimate a hundred dollars a month.  That’s about thirty-seven billion in new revenues.  Billion with a B.  How is that for cutting healthcare costs.

Now suppose, just suppose that Br’er Payor has little motivation to be a good corporate citizen.  I know I am asking you to take a leap of faith.  Silly me, but I have this question that is gnawing at my craw.  What if Br’er Payor collected all these premiums and set the deductible so high that none of their new customers was ever able to file a claim?  The feds tossed the payors right into the briar patch, didn’t they?

Should you consider skipping Meaningful Use?

Posted by

2

I am going through an analysis for my client, a hospital chain who has already installed EHR and CPOE to see if they should change their strategic direction to get the ARRA money, or continue along their original course.

It does not have to be an either or decision.  Their options are not do go for MU, to go for all of the money, to go for it at some combination of their hospitals, or to go for it later.  With so many unknowns, it may be best to slow down and evaluate the options. 2011 is around the corner, however you have five years, until 2015 until the penalties begin.

What’s your take?

Thank you for reading and commenting

Posted by

0

Curious to hear your thoughts as to what impact the election of Senator-Elect Brown will have on the current healthcare legislation?

Who is responsible for your hospital’s HIT strategy, you or the ONC?

Posted by

0

Who is responsible for your hospital’s HIT strategy, you or the ONC?  Here are my thoughts regarding “What’s Next” and the “Gap Analysis”  with regard to the ONC’s interim final rule.  Remember, you don’t have to follow the IFR.

What’s Next:

  • Most if not all of the current HIT was built prior to government constraints
  • The ONC changed the rules after many hospitals already spent millions on EHR and CPOE
  • Nobody knows the staying power of the Meaningful Use rules or the impact of reform
    • Will the implementation be pushed back?  Quite possibly
    • Will the requirements be toughened?  Very likely
    • What if reform reduces revenue and increases demand?
    • What if existing doctor and nurse shortages grow worse?
    • What if some of the most vulnerable and expensive patients continue to have no coverage?
    • What if the ONC changes the rules?
    • What if reform cuts costs by eliminating “disproportionate share” payments?
    • What if there is a reduction in Medicare reimbursements?
    • More is unknown than is known about the impact on hospitals and physicians
    • There are two business models in play;
      • The ONC’s and reform’s nationalization and interoperability of healthcare
      • The mission of your organization
      • Do you build your HIT strategy to align with your hospital’s strategy or with the ONC’s strategy
      • Your pre-Meaningful Use HIT goals likely included:
        • Supporting your strategy
        • Consolidation for shared services
        • Clinical integration
        • Operational excellence
        • Reducing functional duplication between departments
        • Process improvement
        • EHR and CPOE implementation
        • Which of those goals would have to be altered because of Meaningful Use
        • What would your HIT strategy have been if there was no Meaningful Use

What’s the GAP between what you had planned and what your now have to consider?

  • How many millions will it take to meet Meaningful Use
  • What planned HIT projects must be delayed because of timing or resources
  • How do those millions compare to what you will receive from the ARRA funds
  • Even if the funds exceed the cost to get them, how do the changed systems impact your business model
  • You have a number of options to analyze regarding Meaningful Use:
    • Meet Meaningful Use later
      • A wait and see approach buys you time for the uncertainty to settle and for the impact of reform on HIT to become clearer
      • There is no requirement to be first
      • You have five years before Meaningful Use penalties begin
      • If the requirements expand as expected it will likely cost more to modify systems than to wait for a complete set of requirements
  • Do not meet Meaningful Use
  • Meet all of the Meaningful Use opportunities
  • Meet portions of Meaningful Use
  • What projects must be undertaken to achieve each option
  • Will those projects have long-term value for you, or is their only value meeting Meaningful Use
  • What process and change management implications are built into meeting Meaningful Use

How good is your vision?

Posted by

1

So, there I was thinking about all the times I didn’t get the invitations to the technical savants meetings.

I remember when Compaq came out with their first portable PC.  It was about the size of a suitcase and twice as heavy.  There was no way I’d ever have a need to lug around a computer.  A few years later my boss showed me his new cell phone—beige and about the size of a shoe box.  I remember asking him why he needed a phone and not being impressed by his answer.  Another piece of technology that would never get off the ground.

A few years later, out popped the internet.  A friend of mine showed it to me.  I asked him what he does with it.  He replied that it was good for sending messages to his brother.  I suggested he use the phone.

I think the fault I had was I looked at those three things from the perspective of the technology. It didn’t occur to me to look at it from the perspective of what business problems could they solve.

Technology, from the standpoint of its functionality, is often vastly under employed.  This happens not because of limitations of the technology, but limitations of vision.  I needed to not ask, what am I able to do with this, rather, what might I be able to do with this.

For example, let’s look at the fascination, or lack of it, around implementing an Electronic Health Records system (EHR).  By the time the dust has settled on your implementation, say three to five years—by the way, that means you missed the deadline to get the ARRA money, what does the industry look like?

Do you buy the EHR that meets what the industry looks like today, or did you give it enough thought so that your EHR functions at the level needed to support your business in 2015?

What’s the deal with reform?

Posted by

0

In the sixties, the initial funding for Medicare or Medicaid was sixty-five million dollars.  For purposes of this discussion, it does not matter which one.  It’s now more than a trillion.  Most floods start as a trickle.  Stay with me and see if this makes sense.

One cold night, as an Arab (this is not profiling, I pasted it from the web) sat in his tent, a camel gently thrust his nose under the flap and looked in. “Master,” he said, “let me put my nose in your tent. It’s cold and stormy out here.” “By all means,” said the Arab, “and welcome” as he turned over and went to sleep.

A little later the Arab awoke to find that the camel had not only put his nose in the tent but his head and neck also. The camel, who had been turning his head from side to side, said, “I will take but little more room if I place my forelegs within the tent. It is difficult standing out here.” “Yes, you may put your forelegs within,” said the Arab, moving a little to make room, for the tent was small.

Finally, the camel said, “May I not stand wholly inside? I keep the tent open by standing as I do.” “Yes, yes,” said the Arab. “Come wholly inside. Perhaps it will be better for both of us.” So the camel crowded in. The Arab with difficulty in the crowded quarters again went to sleep. When he woke up the next time, he was outside in the cold and the camel had the tent to himself.

Here’s my take on where we are.  I know you didn’t ask, I simply sensed you wanted to know.  Reform will pass.  What kind of reform?  Who knows?  Very few of us. Who cares?  A large number of those voting on it, those whose winter condos lay inside the 495 corridor don’t care.

Will healthcare reform legislation be the 3 AM call of our generation?  Many raised this same question in 1993.  Would it be different had the republicans brought healthcare to the table?  We will never know.  It does not matter if the camel’s nose enters from the left side or the right side of the tent.  Others debate which end of the camel is in the tent.  It matters not.  Once the Chicago Cubs went to night games, we were forced to change how we look at the world.

There are many things in healthcare reform.  I think that the most important one is the government.  It’s like a bad stain, once it’s in, it’s difficult to remove.  You may choose to differ, but I think the crux of the discussion is not what the details are in the reform legislation, but that it exists.

I agree fully that reform is needed.  Unfortunately, once we let the government drive, we never again get the keys.  In for a penny, in for a pound—if you convert from the Euro, it still makes sense.