Reducing Cost or Care? Orszag on HIT

Fascinating ‘insider’ article on the budget process and the Orzag/Obama plan to reduce healthcare costs by building a health IT system ‘wired’ for data mining:
“At the core of both the stimulus bill and the Obama budget is Orszag’s belief that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient health-care providers, thus saving billions of dollars. Obama is in effect betting his Presidency on Orszag’s thesis.” (See Article)

“Orszag seems more right than wrong about how to bring down health-care costs, but the truth is that, while there is obviously a great deal of waste in the American medical system, nobody knows for certain whether Orszag’s plan—which is now Obama’s plan—will work.”

The plan relies on building HIT infrastructure to obtain the data for “comparative effectiveness” research. Republicans question whether this research approach can reign in healthcare spending enough and also fear it will lead to “vast government intrusion into the doctor-patient relationship”. And the plan relies on building an HIT system to data mine ALL data without informed consent.

Our problems with the plan:

1) Orzag/Obama want ALL health data without informed consent for research, which is unethical, illegal, and destroys patient trust in doctors.
2) Orzag/Obama do not seem to realize that compelling the use of all health data will INCREASE the number of Americans who avoid treatment altogether (already in the millions). Many Americans know that avoiding care is the only way to keep health data private.
3) Millions avoiding treatment means millions delay care or never get care, increasing bad outcomes, deaths, and costs.
4) But worst of all for proponents of research: they won’t get the data needed to learn what works best unless they restore privacy and patient control over data. Researchers cannot get the results all of us want with missing and inaccurate data!
5) To find out what the most effective treatments are for many costly conditions we have to actually have all the data in our systems. Today millions of people with Depression and Addiction have NO data in the system because they pay for private care or attend AA or NA so NO data is ever generated.
6) It will be a tragedy never to find out what treatments are most effective—and a HUGE waste of the billions of stimulus dollars to build an HIT system without privacy.

Key Quotes from the article:

• The deficit spectre has loomed over every major debate. The most contentious issue has been health care.
• Orszag came to the debate with a third option, which combined Summers’s concern about deficits and Daschle’s insistence that Obama tackle health care this year. He argued that health-care reform is deficit reduction.
• At the core of both the stimulus bill and the Obama budget is Orszag’s belief that a government empowered with research on the most effective medical treatments can, using the proper incentives, persuade doctors to become more efficient health-care providers, thus saving billions of dollars. Obama is in effect betting his Presidency on Orszag’s thesis.
• Orszag, despite his image as a number-crunching technocrat, considers himself an activist.
• At Princeton, he wrote his senior thesis on the relationship between the Federal Reserve and Congress. One of his conclusions was that “it is clear that Congress suffers from a lack of understanding of even the most rudimentary economics.” Orszag’s paper won an award for the best thesis that year in international economics or politics.
• At the Congressional Budget Office, Orszag hired specialists in health-care economics and turned the institution into a clearinghouse of information about rising health-care costs. When I asked him whether he was an advocate for policies at a place that was supposed to be nonpartisan, he replied, “I would say I was activist.”
• Kent Conrad, the chairman of the Senate Budget Committee, has made eradicating the federal budget deficit his life’s work. He told me that he picked Orszag to run the C.B.O. in 2007, and repeatedly asked him to testify before his committee, because they shared a concern about long-term spending trends.
• If there was one aspect of the President’s budget that demonstrated Obama’s European sympathies, Ryan said, it was health care. More specifically, it was Orszag’s approach to curbing health-care costs. “He believes you need to set up this über-bureaucracy—the institute of comparative effectiveness—which we’ll put smart people in, and they will design the metrics and the processes on how medicine is to be practiced,” Ryan said. “And then the federal government will impose and enforce those processes. . . . It is precisely what they employ in England. It’s precisely what they employ in Canada.” Rather than celebrate Orszag’s attempt to rein in health-care spending, Ryan seemed horrified by it.
• Obama will spend the rest of this year fighting a war on two fronts. On one are Democrats protecting old-line economic interests: oil, gas, and coal companies; agribusiness; student-loan companies; and pharmaceutical companies and medical providers who fear that Orszag’s ideas for cutting health-care costs will hit them hard. On the other are institutional interests. Obama will be battling committee chairmen who oppose his Pell-grant reforms, and placating senators who resent his willingness to use a feature of the budget process known as “reconciliation,” which limits debate and prevents the use of a filibuster, to pass his health-care plan.
• Orszag’s job is to defend Obama’s budget on all fronts, but he will be most deeply engaged in health care. I asked him how he could be so sure that his ideas about how to reduce health-care costs would work, mentioning that I had been surprised to learn that Paul Ryan and other Republicans had seized on health-care cost controls as the issue they believed would bring down Obama’s health-care plan and, with it, they surely hoped, his Presidency. Specifically, they believed that Orszag’s obsession with “comparative effectiveness,” research about which treatment options work best for a given ailment, will lead to vast government intrusion into the doctor-patient relationship. The research, which received major funding in the stimulus legislation and which was also included in Obama’s budget, had assumed a sinister meaning on the right.
• Orszag dismissed the criticism as a caricature. “I don’t see how it interferes with the doctor-patient relationship to suggest that it would be better if your doctor had more information about what would work for you,” he said. “The best way of putting it is that your doctor shouldn’t have disincentives to give you the higher-quality care, which often happens now.” Far from a huge government bureaucracy, he proposes a simple adjustment of incentives: “You get paid more if the treatment has been shown to be effective and a little less if not.”
• Orszag seems more right than wrong about how to bring down health-care costs, but the truth is that, while there is obviously a great deal of waste in the American medical system, nobody knows for certain whether Orszag’s plan—which is now Obama’s plan—will work.
• As Orszag explained his ideas, I couldn’t help remembering an encounter I had with him one day in the hallway at O.M.B. I told him that I had read his Princeton undergraduate thesis. He looked at me and smiled a little sheepishly. He said that at some point after his arrival at graduate school, in London, he had had a sudden realization: that he had made a mistake, and the crucial formula that he had used in his thesis, the one that had won him the prize, was incorrect. “It was so innovative,” he said, “that it was wrong.”

HIT experts warn about EHR investment in open letter to Obama

Two healthcare information technology experts have penned an open letter to President Obama, warning him against investing too many federal dollars in existing electronic health records systems.

Existing EHR systems are too expensive, difficult to implement, disruptive to practice workflows, not proven to improve patient care, and don’t do a good job of sharing information with each other, wrote David Kibbe, MD, a technology adviser to the American Academy of Family Physicians, and Brian Klepper, PhD, founder of consulting firm Health 2.0 Advisors.

“If America’s physician practices suddenly rushed to install the systems of their choice, it would only dramatically intensify the Babel that already exists,” Kibbe and Klepper wrote.

Read their letter

The true problems in HIT

The experts quoted are correct that cost, interoperability, difficulty of use, work-flow disruption, and lack of proof of safety/effectivenss are good reasons not to spend $20 billion in HIT stimulus money on bad products (the equivalent of buying SUVs instead of hybrids and electric cars).

But Kibbe and Klepper should look beyond their own perspectives to consider the wider context and the real make-or-break issue: what must EHR systems have to ensure the public’s trust and willingness to use them?

Of course, doctors must be able to afford, easily use, and know that EHR systems actually work and are effective, but systemic failure is inevitable unless patients trust electronic systems. Today’s health IT systems and products are not even close to meeting the public’s expectations for control over personal data and and ironclad security.

From the consumer perspective, the worst defects in today’s EHR systems are:

1) Patients have no control over the use or disclosure of their personal health information in these systems.

2) Doctors, hospitals, labs, pharmacies, PBMs, insurers, data miners, data aggregators, etc, etc, and software vendors control the disclosure, use, and sale of the nation’s personal health information.

3) Most of today’s EHR technology is extremely primitive (20-30 years old) and does not comply with patients’ longstanding legal and ethical privacy rights:
•most EHRs do not have the functional capacity to segment sensitive records
•human-readable audit trails of disclosures are not required, so patients have no way to know who snooped in their records or where their personal health information has been sent or sold
•the security measures are abysmal. CIO magazine story from 2006 reported that all 850 EHR systems examined could easily be hacked:,289142,sid182_gci1273006,00.html

The most important reason not to buy $20 billion dollars worth of dinosaur EHR technology is that consumers will NEVER trust electronic health systems unless they control sensitive personal data and unless the systems have state-of-the-art security to prevent the frequent breaches, losses, and thefts of millions health records.

Until the American public has PROOF electronic systems can be trusted, failure is inevitable. Why not build EHRs and the electronic health system right from the start, rather than spending billions later to rebuild?

Must we repeat the mistakes made in the UK? The NHS system was built without patient control over data. Billions of dollars and many years were wasted before the government realized that forcing patients into an electronic health system that shares data without consent doesn’t work.

View the full story referenced

Economic Stimulus Package Likely To Cost $850 Billion

The economic stimulus package under development by President-elect Barack Obama and congressional Democrats likely will cost almost $850 billion, including up to $90 billion in additional federal funds for state Medicaid programs…

…In related news, privacy and civil liberties groups on Wednesday sent letters to Pelosi, Senate Majority Leader Harry Reid (D-Nev.), and Obama to encourage them to include privacy protections in any provisions in the economic stimulus package that seek to increase adoption of EHRs, CongressDaily reports. The groups — which included the American Civil Liberties Union, Consumer Action, the National Association of Social Workers and Patient Privacy Rights — said that such protections are needed to prevent unauthorized access to and sale of the medical information of patients. At a briefing on Wednesday, Ashley Katz, executive director of Patient Privacy Rights, said, “We all want to innovate and improve health care, but without privacy our system will crash as any system with a persistent and chronic virus will.”

Sen. Olympia Snowe (R-Maine), Rep. Edward Markey (D-Mass.) and Rep. Lloyd Doggett (D-Texas) have expressed support for such protections. Markey in a statement said, “Without robust safeguards, the health IT systems we are planning for today could turn the dream of integrated, seamless electronic health networks into a nightmare for consumers.”

Senate gets early start on health reform plan

Sens. Baucus and Kennedy are working with a bipartisan group on the goal of moving a consensus bill through the Senate next year.

Washington — Even before Congress had closed the book on its 2008 session, leaders in the Senate began laying the groundwork for comprehensive health system reform in 2009.

Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, on Nov. 12 released an 89-page vision for health system reform. The proposal calls for revising Medicare’s physician payment formula, requiring everyone to have insurance and expanding eligibility for Medicaid and the State Children’s Health Insurance Program. Baucus’ “Call To Action: Health Reform 2009” is the culmination of months of committee hearings.

Sen. Edward Kennedy (D, Mass.), chair of the Senate Health, Education, Labor and Pensions Committee, is staking his own place in the debate. He announced Nov. 18 that three committee members would lead working groups on health reform to tackle the issues of prevention and public health, quality improvement and insurance coverage.

Blues plan to help overhaul U.S. healthcare with healthcare IT

BCBS proposes to Obama transition team a 5 point plan for employer based health IT system.

BCBS contends that President-elect Obama’s plan to build reform on an employer-based system is a good one. The company proposes five initiatives for reform, including:

  • Encouraging research on the procedures, drugs and devices that work best
  • Paying for performance
  • Empowering consumers and providers
  • Promoting health awareness
  • Fostering public-private coverage solutions.

According to Serota, the Blues are comprised of 39 independent health plans serving some 102 million members nationwide. Ninety percent of all U.S. hospitals and 80 percent of all U.S. physicians participate in Blue Cross Blue Shield. By sheer volume, the Blues’ reform plans will have an impact.

Obama Policymakers Turn to Campaign Tools

Network of Supporters Tapped on Health-Care Issues
Barack Obama’s incoming administration has begun to draw on the high-tech organizational tools that helped get him elected to lay the groundwork for an attempt to restructure the U.S. health-care system.
Former senator Thomas A. Daschle, Obama’s point person on health care, launched an effort to create political momentum yesterday in a conference call with 1,000 invited supporters culled from 10,000 who had expressed interest in health issues, promising it would be the first of many opportunities for Americans to weigh in.

Will Technology Cure Health Care — Or Kill It?

Advances in Technology create dilemmas.
Obama says technology will save health care, and it’s true that IT is quickly becoming a medical resource: Google, which recently launched an online medical records service, claims that online search is where consumers turn first for health information. Computerization can eliminate much of the 30 percent of medical costs that are due to inefficiency, according to Dr. Dean Ornish, founder of the nonprofit Preventive Medicine Research Institute. And advanced diagnostics will encourage prevention and reduce costly reactive treatment.
Two weeks ago, a small green box showed up in my mail. Inside was a “spit kit” my wife had ordered me from DNA sequencing startup 23andme. Within a few minutes, I’d completed and returned the sample. In a few weeks, I’ll be able to analyze my DNA online. What if I find something I don’t like?
Thanks to technology, such diagnostics are now within the reach of consumers. As more people test themselves, doctors and insurers may face the additional burden of just-in-case surgery and a “previvor” mentality. So, will technology cure health care, or kill it?