The HIT Transition Weblog

More Uses for English Majors

I feel like I hit the lottery! NAHIT has published its list of healthcare IT jargon definitions. And I win!

We were more or less assuming the RHIO and HIE definitions three years ago. But it seemed like anybody who wanted a for-profit model wanted HIE, while the NPO [Ed. note: That's "Non-Profit Organization," for those of you stuck in the money-making paradigm.], crowd was unafraid of RHIO and its hoary socialist allusions: Regional and Organization. Now maybe everybody won't think they know what I'm talking about when I say RHIO (pinko commie big brother freebie hippie healthcare) versus HIE (fat cat capitalist libertarian survival of the fittest healthcare).

Instead, now HIE -- health information exchange -- is a process of exchanging records, while HIO -- health information organization -- is the thingy that exchanges them, and a RHIO is a "type" of HIO -- presumably a HIO for a R(egion), but NAHIT's still a little cagey on that point.

Glad we got that straight.

Quick! Everybody grab the new keyword!

Prepping for CCS

Last fall, I reported about how much fun I had at the Collaborative Communications Summit. Not "fun" as in golf outings and spa appointments, but "fun" as in meeting some really interesting and influential people, and being surprised at just how much some executives at the top tiers of the healthcare industry actually know about health IT. But CCS is not just about IT, it's about IT-enabled healthcare, which is a different spin from the typically techy-wonky conferences I traditionally attend.

And I didn't just like it enough to go back; I liked it enough to help make the next one happen. [Disclosure: HITTG is a media sponsor for this event. But we don't sell blog endorsements to anybody.]

Multisyllabic Session Title #1
On Tuesday, I'll be moderating a session called, "Unified Vision with the Consumer and Provider through HIT." I've got an incredibly qualified -- and incredibly broad -- array of panelists:

• Carolyn M. Clancy, MD, Director, Agency for Healthcare Research & Quality
• Michael E. Singer, President, Revolution Health Investments, Revolution Health Group
• George Chedraoui, Global Well-being & Health Benefits Leader, IBM
• Grad Conn, Senior Director, Health Solutions Group, Microsoft Corporation

And before you jump to any conclusions, no this is not a PHR vs. PHR smackdown with a government referee. First, you should note that Mr. Chedraoui has a largely HR perspective -- he's on the boards of both the Leapfrog Group and Bridges to Excellence, recently serving a term as the latter organization's chair. So he's bringing IBM-as-employer mojo, not just IBM-as-programmer-to-the-world. And I don't expect Conn is showing up just to shill for HealthVault, since Microsoft's entire health sector -- personal and enterprise -- reports to him.  Singer has a doctorate from the London School of Economics, which means I will probably buttonhole him first and ask if he's ever met Mick Jagger. I think he's working on some sort of portal these days. Singer, that is.

Taking the Moderation out of "Moderator?"
And, just to make sure the conversation is lively, I've given them all a daunting task.

"Engage me."

As a tough-but-interested, enthusiastic-but-skeptical, chronic-conditioned-but-disclosure-averse patient with a checkbook, I could be your best -- or worst -- customer. 

Engage me.

(And yes, I will be nice. I promise. After I set up the challenge.)

Multisyllabic Session Title #2
As if that isn't enough fun, I get to host the second day's "High Performance Leadership" session. This is the slot made famous by last year's CEO roundtable, where athenahealth's Jonathan Bush, Allscripts President Lee Shapiro, Andrew Eckert, CEO of Eclipsys, and Jeff McCaulley, CEO of Wolters Kluwer Health made such an impression on me, I wrote it up as a TV pilot, which was eventually re-cast and optioned as an animated short for the HIMSS conference.

Can we outdo that august assemblage this year? Looks like we'll give it a run. Here's our roster.

• Duncan James, Group President, Health Systems Market, McKesson Provider Technologies
• Oran Muduroglu , CEO, Healthcare Informatics, Philips Healthcare
• Graham Hughes, MD, GM of Product Strategy, GE Healthcare IITS

Like last year, it will be short prepared statements (keep your PowerPoints in their holsters, please, gentlemen!),  followed by a lively Q&A from the assembled C-suiters and opinion leaders in attendance. Last year, the atmosphere by the end of the second day was both congenial and charged with energy. There weren't any yawners or whiners in the group, and you could actually see ideas being connected by people who were very much able to take the next step and make something happen.

Why Wait Until Nomination Time? Let's Get Partisan!
Oh, and if that wasn't enough, the organizers have got healthcare policy advisors for all three presidential candidates to agree to show up at the same time for a pleasant little chit-chat.  I thought they were really reaching when they said they would set aside time for such a forum, but they pulled it off. I guess you'd have to call that a coup.

Just got the lineup today, so it might not be posted on their website yet.

• Tom Miller, Healthcare Policy Advisor Senator McCain
• Chris Jennings, Healthcare Policy Advisor, Senator Clinton
• Dora Hughes, Legislative Assistant Senator Obama

They were too smart to put me in with that crowd. Instead, eHealth Initiative's Janet Marchibroda will get to wear the zebra suit and blow the whistle if they get out of hand. Janet's much more diplomatic than I am, so I think they'll play nice. I'd hate for her to have to pull out a Yellow Card.

But Seriously
I probably said "fun" too many times to say, now, that it would be a wise investment of your time and energies to roll up for a conference that's barely a week away. But if you're in the DC area -- or are looking for a good excuse to be in the DC area -- you might want to check it out. Monday and Tuesday, May 5 and 6 at the Mandarin Oriental.

Cuomo's Probe Gets Bigger

Where's Andrew's Big Fat Lawsuit? posits a mid-afternoon WSJ blog post. The Journal wonders whether last month's warnings were just a matter of brinksmanship, leading up to quiet settlement prior to court action. They quickly pulled an Emily Latella, though, when they learned that the New York AG was broadening his inquiry, subpoenaing payer CEOs and internal emails.

Eet Eess Not My Dog!
Cuomo's missing the point, though, when he emphasizes that there is an inherent conflict of interest that the pricing engine is designed by a software company owned by a payer. UHC could spin Ingenix off tomorrow and they'd still be selling a secret -- I mean proprietary -- system that allows its clients to set prices by adjusting variables in ways they don't have to disclose to anyone.

Free Rider
Okay, here's a question for all you free marketeers.  How many markets allow one party to unilaterally name the price they will pay after the service has taken place and the other party has already taken on the commitment to pay a third party in full?

The University of Because I Said So
The payer community displayed no sense of irony when it suggested that the real culprits were the providers, for setting prices that needed to be discounted. They also cited a helpful academic who established the importance of including systematic bias in their calculations:

Contractually, the health coverage is linked to the in-network status of providers, explains Sara Rosenbaum, a law professor at George Washington University School of Public Health. "I must say I am at a loss to understand the investigation," she tells HPW. "The higher premium is to get the insurer to pay something for out-of-network care. If one buys PPO coverage that allows partial payment for out-of-network care, the insurer is completely free to come up with any methodology it wants to figure out the out-of-network amount. The UCR can be whatever it desires. Otherwise the premium would be astronomical, since it is in-network use that controls pricing for the plan."

Actually, I thought the difference was to be accounted for by establishing a copay or lowering the patient responsibility percentage to encourage use of in-network providers. The policyholder is warned  they will pay a much higher proportion of the fee for out-of-network. The "usual and customary" language is clearly in there to protect the payer from excessive fees, but I don't remember Whatsoever We Desire being in any of the many policies I've owned. Did I miss a footnote somewhere, professor?

I guess I thought "reasonable and customary" meant reasonable and/or customary, not "any methodology [we] want."

Four-F
It's not free, it's not fair, but is it fraud? That depends on what the AG's office finds when it looks under the electronic covers. Unlike a lot of my readers, I'm not one of those throw-em-in-the-clinker critics when it comes to payers' business practices. Our system is designed to propagate such systematic and innovative abuses of policyholders and patients. The reason that so many payers have adopted the Ingenix engine is that so many other payers have adopted the Ingenix engine. If they want to stay in business, they can't pay full price for claims that their competitors discount to a fraction.

(Bet you didn't think that was going to be the fourth F-word, did you? Sorta took me by surprise, too.)

Don't Forget to Wear Sunscreen
It won't be enough for the AG to kick some health plan booty, or even to put payer CEOs to work picking up litter on the Thruway. We need a common pricing system that's fair, open and visible. No more secret pricing.

Transparency has to work both ways, or it's just a mirror looking out on a lot of devastated patients, who put their trust in a system of premeditated avarice.

Are Cuomo's Estimates Too Low?

When we read the coverage of NY Attorney General Andrew Cuomo's accusation that Ingenix, United Healthcare and a host of other payers had systematically underestimated the "Reasonable and Customary" fees used to calculate reimbursements for out-of-network services, one frequently-repeated statement caught our eye:

Lacewell said, in one example, the office's investigation showed that when $200 was a fair market rate for a 15-minute doctor's visit for a common illness, Ingenix determined it was $77. Therefore, United would pay $62 when it should have paid $160, leaving the consumer with a $138 bill. [Emphasis added.]

Actually, the United would probably not pay a dime. The patient would have to pay the entire $200 bill -- at least until the deductible was satisfied. That got us thinking about deductibles, so we took our question over to the AskLeslie group -- those coding and billing folks that handle all those claims for providers and their patients.

We asked this question: When a non-participating plan estimates a U&C price lower than the actual fee, which value gets applied to the patient's deductible -- the actual payment, or just the discounted amount? The response was overwhelming: The patient only gets credit for what the plan says they "should" have paid for the service, not the amount of the check they actually had to write.

Be Careful What You Solve For...
So today, when I read where the Ingenix execs Andy Slavitt and David Ostler say, "We believe that the issue of how to calculate out-of-network charges and reimbursement is an important one, but we also believe that it is a small part of a larger issue: improving the healthcare system by improving the quality and quantity of information available to its participants," I thought maybe I would apply some rules of basic algebra to the "improve the quality and quantity" of information at hand.  To wit: How does such fee repricing affect annual expenses?

HITTG Throws a HISsies Script

Last night's HISsies Awards at the HIMSS conference were presented in a wholly new way. As a cartoon. We produced the seven-minute animated awards ceremony for the folks at the HIStalk blog and had no difficulty casting our co-stars, Cerner's Neal Patterson and athenahealth's Jonathan Bush. Of course, the anonymous Mr. HIStalk and Inga anchored the highjinx as awards presenters a la Oscar. Jon Bush's uncanny resemblance to Michael J. Fox, alongside Patterson's notorious hate-mail to middle management, gave us more than enough material to frolic with.

In case you forgot about Patterson's notorious management style, here's just a taste of that missive:

The parking lot is sparsely used at 8AM; likewise at 5PM. As managers -- you either do not know what your EMPLOYEES are doing; or YOU do not CARE. You have created expectations on the work effort which allowed this to happen inside Cerner, creating a very unhealthy environment. In either case, you have a problem and you will fix it or I will replace you. [Sic. sic sic sic.]

Oh, you didn't know that Healthcare IT Transition Group makes animated HIT videos? Catch up...

Don't Touch That Dial
Over the holidays we invested a few bucks and a lot more time in our media production capacity. This is just the beginning, with even more to come. Last fall, we quietly set up our (pre-beta)... 

Wisconsin Wishes for RHIO Clarity; Tooth Fairy Alerted

Wisconsin has withdrawn its RFP for a statewide health information exchange, issued in December. Apparently, some of the major partners thought that the Request for Proposals hadn't nailed down just exactly how the HIE would be implemented and paid for. Well, those folks in Wisconsin know a lot about cows, but you won't find many cowboys. It takes a real buckaroo to haul off and whip up a RHIO. This here is uncleared land, partner.

If the HISsies Fit...

We're dang sorry we won't be at HIMSS08 later this month.  Not because we want to run the gauntlet of HIT vendor account execs (tip: If "I'm just a consultant!" doesn't work, tell them you're an investigator from the SEC). No, we're just sorry to miss Mr. HIStalk's party Monday night.  But if you're going, we definitely want to extend you his invitation:

The initial response to HIStalk’s reception at HIMSS on Monday, 2/25 is strong. I peeked at the signup list and I’m impressed: informatics people, clinicians, CIOs, VPs, media people, investment folks, and 10 CEOs (!) have RSVP’ed in just the first few days. I’m immensely flattered and I’m honored that you’ve chosen to spend a little time with the HIStalk crowd and the sure to be dolled up Inga (incognito, but lookin’ fine, I predict). If you’re reading this, you are invited - please RSVP here so we can haul in enough liquor and fancy food to keep you happy. ... If you’ve never been to the Peabody Orlando, it’s really nice and is an easy stroll from the convention center (right on the property, pretty much).

Free booze and canapes is usually enough to get us to turn out, but the big deal will be when MrH (or his yet-to-be-identified surrogate) hands out the HISsie Awards for the best and worst of healthcare IT.  We'll be there in spirit, tough. And maybe more than spirit. Remember our little HealthFault video?

Speaking of videos, Michael has produced DVD versions of two of our most popular webinars, Real-Time Adjudication Drivers and Deliverables and Getting ROI from Health IT: An Independent Analysis.Unlike Mr. HIStalk, who claims to be gainfully employed, this is our day job.  Thanks for your support.

Grants Roundup

HHS Awards Grant to Secure Health Information Technology

Independent Sector Urges Senate Finance Committee to Include Nonprofits in Stimulus Package

$1.2 Million for eMAR for Aging Patients

Idaho RHIO To Get $500,000 from State, $11.3 Million from Providers

CDC Grant Opportunity Requires EMRs

AT&T Awards HIT Grantto Local Volunteers in Medicine Group

State HIT Grants in Virginia

PacificCare Gives $700,000 for Safety Net HIE

Opportunity: New Federal Rural HIT Grants

The Old Rural Healthcare Bond Refinancing Ploy

RHIOs Exploring Philanthropy?

Regional Health Information Organizations may be changing their finance strategies. In the wake of high-profile RHIO closings, and in the shadow cast by a recent report published by Health Affairs suggesting that RHIOs are floundering financially, it is not surprising that RHIO organizers are exploring new resources for capital.

Our 2007 RHIO finance survey found that about three-fourths of the U.S. health information exchanges are setup as nonprofit organizations, enjoying both exemption from taxes and the ability to accept tax-deductible contributions from private foundations. However, our report also noted that only very small amounts of private funding was finding its way into the RHIO movement; the majority of the organizations were relying on government dollars to start up operations, and were expecting to pay for ongoing costs by charging healthcare providers for their services.

That’s old news. But now things just might be looking up. There's some interesting evidence that RHIOs may be acquiring some new fundraising chops.

Marty's HIT List 2008

Here's my official list of prognostications for 2008.  In 2006 and 2007, I didn't call them predictions, so I probably don't deserve any credit if anything I said came true.  If you agree -- or not -- you can give me your own scorecard by clicking here.  Give your feedback by January 23 and I'll post the results (and any interesting comments) in a blog at the end of the month. As far as we know, we're the only industry analysts that give you, our valued reader, this critical "You're Full of..." HIT response tool.

Seeking Sustainable RHIO Forest; View Obscured by Non-profit Trees

Health Affairs just published a study by a team of Harvard researchers that has cast a pall on the sustainability of Regional Health Information Organizations (also referred to as Health Information Exchanges). The report, The State Of Regional Health Information Organizations: Current Activities And Financing, by Julia Adler-Milstein, Andrew P. McAfee, David W. Bates, and Ashish K. Jha, seems to imply that the maladies suffered by RHIO efforts around the country might be fatal, at least if you read the many news stories and blogs that are talking about it.  I say "seems to" because our analysis suggests that the industry echosphere is still missing quite a bit of the big picture.  Let's take this step by step, starting with the Harvard study and moving into the invisible economy and the nature of the RHIO challenge.

First, the "scary facts" presented by the researchers:

• 25% of previously-listed RHIOs seem to be "defunct"
• Only 20% of the remainder reported exchanging significant volumes of clinical data
• Most of the data they were exchanging falls into the categories of lab results, inpatient data and medication history
• A majority reported receiving in-kind donations, about half reported grants or financial contributions and slightly less than half reported no financial contributions

You might look at these factoids and come to the conclusion that the current generation of RHIOs are unsustainable.  The quote lifted from the report that has been frequently cited to support this conclusion says: "if RHIOs are to succeed as small businesses, they must be built around sustainable business models, which requires both profitability and value creation for participants."

Red Tuesday: Jan 1 2008

On our Black Swans list for 2008, one of the biggest birds will swoop in on the very first day of the year: January 1.  That's when a huge number of health plan enrollments roll over, and the move to the High Deductible Health Plan model is going to hit providers hard in the pocketbook.  Hence our suggested name for the eventful date: Red Tuesday.

Forecast for the Rich: Richer
The Nashville Business Journal cites unnamed analysts in guessing 2009 HDHP enrollment will double from January 2007's 4.5 million.  But one named analyst is more specific, calling HDHPs "the best idea I've seen for a health plan in 25 years." I guess that's great news if you're a health plan.

The Doctor Will See You Now, Mr. Wimpy
Will providers notice?  Not from what I'm hearing.  Physicians, clinics, hospitals, labs, etc., may be "concerned" about the migration of a big chunk of A/R from a few hundred points of cantankerous collections (i.e. health plans) to tens of thousands of points of empty and slow-paying pockets (i.e. patients), but they're not generally looking at the numbers that matter: Patient Responsibility as a percent of total billing (not "revenue" -- that assumes the money will be collected).  And multiply that by the likelihood of collecting any patient receivable, factoring in that their bill just went up by a thousand percent.

You Mean I'm Going to Stay This Color?
Maybe they will get the picture after the month closes?  Make that Fuscia Friday (Feb 1, 2008), or maybe give them three business days to close and call it Ruby Tuesday (Feb 5)?  Probably not. Months aren't trends.  January's always a slow month, right?

Maybe they'll look at the results after the first quarter.  That would be about April 3.  Surely they should be able to see how much money they are losing by then.  What color should we give it? Thrush Thursday!

But wait.  They won't even bill most of their January patients until the claims get settled by the health plans, and that takes at least 50-60 days.  January's patient payments won't even be overdue by the end of March.  They'll cash their refund checks on April 16, then buy that new Buick, and...

Ice, Ice, Very Ice....

We hear our local weather made the BBC.  Yow.  A-yip-tye-o-ee-yay!

We took in a number of refugees, being the last house among our chosen family to have power.  Then the lights went out at about 4 pm yesterday.  The office is only a half-mile away, and there we have both lights and net, hence this post.

I want to reassure you that this meteorological Black Swan is not going to keep us from doing our webinar tomorrow.  Still, if you have an extra box of double-ought swan cartridges, we could use a little more ammunition.  A rick of seasoned firewood would be nice, too.

Meanwhile, yes, we are going to have something to say about Deborah Peel's attack on her local hospital for daring to store patient records electronically, and even more to say about the premature RHIO obituary that seems to have been published in Health Affairs.

Right now, we're kinda chillin'.

http://hittransition.com/flashpoint/ad_rta.htm

Grant Roundup for 12/05/07

"Disruptive Innovations" Entrants Invited to Apply for Grants
The Robert Wood Johnson Foundation is looking for ways to shake up healthcare, and they may have found some. Among the projects invited to compete for funding:

• Project ECHO: Knowledge Networks for the Treatment of Complex Diseases in Remote, Rural, Underserved Communities - University of New Mexico Health Sciences Center
• Instant Birth Control - Planned Parenthood of the Columbia Willamette
• Develop a universal technology framework for registries focused on capturing outcomes data for cardiovascular disease -- American College of Cardiology
• Clinical Research Information Exchange - CRIX International
• Health Futures Markets - New York University
• The EpiSurveyor Project: Lowering the Barriers and Raising the Bar for Data Collection - The Datadyne Group
• Space age medical care for use on Earth - Henry Ford Hospital
• Rethinking What a Health Insurance Package Can Be - Working Today-Freelancers Union

Colorado Trust Awards $3.9 Million: Some Room for CDSS, eMAR?
Grants totaling $3.9 million to help strengthen patient care and safety in hospitals around the state. Supports the Five Million Lives Campaign, an initiative of the Institute for Healthcare Improvement (IHI) intended to build safeguards against hospital-acquired infections, ADEs, surgical errors and other complications of patient care.

Center for Community Health Leadership: $3 Million Grant for Connected Healthcare
Organization sponsored by Misys Healthcare Systems commits $3 million to the 3 million-population Tampa Bay area.

North Dakota Woman Has A Global Impact
This busy lady was over and above her fair share with her work for rural clinics and working with public safety groups. But then the Navajo nation wanted to track diabetes using PDA/blackberry technology...

Your Grant Dollars At Work: Rochester RHIO Goes Live
The upstate New York RHIO, funded by a $4.4 million state grant and $2 million from local businesses, has started training 20 participating physician office's staff members. Cork the Champagne!

Surprise! Siemens CEO Touts "Big HIT" Solution

In an announcement that should surprise no one, Siemens CEO Erich Reinhardt is advising hospitals to go with a single source for their Healthcare IT software, as well as, guess what? their heavy and pricey diagnostic equipment.  Reinhardt's appearance at the Radiological Society of North America (RSNA) annual meeting was covered by Digital Healthcare and Productivity.

Regular readers of this blog should know by now that we don't do off-the-cuff vendor endorsements -- nor do we take pot-shots at particular companies or products.  Unless, that is, one of their executives says something that sounds a bit unwarranted.

I really don't know Siemens product line -- I know some very smart people that work for the company, and have no reason to doubt they are doing a great job at whatever.

Denial Engines Still Lack Response from Provider Vendors

It's been almost two years since I published my piece on a new segment of payer software tools that offer a suite of editing tools so sophisticated that it basically allowed payers to tune them to whatever percentage of revenue retention they thought providers would tolerate.  I dubbed the tools Denial Engines and suggested that provider vendors had been seriously outflanked and needed to up their game.

This new category of vendors digs deeper, into the literally millions of edits available.  They employ various ways to improve on the previous technology, such as greater selectivity (applying edits to some providers and not others), longitudinal comparisions (i.e. based on patient history), and pattern matching (i.e. upcoding).  Regardless of the approaches they choose, these vendors make the sale based on the fact that they can recover more money than the payers' existing edits, and they provide the analytics to prove it....The "best" of these denial engines point to independent sources for the edits.  This helpful feature allows providers to learn from their mistakes. Such evidence may also tend to keep providers from pursuing appeals that will ultimately prove unsuccessful.

In my research since then, I've learned a lot more.  Some of these DE tools will go so far as to edit against best practices published in medical journals, and integrate a link to the citation in the automated defense. 

Worse, DE tools are being used by Recovery Audit Contractors (RACs) to do commission-based re-adjudication of old Medicare claims.  They're not just subtracting from what they owe you, they're taking back money you thought you'd earned years ago.

Leaving Money on th--Hey!  Where's My Table!?
I even suggested that there were (software) revenue/market opportunities to had, if provider vendors could just alert their clients that they were having an additional 4% or more of their payables systematically denied, and come up with an effective response mechanism.  I even architected a potential solution and showed it to a few of them.

Adding 2.0 to HIT Alphabet?

I've been tracking the Health 2.0 buzz generated by Matthew Holt's blog-boosted thought machine.  The idea that HIT can help remake healthcare, instead of just automate its dysfunctions, has a significant appeal. Marty Tenenbaum's post suggests the creation of a new convening entity, akin to the CommerceNet alliance that bootstrapped web-based commercial exchanges. 

Early CommerceNet members included startups like Netscape, Yahoo, and Amazon as well as established organizations like Visa/Mastercard, FedEx and IBM. The members of CommerceNet collaborated on initiatives like search, catalogs, security, payment, and shipping/fulfillment, leading to complete end-end transactions where one could actually locate a product, buy it, pay for it and get it delivered. Not only was overall market growth accelerated; many business deals resulted, generating a lot of wealth.

Um, yeah.  I guess from an insider's view, though, the deal of creating yet another HIT collaborative after the explosion of alphabet soup bowls we've seen thrown at the walls of US healthcare for the past 10 or 15 years leaves me a little, well, lukewarm.  And sloppy.

Healthcare Needs the Estate Tax

I don't usually like to put off all of my conservative friends at once, but here goes. There's a complex and very important economic dynamic in the relationship between the estate tax and the financial wellness of the healthcare industry. As fiscally conservative as one might want to be, this one comes down undeniably on the side of beneficial taxation. That is, if it is important to you that money stays in healthcare.

First, let's note that the so-called "inheritance tax" is nothing of the sort. The estate tax is a duty assessed on residual value at death; it does not tax heirs on what they receive. Second, it is a tax paid by very few, indeed. In the past twenty years, between 1% and 2% of estates have been subject to the tax. As pointed out in a recent Economist story, it is responsible for only roughly 1% of federal revenues.

On its face, the "Death Tax" seems a perfect political target. Just a 1% hit to the federal budget, right? No. That would be Dead Wrong. And healthcare would be the first, and possibly biggest, casualty. Read on...

Watch Out for the Brown Drugs: A Data-based Solution

Dr. Mark McClellan this week lauded the newley-enacted FDA Amendments Act, an overhaul of drug safety monitoring. A component of the Act will create over five years the largest database of drug patients ever assembled.

eHealth Initiative, Partners Healthcare, Kaiser Permanente and other large organizations will coordinate with insurers like Unitedhealth Group and Wellpoint to collect patient data. McClellan addressed the Lazard Capital Markets fourth annual healthcare confab:

“If they work together and follow the same [ADE definition and data use] rules, then you’ve got tens of millions in the database... Most of the evidence on your products will be coming from sources other than you... If you could have identified Vioxx problems in three or four months instead of five years, it would have had a huge impact.”

McClelland, now Brookings Institution fellow, notes that the much larger and more complete database could detect dangerous side effects earlier. The former FDA commissioner said that the database could prevent a repeat of the Vioxx debaucle.

http://hittransition.com/flashpoint/ad_rhio2.htm

Funding Drought for HIT in 2008?

One survey suggests that many big health plans are going to hold the line on health IT spending in 2008 (though there seems to be a strong move to roll out real time adjudication).  Provider vendors may face challenges, too, as Stark revisions and delays push ambulatory HIT projects out of relatively liquid clinic budgets into relatively bureaucratic institutional budgets. 

Headlines for Mid-November

Federal Health Chief Stumps for Medicare IT Project

AMA adopts guidance for HIT donations

Continuity of Care Document (CCD) Quick Start Guide

Centralization, Commercialization Threaten VistA

Longer Patient Life Expectancies Affecting Finances for Hospices

'Wired' bill fails to win quick Senate passage

California Could Become National Model for Telemedicine

The Value of Provider-to-Provider Telehealth Technologies

Ehealth one of UK's major future technologies

Grant Roundup for November 20

$400 in Grants from FCC for Health Networks
Now that's a government putting its money where its spin usually is. A large majority of the 80 organizations who applied are receiving funding. Examples: the Cabarrus Health Alliance gets $6 million; Copper Queen hospital gets $183,000.

Near Space Technology Brings Healthcare To Navajo Nation
Satellite technology to monitor diabetes funded by the U.S. Department of Agriculture's Distance Learning and Telemedicine Grant program.

Local Philanthropy Funds Health IT
Grocery magnate Hannaford Charitable Foundation gives $25,000 to Saratoga Hospital in its campaign for Electronic Medical Records (EMR) and Computer Physician Order Entry (CPOE).

First Health IT Grant Resource Directory Developed
The "HIT GRD" serves RHIOs, HIEs, hospitals, clinics, rural healthcare and HIT software vendors with information on private funding prospects for RHIO and health IT.

Wealth Transfer To Benefit Illinois Communities
We've been explaining the U.S. intergenerational wealth transfer for years now: Over the coming few decades, many trillions of dollars will pass from the largest generation ever to walk the earth to its heirs and favorite charities (we estimate nonprofit healthcare's slice to be upwards of $2 trillion -- with a T). And we're not alone; communities are catching on...

Resource: Dartmouth Atlas of Health Care
Some of the facts and figues for creating the HIT support case.

Black Swans and Turkey Trends

In Nassim Nicholas Taleb's provocative book, The Black Swan: The Impact of the Highly Improbable, the author warns of the danger of trusting in trends by employing a timely metaphor: The turkey who sees his daily needs met, the food comes in, he grows fat and happy -- everything looks great, and if history is any teacher, life will just continue to get better and better.

Until one fateful Thursday morning in November....

Taleb's analysis is compelling, clever, challenging and very funny.  He presents an overwhelming case for a pair of foundation-shaking premises: The trends that seem reliable, aren't; and the things that matter most are the ones that you can't predict.  He also takes aim at the experts who push trend analyses and forecasting with biting wit and savage statistics.

It's a book that will make you think.  In fact, I hazard to say (knowing how risky it is to predict anything) that it will change the way you think. 

It may even change the way you think about how you think. (Ow, that hurts.)

Forecast for Tonight: Scattered Randomness with a 50% Chance of Chaos
It's especially challenging to us here at Healthcare IT Transition Group, because we live on the edge.  Not in the sense of sleeping out of our cars or going to the trendy nightspots, but in the sense of looking out for what is coming next in healthcare IT, figuring out the complexities, and helping people navigate the transition.  We're Black Swan hunters.

And it's important to emphasize that not all Black Swans are bad.  There are negative Blacks Swans, like market crashes, and there are positive Black Swans, like sudden, peaceful resolutions to long-term violent conflicts. You want to avoid the former and take advantage of the latter.

But wait!  The foundational principle of Taleb's book is that Black Swans can't be predicted!  How dare we even try...?

New Money for Health IT

Mention the word “grant” to almost anybody in healthcare, and they immediately think “federal.” And that’s odd, because the U.S. federal government is responsible for less than 20% of the grant dollars given annually to U.S. nonprofit organizations.

We know (because Mike Leavitt recently reminded us) that unlike nearly everywhere else in the world, American government doesn’t pay for health IT. So why are we still standing here like a row of prairie dogs waiting for peanuts? It’s time to start thinking differently, and start looking to the country’s 50,000 private foundations, Community Foundations and corporate giving programs for money for health IT.

Rather than just repeating that exhortation incessantly to everyone who will listen, we have been doing some of the footwork. Through a two-year research project involving more tedious reading and databasing than I care to remember, we’ve compiled a list of just over 4,000 prospective funders of health IT. And not one of them is the federal government. Read on...

HIT Forums Point the Way for 2008 (Part 2 of 2)

Crystal Blue Persuasion
The mid-week shift to the Blue Health IT Symposium was a bit of a culture shock.  The venue was the elegant-but-somewhat-shopworn Biltmore hotel in LA.  The ornate downtown showpiece was the glitzy scene of a number of the early Oscar ceremonies, with oversized black and white photos of grinning film stars adorning the Historical Hallway.

The symposium is held by the Blue Cross Blue Shield Association for the benefit of its member organizations, whose IT and management staff make up the lion's share of attendees. There were also a number of vendor/sponsors in attendance.  I was among a much smaller handful of speakers who hadn't bought booth space or carried boxes of enlogoed pens, notepads or bouncy balls to distribute.

It was nice to be back among my doers and persuaders, of course, but for the rest of the week, no one insisted upon buying me a single-malt scotch or told me about the night club they built to avoid boredom on their horse ranch in Cucamonga.

I wasn't wearing my journalistic hat at the Blue conference, so I better keep quiet about that breakout session called Mandating Serial Colonoscopies for Documentary Producers: Medical Necessity vs. Karmic Comeuppance.  I can report on a couple of the things I did and said, though.

Standards Development Organizations in Development
One panel session addressed standards development and implementation, and featured a number of speakers I hold in high regard, along with others whom I hadn't met, but had earned high positions in industry-leading private and public organizations.  One of the former was Alix Goss, chair of X12N, the group responsible for developing administrative transaction standards for the insurance industry, including the familiar 837 claim formats.  Earlier in the day, Alix told me that X12 had rolled out a more interactive web presence, and had added a forum for the (unofficial) Provider Caucus, of which I had once been a member.  She knew I would be pleased, because a few years back, I made a case for expanding provider participation in standards development work [NOTE: MS-Word doc file] through the engagement of collaborative technology.

She should have known not to encourage me.  Because when I realized that before me sat the people responsible for developing and implementing healthcare standards at X12, HL7, BCBSA and CCHIT [mynorca limit exceeded for this article-- look them up yourself -ed.], I made the case for SDO 2.0.

[continued]

HIT Forums Point the Way for 2008 (Part 1 of 2)

I was fortunate enough to attend two healthcare IT conferences last week; one as a journalist (really!) and the other as an invited speaker and guest.  Officially, I was gathering information at the first conference and sharing information at the second conference.  Unofficially, I was flogging our products and services -- upcoming webinars on Real Time Adjudication, HIT ROI for provider organizations and the Black Swans of Healthcare IT; and our just-released 5-volume set of healthcare IT funding sources.  Nobody seems to have discovered these ulterior motives so please keep my secret to yourself.  Whatever you do, don't forward this email to everyone you know that might care about saving money or avoiding disaster next year!

How the Other Half of One Percent Lives
The Collaborative Communications Summit is a boutique conference for C-suiters.  The concept is to put the event in a tony venue that pampers the executive appetite and bring in a raft of brilliant speakers and those who move and shake the industry. Last week’s CCS topic, “Transforming Healthcare through Health Information Technology,” was enough to pique my interest when I read about it a few months back. When the conference organizers offered us a media sponsorship that included a free press pass, we jumped on it.  I was already going to be in LA to speak at the Blue Cross Blue Shield Association's Blue Health IT Symposium, so I could make the CCS event for the price of a couple nights at the hotel.  How much could that be?

Historically, my conference experience has been more focused on getting in the thick of things with the doers and persuaders than rubbing elbows with the financers and deciders. I’m pretty familiar with the Metro system in DC, the shuttles at O’Hare and the rental car agencies at DFW, but finding my way to CCS’s ivy-cloaked venue, the Peninsula in Beverly Hills, was a different sort of commute. In my more skeptical moments, I fully prepared myself for one of those fly-and-bye junkets we hear about – the execs make an appearance at the keynote, then head for the golf course, spa or shopping district.

It’s good to be wrong sometimes.

The President is a Lot Smarter Than You Think!
No, not that president.  I’m talking about the president of the company – maybe even your company. The CCS sessions were substantive and dealt with the underlying causes of the challenges and dysfunctions facing the healthcare industry, and the ways that healthcare IT can – and cannot – hope to address them.  The event was intimate – all the sessions took place in a single conference room laid out cabaret style with round tables and a raised dais at one end. 

The vendors were there, of course, but held back from the full frontal sales pitches that seems increasingly characteristic of HIT forums as the industry heats up.  Instead we got case studies, policy analyses and trends.  The interactive style remained consistent throughout, which lent a sense of industry gestalt to the proceedings.

Bullets over Bel Aire
Here are some of the things that seemed to emerge from the group mind.

Health IT Grant Roundup

Creative applications of lifesaving health IT

These examples scarcely glimpse at the wide range of creative ways IT systems are beginning to find philanthropic support, often by emphasizing the critical information technology infrastructure backing up telemedicine and other clinical systems.

Remotely Healthy: Monitors Keep Track of Patients from a Distance
Multi-year grant from Health Foundation of South Florida.

Excellus BCBS Expands Partnership with Hospitals to Combat Hospital-Acquired Infections, Save Lives
$5 million expansion of funding for upstate New York hospitals involving infection control (real-time electronic access to infection-related clinical data component). In the GRD see the related Community Health Foundation of Western & Central New York.

Verizon Foundation Provides Funding for Seven South Carolina Nonprofit Programs
Relatively small grant with a portion for connectivity, communications, translation software.

Indiana HIE Receives $1.7 million Grant
The Indiana Health Information Exchange (IHIE) receives $1.7 million from Regenstrief Foundation to support participation of small primary care practices in the RHIO.

Washington Regional Receives $2 Million From Wal-Mart
Nearing completion of an $8 million clinical information system, the grant supports these technology advancements to generate better information and enhanced data, and streamline processes that produce better patient outcomes.

Case Management Technology Could Cure Some of State's Health Care Ills
Joint venture funding confronts electronic chronic care case management.

Missouri Foundation for Health Infrastructure Grants
17 grants totaling $2.484,023 million to area health departments for infrastructure projects including the purchase of equipment supporting information technology, communication services; includes $576,646 to update the building and information technology equipment for Springfield-Greene County Health Department.

Working with legislators:
Hays Medical Center Receives $500,000 Federal Grant for Telemedicine, Connectivity
"We're very fortunate, Kansans are," said Jodi Schmidt, chief development officer at HMC. "Our congressmen are great about helping us go after federal funds for these sorts of things." Federal grants for these and related projects have totaled about $4 million over 10 years, the most recent (October, 2007) being the largest.

Effective Coattails:
Palo Alto Medical Foundation Receives $1.2 Million Grant for New Diabetes Management Study; Trial Will Evaluate Online Disease Management
Funds a solution developed by several partners including iMetrikus, Epic Systems, Palm and Sprint that will automatically upload blood glucose readings to patient's electronic health record

http://hittransition.com/flashpoint/ad_rhio2.htm

Fair Share of Charity Care

In the form of proposed legislation, Sen. Charles Grassley is expressing his concern about how much nonprofit hospitals spend on charitable care. The ranking Republican on the Senate Finance Committee suggests that more is due in exchange for the billions of dollars in tax breaks received by hospitals.

Finance Committee staff has developed a controversial wish list of reforms, including one that would require nonprofit hospitals to dedicate a minimum of 5% of revenues to free care. The alternative would be to forfeit their tax-exempt status.

As we have noted in our publications, hospitals are the rare bird in the huge nonprofit sector. There are about 3,100 nonprofit hospitals, out of a universe of a million and a half U.S. nonprofit organizations. Looking at it more conservatively, there are 299,000 "reporting public charities" -- organizations large enough to be required to file tax returns with the IRS. Of those, nonprofit hospitals represent only about 3% of the entities, but consume 42% of the total charitable revenues of these reporting public charities.

Shout Out to Mr. H and Inga

Congrats are due to Mr. HIStalk and his sidekick, er, "hero support" co-blogger, Inga.  Mr H and Ms. I run one of the most readable and laudable healthcare IT blogs out there.  This week they logged their millionth visitor.

http://hittransition.com/flashpoint/ad_rhio2.htm

Lucky Sell-off by WellCare Exec Yields $686,000

In one of those amazing coincidences, WellCare Director Neal Moszkowski sold off 10,000 shares of his stock a week before federal investigators busted down the doors.  Conservative math shows the shares worth at least $1,124,400.  If Moszkwoski had waited a week, after the stock tanked by more than 70%, but moments before shares were pulled off the market, his cashout would have been a mere $438,000.  That would have been an unlucky trade indeed.

Baby Needs a New Pair of Cuffs
His good luck couldn't have come at a better time, either, since those Wall Street-savvy defense attorneys charge a pretty high hourly rate.  Luck like that makes me want to take my grocery money down to the Cherokee Casino.

http://hittransition.com/flashpoint/ad_rhio2.htm

A Bad Day Phishing for WellCare?

My inbox is hot as a hornet's tail, and there's two things that are making it blister.  The first is Medicare's "effective immediately" moratorium on granting additional providers or clearinghouses access to its eligibility data.  The second is this  story about the FBI's raid on WellCare Health Plans Tampa.

The eligibility moratorium was invoked for the explicit purpose of "security," according to my sources.  They not only want to know who's connecting to them, they want to know who's connecting to them.  People in the industry are worried about restraint of trade, if Medicare opts to limit the number of connectivity relationships, which are now wildly complex, often hopping between three or more entities between the provider and Medicare.

Do You Want to See My Etchings?
Details on the WellCare raid are sketchy.  We know that there were three agencies and a lot of agents involved (one report listed 200), and it was dramatic enough to cause about a 70% drop in their stock price before Wall Street halted trading on the issue altogether.

The Invisible Hand at Work
WellCare specializes in administering federal managed care plans for Medicare and Medicaid beneficiaries, competing against other companies trying to sell similar coverage to the same patients.  And they must be doing a good job, right?  Because they've grown into a $4B a year business doling out healthcare for those privatizing patriots back in DC.

Cold Cash
Of course, they did get into a little trouble recently when some, um, overzealous independent agents happened to enroll some beneficiaries who had, well, deceased prior to their enrollment.  In terms of quality outcomes, it's worth noting that 100% of those patients stayed dead under WellCare's management.

Put on Your Belts as I Shift into Hypothetical Drive
Now, if you were having a more significant lapse in regulatory compliance, and you wanted to outdistance your competitors in capturing those Medicare and Medicaid patients with promises of better/faster/cheaper care (as long as we're not talking about the taxpayer, at least), they you might be interested to know all the beneficiaries of a particular program in your area.  You know, the kind of answers you might get from, say, sending in an electronic eligibility request. Or maybe a few thousand.  Or a few hundred thousand.  Whatever.

But of course, that would be wrong.  I'm sure the cause of the raid was just a simple misunderstanding, like forgetting to cross an "i" or dot a "t" on their last Medicare provider enrollment form.

Oh, that's right.  They're not a provider, they're a payer.

Nothing to See Here, Folks
So that must mean these two stories aren't related.  Medicare's new policy is directed at healthcare providers.

http://hittransition.com/flashpoint/ad.htm

CIA to Take Over VA Medical Records

[Okay, this was originally a clever and slightly scary story about the involvement of the CIA in a certain Health IT company (true) that is developing certain identification technologies (again, true) that take advantage of a very sophisticated database technology (absolutely true).

Unfortunately, the author of the story has been unable to substantiate a direct connection between that HIT company and the company that develops the database technology, and it is that second company that is working with the VA.  So, the wry, but somewhat worrisome tone of the original text falls pretty much flat on its face.  The editor regrets the error, and the author is scrambling for some old notes.  I wish him the best.

We don't usually do conspiracy stories.  Maybe this is why.  Hope you like the cartoon, which is still valid, as it concerns only the proven connection between Company A and The Company, as it were. -Ed.]

Will RTA Keep Primary Care Providers Engaged?

One of the things that jumped out at me during last week's ASC X12/WEDI Real Time Adjudication Conference was that the consequences of high deductible health plans was going to affect certain provider settings much more severely than others.

The push to make patients responsible for a larger component of their health care spending makes sense to employers, who see the immediate consequences of the choices are making today.  The long range impact of those choices doesn't necessarily play into such calculations, given the transient nature of the modern workforce.

Be Very Afraid
Providers are -- or should be -- scared to death, because patients are notoriously negligent in paying their medical bills.  Moving a large percentage of your revenue from the conflict-ridden but semi-reliable private payer category into the conflict-ridden but entirely unreliable patient responsibility category means a lot of dollars will go uncollected.  An increasing number of dollars will be at stake as the HDHP phenomenon becomes more widespread.

Providers will need to change their processes just to maintain viability.  But some providers will be much harder hit because of their patient mix and the types of services they offer.

Nonprofit Hospital Foundations Enjoy Growing Returns

Commonwealth Institute just released a report finding that U.S. healthcare nonprofit organizations (NPOs) -- largely hospital/health system operating foundations -- reported an average return of 10.6 percent in 2006.

According to the 2007 Commonfund Benchmarks Study Healthcare Report, the average return increased from 6.3 percent in 2005 and 8.2 percent in 2004. Oorganizations with more than $1 billion in operating funds reported an average return of 12.2% for 2006, up from 7.2% for 2005 -- the second highest return since the study was started.

Returns averaged over three years have fallen somewhat, due largely to an outlier in 2003 at 14.1%, which has now dropped off the average. The three-year average on NPO healthcare returns now stands at 8.8%.

So, what are nonprofit healthcare organizations investing in to get these returns? Read on...

More PHR Bads

Click to view the HIT Bottom animated cartoon "HealthFault from Microsoft" >>