Transcript Slide 1

Advancing a Short Circuit to Avoid
Health IT Investment Backlash
Stephen T. Parente, Ph.D.
Associate Dean and Professor, Finance, University of Minnesota
Director, Medical Industry Leadership Institute (MILI)
Governing Chair, Health Care Cost Institute
Principal, HSI Network LLC; The Morning Consult LLC
December 2, 2014
7/21/2015
Agenda
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The Road to the Current Health IT initiative
Favorite Movies to support Health IT
The Fable of the Trojan Rabbit EMR
Parallel Universes & Flux Capacitors
Cheaper than Bribery: Retool current infrastructure
How Real Time Health IT may affect care & insurance
Short List of Pragmatic Health IT Policy Prescriptions
The Road to ARRA Funded Health IT - 1
• 1991: HHS Secretary Sullivan proposes Health IT
infrastructure improvements.
• 1993: Health Security Act includes provisions for
modernized Health IT infrastructure: TBD
• 1996: HIPAA – Kennedy-Kassenbaum mandates health
insurance standard and advocates for electronic medical
record standard by next decade
• 1998: David Brailer, PhD, MD starts Care Science, Inc.
and proposes health IT data ‘interoperability’ between
medical practices using financial services firms as
paradigm.
The Road to ARRA Funded Health IT - 2
• 1999: IOM’s ‘Too Err is Human’ makes Patient Health
Safety the policy reason for Health IT advancement:
– One 747-400 crashes full with no survivors for 225 days.
• 2001: IOM’s ‘Crossing the Quality Chasm’ – Health IT
is required for structural change.
• 2004: Office of National Coordinator formed. David
Brailer chosen as first Coordinator. $50 million
committed
• 2007: First AHRQ Health IT Economics R01 funded
• 2008: First Health IT Economics RWJ study funded
• 2009: HITECH and $34billion committed.
Six Movie for Touchstones for Health IT
What if No One Wants a Trojan Rabbit?
• Sir Bedivere the Wise: “Now once
we have gotten all the physicians to
buy a ARRA-financed Dell
computers from Wal Mart for an
EMR/EHR install, we can
distribute the software to them to
place more data entry onto their
existing workflow and then pay
them less when we use the
Meaningful Use criteria to tell them
they are under-performing in their
new medical home or Accountable
Care Organization CMS Pilot.”
Spinal Tap - “This Goes to 11”
Some Napkin Calculations
• Assume $34 billion ARRA HIT funds distributed only
to doctors:
– $68,000 per physician
• Buy hardware & software
• Offset training and indirect cost learning expense
• Compared to cost of malpractice premiums:
– In 2002 in Dade County, FL (granted – higher then ave.):
• $56,153 (internal medicine)
• $174,268 (general surgery)
• $201,376 (OB/GYN)
• Bonus from HIT!!! EMR produces terabytes of
discoverable data for medical malpractice.
Let’s Rev Up the Flux Capacitor
“When the Medicare Debt Hits $88 trillion you’re going to
see some serious…debt reduction commissions”
Parallel Universe Number One
• Veteran Administration
(VistA) System
• Started 25 years ago
• Has received $8 billion
• Links 153 hospitals
• Links 768 outpatient clinics
& pharmacy
• (near) real-time access
• Add-ins: Indian Health
Service, DOD military
hospitals
Parallel Universe Number Two
• Financial Services industry
– Started 25 years ago too
– ATM transfers was key
– Electronic credit cards were
rife with fraud by early 1990s
– Created fraud scoring
technologies & data to flag
suspicious transactions in realtime
– Data was siloed like HIT
– Led to FOUR near-time
repositories of all financial
services data.
Applying Financials Services Lessons to
Stop Health Care Fraud Before Payment
 TerraMedica’ fraud
and abuse
identification and
prevention solutions
can be plugged into
virtually any point
in the healthcare
value chain
 Need to identify fraud and
abuse and stop payment. This
is the only way to get the
savings from fraud & abuse
prevention activities at an
industrial scale with verifiable
outcomes.
 Can plug in intervention
before or after payment by an
insurer / Medicare /
Medicaid. Ideally, you want
to not pay a fraudulent claim.
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Such Technology Could Yield ‘Dartmouth
Atlas’ of Medicare Fraud
Except this graph would be updated in real-time and
not sit static in top-tier journal with living trend revealed info
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Today’s World
<90% Income Federal
Government
What ~$30 billion better build
Congress
Main Street
Medical Technology
Big Business
91-99% Income
Courts
Insurers/Banks
Physicians Hospitals99% Income
A Few Good Men
“Do You Want the Truth?”
A Slow Waltz of Fear and Loathing to ACO
Failure (at national scale)
Insurers (Public & Private)
• We need Fee for Service (FFS)
claims to make our systems work.
• How will we measure performing
exactly?
• OK. Great. Give us that and the
FFS data and we are good.
• Guess so. You always have an
another way. Cash practices.
• OK. Then we’ll pay old school.
• Fee for service
Providers (Hospitals &
Docs)
• We hate FFS claims because it
puts us on the factory floor. Just
pay us for performing .
• With the ACO/medical
home/EMR software you got us.
• What?@$^&?! That is more
work and you will pay less.
• We haven’t done that since the
Depression, then you came in….
• Great. What’s that?
• Argh!! (repeat)
What’s Wrong With Today’s Health IT Picture?
TOO MANY SILOES!
10% of
Care
25% of
Care
15% of
Care
15% of
Care
35% of
Care
Data Available to the Average Medical Provider About a
Patient’s Care
Ghostbusters
…”Cross the streams”
Short Circuit - Defined
short circuit
noun
(Electronics) a faulty or accidental connection between two points of
different potential in an electric circuit, bypassing the load and
establishing a path of low resistance through which an excessive
current can flow. It can cause damage to the components if the
circuit is not protected by a fuse
verb short-circuit
1. (Electronics) to develop or cause to develop a short circuit
2. (tr) to bypass (a procedure, regulation, etc.)
3. (tr) to hinder or frustrate (plans, etc.) Sometimes (for senses 1, 2)
shortened to short
Instead of Meaningful Use Bribery Tap Existing
Technology and Infrastructure for Health Reform
1) Get actuarially certified risk profiles for all insured based on existing
data.
Let people get them like a they would a credit report.
Equifax and Experian are standing by and waiting for the go-switch.
2) Government and private federal exchanges portals.
Take risk profiles from (1) and provide a ‘lock in’ by Internet click.
Target the younger population not buying coverage today through the web. Have
brokers handle the rest. Gives brokers time to get a Plan B.
3) Where the market fails from (2), auction off the high risk
Given (1) and (2), who are the vulnerable and why
Target resources to fill the insurance gaps using federal and state resources.
4) Let the Employer-sponsored market evolve; it’s not broken.
Instead of Bribery Tap Existing
Technology and Infrastructure
Insurers
• Let your systems be the
conduits and record
locators of clinical data.
• Sell/spin off or lease too
data marts and sell retail
insurance services in
exchanges.
• Use coming ANSI X12
standard with ICD10 to
harmonize all platforms
Providers
• Attach clinical data to
billing records in return
for prompt (<3 day to
seconds) pay for
ambulatory care.
• Stop customizing and get
your data on an ICD10
compliant cloud.
• Walk away from ACO
mutually assured
destruction
How might this Real Time HIT
operate in the ideal world?
Consider Anna a consumer with a diabetes.
1. On January 1, 2014, she begins health coverage in a new health plan with Real
Time HIT technology, an Integrated Health Card (IHC).
2. The IHC web site provides a list of endocrinologists accepting patients in her
area and quality scores for providers as well as those accepting IHC.
3. Prior to the visit, the Anna logs onto a secure IHC web site from the
health plan to verify her eligibility and requests her previous pharmacy
history from a different health plan.
4. When she visits the endocrinologist, the physician’s assistant swipes the
health card using a USB swipe card machine connected to the Internet.
5. The physician sees on the IHC web site that the patient has already
authorized the provider to review her past history. The physician
reviews all prior drug history and proceeds to conduct an initial
evaluation with some sense of patient compliance with medications for a
chronic illness as well as prior dosing.
6. During the visit, the physician orders tests for Glycolsolated
Hemoglobin, blood sugar, and creatitine - records blood pressure,
weight and height.
Anna’s Story - 2
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The physician’s assistant bills for an initial evaluation on the IHC web site
which requests standard claims data as well as the patient’s height, weight and
blood pressure
Since the patient’s eligibility information is already known the allowed
amount for the initial consultation is transferred directly to the physician’s
practice business account.
The patient sees the endocrinologist four more times during the year and
keeps recording stable or improving lab values.
At the end of year, the health plan invites the patient to comment on
quality of care she has received since her HbA1c scores improved. If she
comments, she will receive either a reduction in her co-insurance rate or a
credit to her health savings/reimbursement account if she is enrolled in a
consumer directed health plan.
Anna decides to shop for a new health plan using her IHC data with
clinical information, preferences and comments, and lab values. She
finds she can get a 15% discount from another plan because of her healthy
habits as a diabetic patient. She decides to take the new plan and keeps
her IHC.
The only changes are the designation of her health plan and eligibility
criteria as well as the plan’s provider panel.
Pragmatic Health IT Policy
Prescriptions - 1
1. Use Medicare Fee for Service IT Platform as Proof of
Concept of the Value of Attaching Specific and Limited
Medical Data to Claim Transaction
2. New and emboldened CMS leadership changes terms on
claims processing contracts to require the following for
payment:
• Lab Values
• Hosting vendor and secure URL for images
• Height, weight, blood pressure, temperature (when
available)
Pragmatic Health IT Policy
Prescriptions - 2
“Are you on Crack Professor”? Scotch Maybe, But Consider
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Original 1966 Medicare statute won’t let you CMS manage medical care.
But ‘Program Integrity’ (aka Waste Fraud and Abuse) is required to minimize
inappropriate payments
And the current fraud prediction analytics would greatly benefit from ‘more
signal’ from clinical data.
And if clinical data crossed with administrative data makes you more secure for
payment, you can enable real time transactions for payment
Once you have real time transactions for payment, you have short-circuited your
way to clinical data available on a real time basis
And once CMS has the data this way, meaningful use carrots and sticks forcing
providers to participate in the Health IT no longer become barriers for full health
IT implementation.
How Health Reform Fits In
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Individual mandate insurance coverage enforced by federal government.
– New national health identity number introduced and used from
womb to tomb.
– National provider number from medical school to retirement.
Minimum benefit standard with two flavors and fixed payment per
person. Both have free prevention and coverage of generic medications
for chronic illnesses.
– High deductible health insurance to be discouraged and used only as
last resort
– Preferred design is similar to federal health employee plans
Employers have options to provide insurance or pay a fine if they don’t
to subsidize private plans.
Individuals pay community rated (region) premiums.
Large federal subsidies for insurance (coming in 2014) that will need IT
to keep cost projections low.