5 ways telemedicine is driving down healthcare costs

Telemedicine and mHealth have the potential to help the healthcare system meet the Institute of Healthcare Improvement's triple aim to simultaneously increase the quality of care, improve the health of populations and reduce the per capita cost of care.

"Collectively, investments in telemedicine and mHealth have great potential to reduce healthcare system costs," said Adam C. Powell, president of Payer+Provider Syndicate, a consulting firm that uses techniques from health services research to bring about change in the health insurance and hospital industries.

A 2011 study by Anna Sommers and Peter Cunningham released by the National Institute for Health Care Reform found that hospital readmissions within a month of discharge have cost over $16 billion each year. Telemedicine can be used to reduce readmissions and other adverse events at a cost that is less than the cost of the problems themselves.

Powell recently outlined the five ways that telemedicine can play an important role in decreasing overall healthcare spending.

1. Use of remote analysis services. Remote analysis services, like telepathology and teleradiology, can contribute to lower cost and higher quality care as they enable highly trained professionals to work as a pooled resource. Use of these remote services enables low-volume providers to have around the clock coverage at a lower cost. In smaller facilities, there may not be sufficient volume to keep a pathologist or radiologist fully occupied. Telemedicine enables fractional employment.

2. Remote monitoring technologies. Remote monitoring technologies are enabling patients to be monitored on an ambulatory basis when they previously may have needed to be monitored as inpatients. Given the high cost of providing inpatient services, though, moving some forms of observation to an outpatient basis substantially reduces the costs borne by the healthcare system.

3. mHealth monitoring technologies. The use of mHealth monitoring technologies reduces the cost of complications due to chronic disease. For instance, an increase in body weight due to fluid retention is often a sign that someone may soon need to be hospitalized due to heart failure. Disease managers with access to daily weight information may be able to help a person experiencing fluid retention get the care they need before a crisis occurs. Averting crises both improves the quality of care and lowers costs.

4. At-home triage services. At home triage services facilitated by televisits with nurses and primary care physicians reduces the unnecessary (and expensive) use of emergency room visits.

5. Telemedicine appointments. By offering telemedicine appointments, providers can reduce the amount of their unused capacity that goes to waste. Many services allow providers to start or stop accepting patients based upon their current availability. As this capacity would otherwise not produce any revenue, providers are able to provide remote patient visits at a rate that is lower than the one they normally offer. This in turn reduces system costs by enabling patients to receive care at a lower price point.

Lessons Learned from Health Reform: Then and Now

The Clinton Administration failed to pass health reform legislation in the 1990s, but the process provided lessons that helped the Obama Administration craft a successful game plan for passage of the Affordable Care Act.

Now that the U.S. Supreme Court has declared the Affordable Care Act constitutional, it may be time tocompare the "now" of the Obama Administration's health reform with the "then" of the effort during the Clinton Administration in 1994.

The latter failed while the former finally succeeded. But it's not really that simple.

What the Clinton Administration ��of which I was a part���tried to do with health reform may not have succeeded legislatively, but it taught us a lot of lessons that informed the Obama Administration's efforts 25 years later.

Lesson #1 � How you do it is as important as what you do

The Clinton Health Care Reform Task Force was primarily a closed process, although there were more than 600 people who participated on a daily basis in the Old Executive Office building, and ultimately we met with all the key interest groups. However, the Clinton White House controlled the process, leaving Republicans and even some of their Democratic Congressional supporters completely out of the loop.

In contrast, the Obama White House delegated the process of developing legislation to Congress from the beginning. Obama was determined not to make the Clinton mistake of cutting Congress out of the development of a bill. He was criticized heavily at times for not pushing harder on Congress, but the success of the bill came mainly because it belonged to the Democrats in Congress.

Lesson #2 � Get support from your key opponents early in the game

The Clinton White House met with hundreds of interest groups, but there were very few formal "bargains" struck with key potential opponents in advance of the release of the bill language to Congress.

The Obama team focused on getting buy-in from key interest groups early on, such as hospitals, doctors, pharmaceutical companies, patient advocacy groups, seniors, labor, nurses, etc. For example, the pharmaceutical companies did not want the government to be able to negotiate for drug prices or allow importation of drugs from Canada and Europe at cheaper rates. Other interest groups had similar interactions in exchange for their support.

Lesson #3 � Piecemeal reform won't work. It must be comprehensive.

Early on, the Clinton Task Force considered just covering children as a starting point, but arguments in favor of a comprehensive approach won out. The policy people believed strongly that doing health reform in pieces could not solve the complex problems of one-seventh of the economy.

Some of Obama's staff also counseled against pushing for comprehensive reform, but those who had worked on the Clinton effort knew how hard it would be to get anything through Congress in pieces.

Lesson #4� Be careful how much change you introduce

As for the two plans, how much health system change did they assume? The Clinton plan was much more centrally and federally controlled, and it relied heavily on managed care.

"We got managed care," says Chris Jennings, who was one of Clinton's top health-care staffers. "But we didn't get the things that would protect us from managed care. We got the Wild West version of it."

The Obama plan delegated many powers to the states, too many some felt (e.g. the essential benefits). But the Obama plan relied heavily on the insurance industry, which displeased his many single-payer and progressive supporters who really wanted a "Medicare for All" approach.

Ironically, even though the Obama plan delegated more to the states and kept the status quo of the insurance industry, it was still called a "government takeover."

Lesson #5 � Talk about health reform early and often. Sophisticated communication is critical.

Here is where both the Clintons and Obama made the same mistake. They both assumed that people were paying attention, cared about the issue, and that they didn't need a big budget to communicate the results. And they were wrong.

We tried to bring communication experts into the White House in 1994 to help devise a savvy strategy for communicating the Clinton plan. But there was suspicion about using any slick communication/marketing consultants and the effort failed. By the time the Clinton bill got to Congress it was widely misunderstood and opposed.

Even though the media and the Obama Administration talked and wrote pretty constantly about the Affordable Care Act throughout 2009 and 2010, the main points never seemed to sink in. The opposition to the ACA from the right wing was loud and simplistic � it built on and surpassed the Harry and Louise message. The ACA became "Obamacare" and hatred for Obama sucked the life out of any positive messages. Lies and distortions circulated on the internet in a constant stream of emails and Facebook postings. Social media made it much easier to communicate an anti-health reform message than was possible in the 1990s.

Although we have made a significant progress toward universal coverage in the U.S., there is still a lot to do to protect the ACA from its attackers. I hope what we have learned this time is that we must constantly reinforce the messages of health reform. There will be no rest for weary health reformers now!

Finding Out If Your Health Insurer Is Providing Value for Your Premiums

When hardworking Americans pay for health insurance for their families and themselves, most of what they are paying for should be medical care, not CEO bonuses, slick advertising or administrative costs. That is why one of the pillars of the Affordable Care Act is to help consumers get good value for their health insurance premium dollars.

The health care reform law holds health insurance companies accountable to consumers and ensures that consumers are reimbursed when insurers don�t meet a fair standard of spending premium dollars on care. Because of the new �80/20 rule� in the Affordable Care Act, insurance companies generally must spend at least 80 cents of every dollar you pay in premiums on your health care or activities that improve health care quality. If the insurer fails to meet this standard � the �medical loss ratio� � in any given year, it must pay its policyholders the difference. This could mean a rebate check or a reduction in future premiums for you and your family.

Under the health care law, nearly 13 million Americans are expected to benefit from $1.1 billion in rebates from insurance companies due by Aug. 1, 2012, because of the 80/20 rule. All insurance companies for the first time will send their policyholders a letter informing them of the rule and whether the insurer met the standard. Those that do not meet the 80/20 rule standard will inform consumers that they will receive a rebate.

Want to know whether your health insurance company is required to provide a rebate?� Today, on HealthCare.gov, we�re launching a new tool that will allow you to enter your state and health insurance company information and see the average rebate your insurer is required to pay. See the sample screenshots below:

But remember, that�s just an average, and you may see the �rebate� in a number of ways. These include:

A lump-sum reimbursement to the same account that was used to pay your premium if it was paid by credit card or debit card;A rebate check to you in the mail;A direct reduction in your future premiums; orYour employer using one of the above rebate methods, or applying the rebate in a manner that benefits employees.

Many Americans are working hard to provide for their families and they do not deserve to have their health insurance premium dollars wasted on excessive administrative costs and profits. The 80/20 rule is one of the many ways that the Affordable Care Act is making sure that millions of Americans get value for their premium dollars.

For a detailed breakdown of these rebates by state and by market, please visit
http://www.healthcare.gov/law/resources/reports/mlr-rebates06212012a.html

To learn more about the 80/20 rule provision in the Affordable Care Act, please see http://www.healthcare.gov/law/features/costs/value-for-premium/index.html

Self-fulfilling media narratives

How did one Supreme Court Justice � Chief Justice John Roberts � end up with the power to decide the fate of the Affordable Care Act? Blogger Maggie Mahar says we should look to the media for the answer.

Note to readers: I welcome reader comments and questions, and will try my best to reply in a timely manner. I ask only that you do your part to keep our discussion both reasoned and polite. � MM

Personally, I am delighted that Chief Justice Roberts voted to uphold the Affordable Care Act. But, I am troubled that the fate of U.S. healthcare turned on one man's opinion. This is not how things are supposed to work in a democracy.

Healthcare represents 16 percent of our economy. It touches all of our lives. If we don't like the laws our elected representatives pass, we can vote them out of office. The Supreme Court, on the other hand, doesn't have to worry whether its decisions reflect the will of the people. The Justices are appointed for life. This is why they are not charged with setting public policy.

How then, did the Court wind up with the power to affirm or overturn the ACA?

The media shapes our expectations

As I suggested when oral arguments began back in March, a "media narrative" drove the case to the Court � a fiction that caught on, in the press, on television, and in the blogosphere, where it began to take on a reality of its own. A handful of "state attorneys general and governors" saw "a political opportunity" and floated the idea that the law might be unconstitutional. The media picked up the story, repeated the heated rhetoric, and "fanned the flames … Before long, what constitutional experts thought was a non-story became a Supreme Court case."

These media narratives are based on what "that those in power and in the media have concluded is likely to happen," observes Lyle Denniston, known by some as the Dean of Supreme Court reporters.

Writing on Scotusblog.com, he observes: "One ‘narrative' about the health care law began building up in Washington, and perhaps beyond, right after the Supreme Court held its hearings in late March. The mandate, it was said, was going to be struck down, the government's lawyer had blown it, and the President was going to be deeply wounded politically over the loss of his treasured domestic initiative." Some media outlets were so persuaded by their own myth-making that initially, they reported that the Court had ruled against reform!

Denniston explains that once the story goes viral, the conventional wisdom is then repeated, over and over, until "often, it seems, such ‘narratives' become self-fulfilling."

He then points a "currently prevailing ‘narrative' that most of the country is stubbornly committed to the Tea Party's wish to limit the power of the federal government." The facts contradict the fiction: Tea Party Candidates have been "losing steam" in recent elections.

In April, a WashingtonPost/ABC poll revealed that support for the Tea Party among young adults had plunged to 31 percent � down from 52 percent in the fall 2011. Half of those polled said that the more they heard about the Tea Party, the less they liked it.

Tea Partiers claims that the Court's decision invigorated its base, but offer little evidence. As I reported onHealthBeat last week, polling suggested that the ruling lifted support for reform among Independents, while having little effect on Republicans.

Media props up Governors' threat to thwart ACA

Nevertheless, belief in the Tea Party' grip on the country is now leading many to suggest that because far- right conservatives "hate the poor," some states will turn down federal funding to expand Medicaid.

I doubt it. The money is too good. The Federal government would cover the entire cost for the first three years, 90 percent thereafter. Over eight years (2014-22) the Center on Budget Policy and Priorities calculates that state spending on Medicaid spending would increase by only 2.8 percent.

Moreover, as former CBO director Peter Orzag pointed out�yesterday on Bloomberg,�Medicaid expansion will reduce others state costs: "As the number of uninsured decreases, so does the cost of uncompensated care. In 2008, state and local governments paid roughly 20 percent of the hospital costs for uninsured people, according to an Urban Institute Study."

Tea Party Governors may threaten to opt out, but The Incidental Economist's Aaron Carroll observes they will "face enormous pressure from doctors, hospitals, pharma, etc." who now provide billions of dollars worth of uncompensated care. "They have pretty good lobbying groups," he adds."

And Medicaid dollars would translate into new jobs for hospital and lab workers � something state legislators cannot ignore.

But "that won't stop the media from breathlessly covering the [governors'] threats as reality" Carroll notes. "The ‘battle' will likely sell a lot of advertising." There, he puts his finger on why even moderate to liberal publications repeat the conservatives' fictions: the image of a governor shaking his fist at Washington sells newspapers.

Keep in mind these governors are not all-powerful. State legislatures will have a say. And, while the Tea Party Tide swept many candidates into office in 2010, some will be swept out in coming elections.

Commenting on upcoming gubernatorial races, healthcare economist Len Nichols recently toldKaiser Health News "Medicaid will be an issue anywhere Democrats have a chance to win," He named West Virginia, North Carolina, Washington state and possibly Missouri."

Next: How the Court's decision buys time for health reform.

Join Us for an Online Women’s Health Town Hall

As part of our focus on women�s health, the White House and the U.S. Department of Health and Human Services (HHS) would like to invite you to participate online in a Women�s Health Town Hall on Thursday, June 7, 2012. The event will be streamed live from the White House from 10 a.m. to 11:30 a.m. ET.�

The event will be an interactive, open dialogue about how the health care law, the Affordable Care Act, is improving the health of women and their families.�

Do you know how the law affects you, your mother, and your daughter?

Here are some highlights:

The law requires insurance companies to cover people with pre-existing conditions, and means the end of women being denied or charged more for coverage just because they�re women.It also zeroes in on ensuring access to preventive services like mammograms and blood pressure screenings by making them available without a co-pay.It strengthens the Medicare program by cracking down on fraud, waste and abuse and closing the prescription drug gap known as the �donut hole,� which means lower prescription drug costs for all seniors.

We encourage you to send us what you want to know about the law. Submit questions using the Twitter hashtag #WomensHealth or on the HealthCare.gov Facebook page.�

Participants include:

Valerie Jarrett, Senior Advisor to the President and Chair of the White House Council on Women and GirlsKathleen Sebelius, Secretary of Health and Human ServicesTina Tchen, Executive Director of the White House Council on Women and Girls and Chief of Staff to First Lady Michelle ObamaCecilia Mu�oz, Director of the White House Domestic Policy CouncilMayra Alvarez, Director of Public Health Policy, Office of Health Reform, Health and Human ServicesCaya Lewis, Counselor to the Secretary of Health and Human ServicesJudy Waxman, Vice President of the National Women�s Law CenterMargarita Bertsos, Health Editor of REDBOOKKelly Wallace, Chief Correspondent and Executive Director of Digital Video of iVillage

Mark your calendar!

Child CT scans could raise cancer risk slightly

LONDON(AP)�Children who get several CT scans have a slightly higher chance of brain cancer and leukemia in later life, though the risk is still small and probably outweighed by the need to get the test, researchers reported.

The use of CT scans has risen rapidly since they were introduced 30 years ago. For children, they're used to evaluate head, neck or spine injuries or neurological disorders.

International researchers studied nearly 180,000 patients under age 22 who had a CT scan in British hospitals between 1985 and 2002. They followed those patients until 2008. They found 74 of them were diagnosed with leukemia while 135 had brain tumors.

The scientists didn't measure the number of scans, which were mostly of the head, but looked at data measuring radiation doses from the scans. That's because the amount of radiation received by body parts such as the brain and bone marrow depends on the age and size of the patient.

The children who later developed leukemia or brain tumors were compared to a group of people who got a very low dose of radiation to the same parts of their bodies.

"CT scans are very useful, but they also have relatively high doses of radiation, when compared to X-rays," said Mark Pearce of Newcastle University, the study's lead author, at a press briefing Wednesday. He said CT scans were warranted in most situations but more needed to be done to reduce the amount of radiation.

Pearce and colleagues concluded the risk of brain tumors was tripled if children had two to three scans and the risk of leukemia was tripled with five to 10 scans. But he emphasized these were rare diseases and that the higher risk was still small. The risk of leukemia in children is about 1 in 2,000, so having several CT scans would bump that up to about 1 in 600.

"This (risk) is important, but the CT scan may be even more important," said David Spiegelhalter, of the University of Cambridge. He was not connected to the research.

"A judgment has to be made," he said in a statement.

The researchers noted that modern CT scanners give off about 80% less radiation than the older machines used in the study. Even at low doses, the radiation can damage genes that may increase the patient's risk of developing cancer later.

The study was paid for by the U.S. National Cancer Institute and the U.K. Department of Health. It was published online Thursday in the journal Lancet.

In the U.K., laws already require radiation from medical scans be kept as low as possible. In the United States, the government is pushing manufacturers to design new scanners to minimize radiation exposure for the youngest patients. And it posted advice on the Internet urging parents to speak up when a doctor orders a scan � to ask if it's the best option or if there's a radiation-free alternative � and to track how many their child receives.

The American College of Radiology warned that fears of radiation should not prevent parents from getting necessary scans for their kids.

"If an imaging scan is warranted, the immediate benefits outweigh what is still a very small long-term risk," Dr. Marta Schulman, chair of the group's Radiology Pediatric Imaging Commission, said in a statement. "Parents should certainly discuss risk with their provider, but not refuse care that may save and extend their child's life."

6 tips to mitigate cloud-computing risks

A recent Healthcare IT News survey found 48 percent of respondents planning to incorporate cloud computing into their health IT endeavors; 33 percent had already taken the plunge. But 19 percent answered with a "no," and according to Rick Kam, president and co-founder of ID Experts, one of their biggest fears could very well be security issues surrounding the cloud. 

"Cloud computing poses great risks for healthcare organizations, providers and entities responsible for safeguarding protected health information (PHI)," said Kam. "Healthcare entities are responsible under Federal HITECH and HIPAA regulations for the security of PHI in the cloud, though they often have little or no control where or how this data is moved, processed, or stored."

Kam outlines six tips to mitigate your cloud computing risks. 

1.Have business associates sign an agreement. According to Kam, covered entities should review the terms and conditions of a cloud provider's service-level agreement (SLA) to fully understand what their liabilities and risks are, and to be prepared to "absorb" those risks. "Detecting responsibility for a data breach among cloud managers, storage providers, and application developers is nearly impossible," he said. 

2.Limit user access. Larger, covered entities can offset dangers with a private cloud, said Kam. "They simply limit access to their own organization and subsets, such as business associates," he said. "Smaller covered entities are at the mercy of the cloud providers they can afford."

[See also: Cloud computing, digital signatures speed clinical trials.]

3.Research applications. Cloud-level applications present problems when it comes to security, said Kam. Not to mention, federal law requires access to PHI be controlled and limited to the "minimum necessary" data fields required for the purpose involved. "This means access is limited to only authorized and authenticated users, and that IT can log and audit all accesses," he said. "But this is a function of the application itself – and not all applications are designed to meet such security needs." Additionally, he continued, another issue remains with application interoperability and the inability to move data smoothly and securely between applications, leaving data at risk for exposure. "Developing standards and protocols for interoperability between two applications is important," said Kam. "[It's] up to the vendors but is often not a high priority."

4.Secure third-party validation. Smaller covered entities have little say in the way a cloud provider secures the PHI in their care, said Kam. In turn, one way to "level the playing field" is for clinics and other small covered entities to as a medical association or organization to create a certification for cloud providers that meets HITECH and HIPAA security requirements. A similar program already exists in the federal government, he pointed out: FedRAMP, or the Federal Risk and Authorization Management Program.

[See also: Clouds roll in to handle stratospheric capacity needs.]

5.Take an inventory of PII and PHI. According to Kam, an inventory provides a complete account of every element of personally identifiable information (PII) and PHI an organization holds with either paper or electronic format. "It helps determine how an organization collects, uses, stores, and disposes of its PHI," he said. "A PHI inventory reveals the risks for a data breach, so organizations can strategically protect PHI data and the best plan for a response based on real information." An inventory of PII and PHI, he added, as well as a privacy and security risk assessment, can help demonstrate compliance and mitigate the impact of a data breach. 

6.Develop an incident response plan (IRP). An IRP is an effective, cost-efficient way to help organizations meet HIPAA and HITECH requirements while developing guidelines related to data breach incidents. "The IRP designates roles and provides guidelines for the response team's responsibilities and actions during a privacy incident and provides instructions on determining notification requirements, including to regulatory authorities," said Kam.

CUREXO to launch new robotic surgery technology

SACRAMENTO, CA – CUREXO Technology Corporation announced Monday it will launch ROBODOC, its new robotic orthopaedic surgical application at the American Association of Orthopaedic Surgeons Annual Conference at the Sands Expo Center in Las Vegas, Feb. 25-27.

CUREXO officials said for the first time the company will display the accuracy of ROBODOC through active demonstrations of hip and knee replacement surgeries. In addition, Dr. William Bargar, assistant clinical professor at the Department of Orthopedic Surgery at the University of California Davis School of Medicine will be sharing his clinical experiences using the system.

"I am very pleased to share my experience using ROBODOC with interested surgeons at the AAOS," Bargar said. "The ROBODOC system allows surgeons to be very accurate. By preoperatively planning and being able to execute what you plan, you can now address issues such as implant fit and sizing, as well as off-set and leg length which are very important in terms of how the hip functions. The system allows you to not only plan the surgery better, but more importantly, you can execute the plan with sub-millimeter accuracy."

Brent D. Mittelstadt, president and CEO of CUREXO said, "While the System has been in use for many years having completed more than 24,000 surgeries around the world, now with our recent FDA clearance for total hip arthroplasty, we can offer our products to U.S. surgeons. In addition, we are further developing strong technical and marketing initiatives, and are prepared to move forward into the U.S. market."
 

CCHIT to add certification programs

CHICAGO – The Certification Commission for Healthcare Information Technology plans to expand its certification activities, Chairman Mark Leavitt announced Thursday.

Leavitt said the panel would, at the same time, remain flexible and responsive as the impact of the American Recovery and Reinvestment Act emerges.

"I believe this is the most important turning point in the history of health IT, and of our organization as well," he said. "With about $20 billion in funding and incentives for EHRs, health information exchange (HIE) and associated technologies - based on certification as a key qualification - we must be very flexible and responsive as federal health IT initiatives emerge and grow."
 
The nine new programs for launch in 2010 and beyond will extend certification to new specialties, settings and populations, while also opening the door to labeling that recognizes advanced capabilities in electronic health records as users become ready to adopt them, Leavitt said.
 
The board of commissioners voted to begin development of four programs - clinical research, dermatology, advanced interoperability and advanced quality - for launch in 2010. These are in addition to two areas previously scheduled for a 2010 launch - behavioral health and long-term care.

Four other certification programs were identified for launch in 2011: eye care, oncology, advanced security and advanced clinical decision support.

Development of obstetrics/gynecology certification was placed on a schedule for possible launch in 2012.

The final expansion roadmap and public comments are available. Volunteer work group recruitment for new and existing certification programs will begin on March 23 through April 20.
 

Public comment on e-prescribing security

A period for public comment continues through March 4 on security criteria and test scripts proposed for CCHIT's certification program covering stand-alone e-prescribing systems. The program, which has been in development since November 2008, is on an accelerated track separate from other certification development cycles as a result of legislation that provides Medicare bonus payments to clinicians using a qualified e-prescribing system with certain advanced features. The e-prescribing provisions were part of the Medicare Improvements for Patients and Providers Act of 2008.
 

HIE Certification Program

Two public comment periods begin Feb. 23 for elements of the HIE certification program, which is being introduced in phases during 2009. The public can comment on final test scripts for two transactions, a lab report document and a patient summary, through March 6. These are for the third phase of HIE certification, which began October 2008 by testing security and added in January the ability to receive and send a lab result. In addition, public comment will be taken through March 24 on a set of roadmap criteria for HIE certification in 2010 and beyond.

 

Physicians' EHR success recognized at White House event

WASHINGTON – Eighty-two healthcare providers from across the country will be recognized for their successful implementation of electronic health record (EHR) technology at Tuesday's White House Health IT Town Hall in Washington, DC.

At the town hall, senior White House and HHS officials will discuss progress and barriers on the road toward a national health IT system. The HHS Office of the National Coordinator for Health IT (ONC) is hosting a variety of healthcare professionals to share lessons learned in adopting, implementing, and meaningfully using EHRs.

Among the providers attending the meeting will be Jeff Hummel, MD, medical director for health informatics at Qualis Health and the Washington & Idaho Regional Extension Center (WIREC), and Gregory Reicks, MD, who will be representing Colorado Beacon.

Hummel has been an EHR user and advocate since 1998 and will be discussing leveraging health IT to promote better health in communities, including solutions to health IT barriers such as privacy and security and the challenges of building systems that can “talk to each other.”

One of these challenges is delivering a clinical summary to each patient after a visit, which is a requirement for meeting the first stage of meaningful use. Like most of his colleagues, says Hummel, “my effort to give my patients clinical summaries at the end of each visit were usually characterized by good intentions that were usually abandoned by mid morning each day in an attempt to stay on schedule.”

When he was handed an after-visit summary at the end of a visit to his own primary care physician, he was intrigued. “I spent the next year figuring out how to redesign my clinic workflow so that entering and updating the information for the clinical summary was built into the structure of the visit, and reviewing the clinical summary with the patient became the end of the visit ritual that my patients came to expect. Now over 80 percent of my patients receive clinical summaries, and I go home on time.”

Reicks, who has seen health IT transform care delivery at Colorado Beacon, said this is a "tremendous opportunity for someone in the trenches, working with practice transformation every day, to engage with high level staff who are involved in this transformational work at a national, big-picture level," Reicks continued, "I look forward to sharing the direct impact these federal dollars are having on my region and my practices."

In addition to discussing the meaningful use of EHRs, providers will likely share their insight on the important role that health IT programs, such as the Regional Extension Centers (RECs), have played in helping them implement EHRs. More than 132,000 primary care providers, almost half in the country are partnering with RECs to overcome the significant barriers that primary care and rural providers face in EHR adoption.

Geisinger, Merck partner on patient engagement

DANVILLE, PA – Geisinger Health System and Merck have embarked on a multi-year collaboration to develop new methods and technology to spur shared decision making between patients and physicians and to improve adherence to treatment plans and clinical care processes.

First up is the development of an interactive Web application designed to help primary care clinicians assess and engage patients at risk for cardiometabolic syndrome. Cardiometabolic syndrome is a clustering of various risk factors that put an individual at risk of developing type 2 diabetes and cardiovascular disease.

[See also: Geisinger cuts readmissions with tech help]

“We believe that healthcare is most effective when patients are active partners in their care,” said Glenn Steele Jr., MD, president and chief executive officer of Geisinger Health System. “Our collaboration with Merck will allow both organizations to leverage our individual expertise and joint resources to improve patient engagement, including finding new interventions to increase the likelihood that patients will adhere to their treatment plans.”

Teams from Geisinger and Merck will work together to improve patient adherence, increase the role of patients in making decisions to help manage their conditions, share information among extended care teams and improve clinical care processes.

“When you have two leading healthcare companies that share a commitment to improve health outcomes and are focused on fundamental problems that have plagued the healthcare system for years, the results have the potential to be transformative," said Mark Timney, Merck's president of Global Human Health – U.S. Market. "We're excited about the opportunity to work with Geisinger to address these critical areas."

[See also: Geisinger cuts readmissions with tech help]

The Web application and other care management solutions that Merck and Geisinger develop will initially be tested within the Geisinger system. Geisinger has been at the forefront of the development of innovative healthcare delivery models focused on improving adherence and developing methods to better engage patients. Merck has conducted scientific research to better understand the drivers of non-adherence and develop evidence-based interventions.

”A rapid learning process will be used to integrate, evaluate and improve the performance of each solution in primary care clinical settings," said Steele. "We will closely monitor patient acceptance, treatment adherence, and other metrics to determine which tools and solutions have the ability to improve patient care and are ready to be deployed on a broader scale.”

Recalculating The Health Bill In McAllen, Texas

iStockphoto.com

Branded: Hospitals in McAllen, Texas, may not be as costly as first thought.

Remember McAllen? It's the Texas border town that became synonymous with wasteful medical spending during the nation's big health care debate. Even Barack Obama was talking about it.

In part because of McAllen's bad reputation, based on studies by the Dartmouth Atlas, Congress ended up instructing Medicare to reward hospitals that provide care efficiently, and take money away from those where patients end up getting a lot more tests, doctors' visits and procedures.

In an ideal world, the thinking went, patients with the same health and diagnosis should cost the same to treat � especially since Medicare pays set fees and doesn't haggle with providers the way private insurers do.

Fast forward two years later, and the government has identified hundreds of hospitals where Medicare patients are incurring especially high or low bills. Hospitals around McAllen, it turns out, aren't as terrible as they were made out to be, according to Medicare's calculations of how much it spent for the average patient from three days before admission to a month after discharge.

 

Look at Doctors Hospital at Renaissance, which was singled out in the influential New Yorker article by Atul Gawande that popularized the Dartmouth findings. The average patient from Doctors Hospital cost Medicare $18,708, 4 percent more than the national median per patient payment of $17,988.

Sure, treatment of patients at Doctors was more expensive than those at 2,555 hospitals in the nation. But the costs to Medicare were the same or less than those for patients at 790 hospitals. Medicare paid as much for the average patient at Doctors as it did for patients at MedStar Georgetown University Hospital in Washington, D.C., Florida Hospital in Orlando or Wyoming Medical Center in Casper.

Hospitals in other regions look much worse than McAllen, where the priciest hospital � South Texas Health System � cost Medicare 7 percent more than the median. In Las Vegas, patients at 14 of 16 hospitals cost Medicare 9 percent or more above the national median. Los Angeles has hospitals whose patients cost Medicare 30 percent or more above the national median.

The Medicare data can pinpoint differences between hospitals wherever they might be � across the country from one another or right next door. Los Angeles Community Hospital's patients cost Medicare $24,644, which is $7,000 more than it cost for Ronald Reagan UCLA Medical Center's patients. If Medicare's calculations are right, there may be a little bit of McAllen in a lot of places.

Healthcare IT slated for $19B in proposed stimulus package

WASHINGTON – Congress is expected to approve $19 billion toward health information technology, with $17 billion allotted to incentives and $2 billion to jump-start healthcare IT adoption, according to a Wednesday night draft of the stimulus package.

The original House version of the bill designated $20 billion for healthcare IT, with the Senate setting aside $22 billion.

The $789 billion conference agreement between the House and Senate versions of the American Recovery and Reinvestment Act (H.R. 1) still faces potential amendments before a final vote, and some healthcare provisions of the bill were not scored as of Wednesday night.

Speaker of the House Nancy Pelosi (D-Calif.) said a final vote is expected before Saturday.

The conference agreement includes measures to codify the Office of the National Coordinator for Health Information Technology (ONC) and establish an open and transparent process led by the national coordinator to develop standards by 2010 that allow for secure nationwide electronic exchange of health information.

It also would improve and expand current federal privacy and security protections for health information, such as requiring that an individual be notified if there is an unauthorized disclosure or use of his or her health information and requiring a patient's permission to use his or her personal health information for marketing purposes.

Medicare and Medicaid HIT provisions in the bill include funding for the adoption and use of health IT, such as electronic health records by providers who serve Medicare and Medicaid patients. It would provide temporary bonus payments ranging from $44,000 to $64,000 for physicians and up to $11 million for hospitals that meaningfully use electronic health records.

The bill supports Medicare and Medicaid incentive payments for critical access hospitals, federally qualified health centers, rural health clinics, children's hospitals and others and phases in Medicare payment penalties for physicians and hospitals not using electronic health records starting in 2014. It seeks a 90 percent HIT adoption rate for physicians and 70 percent for hospitals for using electronic health records and would generate savings of more than $12 billion through improvements in quality of care and care coordination and reductions in medical errors and duplicative care.

Microsoft CEO Steve Ballmer sent a letter to Congress urging quick passage of the bill.

"We believe information technology can help create a connected health system that delivers predictive, preventive and personalized care – a system that will improve the health of Americans and help control healthcare spending," he said. "Government support for rapid adoption of information technology is essential and measurable outcomes are needed to help the Administration and Congress achieve the goals of increased access, lower healthcare costs and improved quality of care."

New mobile diabetes management solution for healthcare unveiled

CLARK, NJ – The first commercial trial of mPRO Care, launched by Mobile Health Tech at Clarkstown Medical Associates, PC in New York, touts a two-way mobile diabetes solution that provides automated reminders and accepts readings using standard cell phones on all major U.S. service providers.

mPRO Care was developed to help improve patient medication and treatment compliance for improved healthcare outcomes and reduced cost of care for patients with chronic conditions such as Diabetes, Coronary Artery Disease and Hypertension, Asthma and Obesity.

There are currently over 23 million diabetics in the U.S., about 8 percent of the total population, with approximately 2 million new diabetics diagnosed each year.

Clarkstown Medical Associates, an internal medicine practice, is offering mPRO Care for its diabetes patients, in this trial, to evaluate its effectiveness in helping manage this hard to control disease.

The solution sends custom tailored medication reminders, motivational and behavioral trigger messages, and condition reading requests to patient cell phones in the form of text messages (SMS). Diabetes patients text back their blood sugar readings which are captured and plotted on a patient diary card graph in a secure portal for online access by either patient or physician.

"In today's mobile lifestyle, it has become increasingly difficult for many patients with chronic conditions to be medication and treatment compliant," said Howard Feldfogel, MD, CMA partner and chief of medicine at Nyack Hospital. "The mPRO Care system offers potential to help patients improve their compliance and management of diabetes and other chronic conditions."

Bob Gold, president of Mobile Health Tech, said, "Because the solution is software as a service (SAAS), there is no hardware or software to install. In a matter of hours, a medical practice can begin to use mPRO Care to enhance patient care, reduce costs and improve outcomes."

The Big Three Automakers Push For Single Payer!

…In Canada.

Please note that this letter was signed about ten years ago. But we need to remind them of this with the ACA ruling fast approaching.

The Big Three automakers, GM, Chrysler and Ford along with the Canadian Autoworkers pushed the Canadian government to strengthen their single payer system.

“The public health care system significantly reduces total labour costs for automobile manufacturing firms, compared to the cost of equivalent private insurance services purchased by U.S.-based automakers; these health insurance savings can amount to several dollars per hour of labour worked.

Publicly funded health care thus accounts for a significant portion of Canada’s overall labour cost advantage in auto assembly, versus the U.S., which in turn has been a significant factor in maintaining and attracting new auto investment to Canada.”

This is a complete slap in the face to the Republicans and some conservative Democrats who say it will hurt business. The automakers urged the Canadian government to fix the problems in the system that was caused by underfunding the program.

“Canada’s publicly funded health care system is now facing demographic, technological, and fiscal pressures. The erosion of publicly funded health care � through measures such as the delisting of currently-covered services, the imposition of user fees, the failure of the public system to keep up with the changing nature of health care, and new costs such as prescription drugs and home-care, � will impose significant costs on automotive employers and undermine the attractiveness of Canada as a site for new automotive investment.”

In fact these corporations will even endure higher taxes if necessary saying,

“To this end, General Motors and CAW-Canada jointly urge the federal and provincial governments to take appropriate actions to preserve the public health care system, secure its funding base, and modernize the range of services which it covers.”

So with this joint letter to Canada, the Big Three automakers have given progressives that ammunition to fight back against the tall tale that universal healthcare is bad for business. If it was, why would they be pushing for it to be stronger.

Read the entire letter here.

Convenience And Efficiency Fuel Boom In Retail Clinics

Enlarge Mike Derer/AP

Shanda Johnson, right, a nurse practitioner, interviews patient Bill Gilligan at a MinuteClinic at the CVS drug store in North Brunswick, N.J.

Mike Derer/AP

Shanda Johnson, right, a nurse practitioner, interviews patient Bill Gilligan at a MinuteClinic at the CVS drug store in North Brunswick, N.J.

For years, there's been a debate about how walk-in clinics at stores fit into the health care mix. Are they an adequate substitute for a visit to the doctor?

Through it all, the number of clinics has kept growing, numbering 1,355 at the beginning of 2012, a 10.4 percent annual increase, according to consultants Merchant Medicine.

MinuteClinic, a division of CVS Caremark and the largest clinic operator by far, is on track to nearly double the number of clinics it operates to 1,000 by 2016.

The companies expect plenty of demand. "We have a primary care shortage," says Tom Charland, CEO of Merchant Medicine. The operators of clinics, he says, are "betting on the extra capacity they have with their nurse practitioners, who in many states practice with the full authority of a doctor."

 

In addition, by expanding the number of MinuteClinics, which are located inside CVS drugstores, the company increases foot traffic and potential sales of medicines and other merchandise.

There's another big factor in walk-in clinics' favor, says MinuteClinic President Andrew Sussman, in an interview about plans for the clinics. A clinic can provide care at less expense than a doctor's office, urgent care center or hospital emergency room, he says.

A 2009 study by researchers at the Rand Corp. found that the cost to treat three common illnesses � sore throat, ear infection and urinary tract infection � was at least 30 percent lower at a walk-in retail clinic than in other settings.

A walk-in clinic visit, including follow-up care, cost $110, on average, according to the study. That compared with $156 at a physician's office, $166 at an urgent care clinic and $570 at an emergency department. The quality of care was at least as good in a retail clinic as in other settings, the study found.

To be sure, not all clinics succeed. Some close, even as others open up. Merchant Medicine's June report on the state of the industry put the total number of clinics at 1,357, a decline of of eight from the previous month.

Even so, clinics' ability to provide routine care cheaply may make them especially attractive to hospitals and physicians that are forming accountable care organizations, say experts. Under these alliances, providers agree to take responsibility and get paid for keeping a group of people healthy rather than providing services a la carte. They share in any cost savings they achieve.

"If physicians are being paid not by the volume of services but on keeping people healthy, then they might embrace retail clinics," Charland says.

If the individual mandate’s struck down, what next?

In Sunday's edition of the New York Times, blogger Maggie Mahar responded briefly to the question, "What would the future hold if the Supreme Court strikes down the most controversial part of the health care law, the individual mandate?" We asked Mahar to elaborate on the question in this post.

Betting the individual mandate will be upheld

If the Affordable Care Act's individual mandate is ruled unconstitutional by the Supreme Court this month, Maggie Mahar says, the government will have to take a carrot-and-stick approach to attracting healthy Americans to buy individual insurance - and it will likely have to focus much more on carrots.

Ezekiel Emanuel says he has been betting on how the Supreme Court will decide the case challenging the constitutionality of the Patient Protection and Affordable Care Act�(PPACA).

Speaking at the annual meeting of the Jewish Social Policy Action Network in Philadelphia not long ago, Emanuel, who served as Special Advisor on Health Policy to the Obama administration when the bill was being drafted, confided that he has placed five wagers expressing his optimism that "the mandate will survive" along with the rest of the legislation.

"I think the vote will be 6:3 in favor with Kennedy and Roberts voting for."�There is "No doubt it is constitutional," he declared. "Legally, this is an open and shut case."

Emanuel, now chair of the Department of Medical Ethics and Vice Provost for Global Initiatives at the University of Pennsylvania, also revealed that he recently had dinner with Supreme Court Justice Antonin Scalia. Emanuel says Scalia will not vote for the reform bill. (No surprise there.)

For reasons I have explained in earlier posts here and here, I tend to share Emanuel's optimism. Nevertheless, I could easily be wrong.

As Emanuel observes, there remains the danger that the Justices will overturn the mandate. In that case, the vote "will be 5:4 against. If that happens, the country will have bigger problems because then it will be a partisan ruling along party lines," he noted, referring to polls showing that the American public is losing confidence in the integrity of the Supreme Court as an institution that stands above the political fray.

Fat carrots and skinny sticks

If the Justices do declare the mandate unconstitutional, what happens next? Will this spell the end of reform? Absolutely not.

The goal of the mandate is to draw more healthy people into the insurance pool, so that the cost of care when we become sick can be spread over a larger group. But the mandate is only one of many provisions in the PPACA that makes health insurance more attractive and more affordable.

Here are some of the "carrots" that should draw people into the pool:

Under the law, middle-income and low-income families purchasing their own insurance will receive tax credits to help them pay premiums. The subsidies will be calculated on a sliding scale for households with income up to four times the poverty level ($92,200 for a family of four and $44,680 for a single person).The PPACA limits how much insurers can ask patients to pay out-of-pocket.Insurers selling policies to individuals and small groups will have to cover all "essential benefits." No more "Swiss cheese" policies filled with holes.Insurers won't be able to hike your premiums because you're sick.They also won't be able to charge you 30 percent more simply because you are a woman.When covering a large group, insurers must pay out 85 percent of the premiums they collect for medical care. When insuring a small group, administrative costs are higher, so they can keep 20 percent. If they don't spend the required percentage of premiums on care, customers will receive refunds.There will be no co-pays for preventive care, and the deductible will not apply.

These provisions should encourage many young, healthy Americans to purchase insurance. Research shows that younger people don't buy insurance � not because they think they're invincible, but because they can't afford it. Subsidies will help many of them.

Making the hard sell

But the majority of Americans are totally unaware of the ways that reform makes insurance more affordable and more attractive.�This is why Washington & Lee Law Professor Timothy Jost suggests that if the mandate is overturned, reformers should launch "an aggressive, televised marketing campaign." As Jost explained to me in a recent phone interview, "if you really look at who is subject to the mandate, a lot would have every reason in the world to get insurance, and no reason not to even if there is no mandate."

Would the carrots be as effective as the financial penalties in persuading healthy people to buy insurance? Probably not. Many observers argue that without the penalties, people just won't sign up ��no matter how many carrots you dangle under their noses.

I'm not convinced. It's impossible to predict human behavior, especially over a period of years. It remains to be seen how younger Americans will respond to the tax credits, and the rules that require insurers to offer more comprehensive protection, including maternity benefits and preventive care without co-pays.

Moreover, if you read the PPACA, the mandate was a pretty skinny stick. Those who oppose the mandate object that it "forces" Americans to buy insurance. But the truth is that in 2014, someone who decides to opt out would pay a fine of just $95 or 1 percent of taxable income ��whichever is higher � up to $285 per household.

This hardly constitutes "force." Even in 2016, when the penalty peaks, it amounts to only $695 or 2.5 percent of taxable income, up to $2,086 per household ��much less than the cost of insurance.

No question, if the mandate is eliminated, fewer people will be insured. But if reformers do a good job of communicating the benefits of reform, they could draw millions into the pool.

Losing the mandate may not be nearly as great a blow to reform as some suggest.

Note to readers: I welcome reader comments and questions, and will try my best to reply in a timely manner. I ask only that you do your part to keep our discussion both reasoned and polite. � MM� ��

Virtual teaching hospital aims to transform medical training

LEICESTER, England – A computer system enabling medical students to practice diagnosing and managing patients in simulations using real patient data is being developed in an interdepartmental collaborative project between UK-based Leicester Medical School and the Computer Science Department at the University of Leicester.

The software development, led by Professor Reiko Heckel in collaboration with Dr John Barry Omara, will improve supervision of medical students during their clinical placements and provide feedback on their diagnoses and treatment choices through a Web-based medical decision support system.

The way it is designed to work is that in simulated context, medical students will talk to patients and put the clinical symptoms signs and laboratory or radiological data into the system, which then makes suggestions as to possible diagnoses. The students then have to interpret these suggestions and give reasons for their conclusions.

The project grew from an idea from Dr Omara, part-time lecturer at the School of Medicine, to improve healthcare in rural areas of Africa, and has evolved through a number of past and on-going projects by computer science students. In its present form as a training tool for medical students, it will not be used to treat hospital patients.

The "Virtual Teaching Hospital System" project is carried out in cooperation with Dr Omara and in consultation with the Department of Medical and Social Care Education.

Professor Heckel said: "This is an ongoing series of group projects for second-year computer science students. Five groups of six to eight students each work on the project for one term. We are about to begin another round of group projects this winter to extend and improve the system and we will carry on offering it as an option to our students as long as there is a significant amount of work to do on it.

Dr Omara said: "The project, when implemented, will make it easier to explain and teach the complex process involved in making clinical diagnosis (The Clinical Thinking Process)."

Dr Jonathan Hales, Department of Medical and Social Care Education, said: "The value of the system lies in the way the VTHS can be used by medical students to explore 'what if' scenarios - i.e. 'what if this same patient presented with the same symptoms and signs but also with a temperature (or, but without the abdominal pain)?' The value of the system does not therefore lie solely in its ability to come up with useful differential diagnoses, but in its educational capacity, when used by a thoughtful, questioning, exploratory student."

Convenience And Efficiency Fuel Boom In Retail Clinics

Enlarge Mike Derer/AP

Shanda Johnson, right, a nurse practitioner, interviews patient Bill Gilligan at a MinuteClinic at the CVS drug store in North Brunswick, N.J.

Mike Derer/AP

Shanda Johnson, right, a nurse practitioner, interviews patient Bill Gilligan at a MinuteClinic at the CVS drug store in North Brunswick, N.J.

For years, there's been a debate about how walk-in clinics at stores fit into the health care mix. Are they an adequate substitute for a visit to the doctor?

Through it all, the number of clinics has kept growing, numbering 1,355 at the beginning of 2012, a 10.4 percent annual increase, according to consultants Merchant Medicine.

MinuteClinic, a division of CVS Caremark and the largest clinic operator by far, is on track to nearly double the number of clinics it operates to 1,000 by 2016.

The companies expect plenty of demand. "We have a primary care shortage," says Tom Charland, CEO of Merchant Medicine. The operators of clinics, he says, are "betting on the extra capacity they have with their nurse practitioners, who in many states practice with the full authority of a doctor."

 

In addition, by expanding the number of MinuteClinics, which are located inside CVS drugstores, the company increases foot traffic and potential sales of medicines and other merchandise.

There's another big factor in walk-in clinics' favor, says MinuteClinic President Andrew Sussman, in an interview about plans for the clinics. A clinic can provide care at less expense than a doctor's office, urgent care center or hospital emergency room, he says.

A 2009 study by researchers at the Rand Corp. found that the cost to treat three common illnesses � sore throat, ear infection and urinary tract infection � was at least 30 percent lower at a walk-in retail clinic than in other settings.

A walk-in clinic visit, including follow-up care, cost $110, on average, according to the study. That compared with $156 at a physician's office, $166 at an urgent care clinic and $570 at an emergency department. The quality of care was at least as good in a retail clinic as in other settings, the study found.

To be sure, not all clinics succeed. Some close, even as others open up. Merchant Medicine's June report on the state of the industry put the total number of clinics at 1,357, a decline of of eight from the previous month.

Even so, clinics' ability to provide routine care cheaply may make them especially attractive to hospitals and physicians that are forming accountable care organizations, say experts. Under these alliances, providers agree to take responsibility and get paid for keeping a group of people healthy rather than providing services a la carte. They share in any cost savings they achieve.

"If physicians are being paid not by the volume of services but on keeping people healthy, then they might embrace retail clinics," Charland says.

Countdown To The Supreme Court's Ruling On Health Care

Enlarge Alex Wong/Getty Images

People wait outside the Supreme Court last week for word on the fate of the federal health overhaul law.

Alex Wong/Getty Images

People wait outside the Supreme Court last week for word on the fate of the federal health overhaul law.

Anticipation has reached a fever pitch, and the waiting is almost over.

This week, the Supreme Court is almost certain to issue its decision on the constitutionality of President Obama's health care law. The decision could have far-reaching implications for the legal landscape, the nation's health care system and even the Supreme Court's legacy.

The court will have to answer four distinct legal questions raised by the challenge to the Affordable Care Act. The threshold question is whether the court may decide the case now, or whether it must wait until 2015, when all of its provisions � including the individual mandate � have gone into effect.

 

At oral argument in March, the justices seemed uniformly inclined to decide the case now.

The second question for the court is the one most politicians and political pundits have focused on exclusively: Is the provision requiring virtually all Americans to have health insurance constitutional?

The court will have to determine whether Congress exceeded its powers to regulate commerce by creating a mandate that would force most Americans who aren't otherwise insured to buy coverage,

Related NPR Stories Judging The Health Care Law June 28, 2012

Third is the question of the law's expansion of Medicaid, which adds 17 million more people to the rolls. The states challenging the overhaul law have argued that even though the federal government will pay almost all of the cost, it is still impermissibly coercive.

Finally, the court will decide whether, if any part of the law is unconstitutional, it can be separated out, or whether the entire law has to be invalidated.

How the court will settle these various legal questions is only the first uncertainty. The entire health care system, including insurance companies, is anxiously awaiting a decision that is almost certain to have fundamental ramifications for their business.

Indeed, the only way the court's ruling would have no effect on the health care system would be if the law were upheld in its entirety.

Even striking down just a small piece could have numerous consequences —both intended and unintended.

Many provisions of the law are extremely popular, such as a ban on insurers denying coverage because of pre-existing conditions and the rule, already in place, that allows adult children to remain on their parents' insurance plans until age 26. If the law is struck down,therewill be enormous pressure to keep those provisions in place.

The problem is that without the mandate, insurance companies say they could not afford to accept all comers, especially those with previous medical conditions. As for including adult children on parents' policies, that too could be problematic, for different reasons.

True, some of the biggest insurance companies have vowed to keep this provision in place, but if the court invalidates the law, those additional benefits might be taxable. The law waived a key tax provision to ensure that health insurance benefits are not taxed as income. But without the law, parents may have to pay income taxes on those benefits and employers could face higher payroll taxes.

This scenario would cause "utter confusion" for employers, explained James Klein, president of the American Benefits Council, which represents large-employer health plans and companies that provide services to those plans.

"Because after all, there would be some 24-year-old kids who are legal dependents, for whom there would be no income tax owed. And then there would be others for whom they're not legal dependents and so there would be tax that would be owed," he said. "It would be extraordinarily confusing."

The decision could also have a big impact on the court's legacy. If it strikes down the mandate as exceeding Congress' powers under the Constitution, this would be the first time since the New Deal that the court has invalidated a major piece of regulatory legislation.

Already, the case has exposed a major shift in conservative legal thinking. For the last half-century, conservatives, and particularly congressional Republicans, have championed the idea of judicial restraint, arguing that the courts should usually defer to the elected branches. But now, conservatives are explicitly calling for judicial activism. Conservative columnist George Will, for example, wrote this week that "judicial deference to elected representatives can be dereliction of judicial duty."

Can SEIU Help Vermonters Win Single Payer?

While the nation waits for an overdue Supreme Court decision that will decide the fate of President Obama�s Affordable Care Act, another health care drama with wide implications for universal health care is just starting in Vermont.

Prodded by a strong grassroots movement, the Vermont legislature voted last year for a single-payer state health care system where every citizen will eventually be eligible for publicly funded health care.

The new system will take five or six years to fund and implement, however, between phasing out existing insurance arrangements, overcoming legal obstacles, dealing with provisions of the Affordable Care Act, and finding the money to pay for it all.

Meanwhile, the local business community, private insurance companies, and right-wing PACs have regrouped and counterattacked, with non-stop advertising. They�re doing their well-funded best to make sure that single payer never happens in this state or any other. They know that a lot can change, politically and in the state budget, between now and final implementation of Vermont�s health care law, particularly in a state with two-year gubernatorial terms.

Business-Backed Counterattack

Last year�s overhaul was backed by Governor Peter Shumlin, a multimillionaire businessman who faces re-election this year after narrowly winning office in 2010.

Single payer continues to poll well in the state, despite its lack of concrete benefits for even one Vermonter so far�a weakness that conservative opponents are exploiting in their campaign of disinformation and fear-mongering. A recent poll conducted by several Vermont media found nearly 48 percent of those surveyed still favor single payer; 36 percent are opposed.

Shumlin is likely to defeat GOP candidate Randy Brock, whose top adviser is Darcie Johnston, founder of Vermonters for Health Care Freedom, a key conduit for anti-single-payer propaganda, financed by business.

But even if Brock and fellow Shumlin critic Wendy Wilton, who is running for state treasurer, lose this fall, progressives fear they will spread doubt about reform. As a centerpiece of her campaign, Wilton predicts that Vermont will be running budget deficits above $2 billion by 2018 if �Green Mountain Care� becomes a reality. Right-wingers also warn about the new taxes everyone will be required to pay.

�Air War� for Single Payer?

To counter conservative attacks, Shumlin and friends will soon unveil �Vermont Leads: Single Payer Now!,� their own vehicle for advertising and door-to-door canvassing in favor of Green Mountain Care. This new addition to the existing constellation of health care reform groups will spend more than $100,000 on a six-month drive �to engage and activate Vermonters through media and grassroots organizing.�

According to Peter Sterling, an experienced local political operative who was just named director of the group, �more is expected in 2013 for TV ads,� when the legislature reconvenes.

Unfortunately, Vermont Leads doesn�t draw on the formidable grassroots network created since 2008 by the Vermont Workers� Center�and seems designed to bypass the group, which is the state�s most influential single-payer advocate. The VWC�s �Health Care Is a Human Right� Campaign has been widely credited, both locally and nationally, with spearheading the multi-year community-labor mobilization needed to pass the legislation last year.

While working closely with Shumlin and key Democratic legislators to achieve that goal, the Workers� Center has also been willing to sound the alarm and swarm the statehouse when things got off track. Last May, for example, VWC organizers brought more than 1,500 Vermonters to the Capitol to thwart a bid by legislative insiders to exclude undocumented workers from the scope of the law.

The VWC has long received strong backing from unions with members who live and work in Vermont�like the United Electrical Workers, Communications Workers, and Vermont Federation of Nurses and Health Professionals, which bargains for most unionized health care workers in the state.

In contrast, Vermont Leads is being funded by just one union�the 1.9 million-member Service Employees, which has no members working in the state and failed to affiliate the still-independent Vermont State Employees Association more than a decade ago.

�Working with People Who Have Money!�

For Vermont Leads� volunteer board members, SEIU�s sudden arrival, with a wad of cash large by local standards, is cause for some rejoicing. One new recruit is former state AFL-CIO President Jill Charbonneau, a postal worker, who noted in an email to friends that she was �not used to working with people who have money!�

Another Vermont Leads enthusiast is Middlebury College anthropology professor Ellen Oxfeld, who has campaigned under the banner of a small group known as Vermont for Single Payer. SEIU funding is �a gift from heaven,� she told me. �We want to combat the lies, keep up the momentum for single payer, and organize around the financing package� to be adopted by legislators next year.

Deb Richter, leader of Physicians for a National Health Program in Vermont, gave similar reasons for joining Vermont Leads. �We�ve got six more years of fighting to do to keep this on track,� she said. �We now have the ability to spend more for ad campaigns and literature drops. Instead of using existing groups, it made sense to have this one be a separate entity.�

As for SEIU, �they�ve always been single-payer supporters,� Richter asserted. �That�s what I�ve been told.�

Looking a Gift Horse in the Mouth?

Others in single-payer circles wonder whether this particular gift horse could become a Trojan horse that will weaken Vermont�s movement for health care as a human right.

SEIU�s sudden appearance in the state is worrisome to union friends and political allies of the VWC, now in the middle of its own fundraising drive to support an energetic staff of eight who coordinate the work of scores of volunteers around the state.

The VWC is enlisting nationally known figures for a public statement of support titled �Vermont Can Lead the Way.� In an open letter soliciting 1,000 such endorsers, VWC leaders argue that �we will never be able to outspend giant healthcare profiteers and other big money groups in an �air war.� But we can out-organize them on the ground!�

SEIU�s lack of any members on the ground, plus its unhelpful role nationally in health care reform from the Clinton to the Obama eras, has led some labor activists to question its motivation for becoming a single-payer sugar daddy, virtually overnight.

One explanation involves SEIU�s competition with AFSCME to represent personal care attendants in Vermont. Neither union can gain 5,000 new members in that workforce without Shumlin and the legislature agreeing to create a new homecare bargaining unit, plus some sort of card check or election mechanism for union recognition by the state.

And if Shumlin, in the meantime, needs to do some back-pedaling on single payer�under pressure from business interests�SEIU could easily provide political cover for him, local activists fear. For the union, the quid pro quo would be the governor favoring SEIU over AFSCME to represent homecare workers.

Bad Record Elsewhere

Elsewhere in the U.S. and at the federal level, SEIU has undercut other unions� attempts at single-payer legislation (even though its own affiliates have passed many pro-single payer resolutions over the years).

In California, SEIU lobbied against other unions� attempts for single-payer legislation. Then-SEIU President Andy Stern cooked up a plan with Governor Arnold Schwarzenegger that would have required all Californians to buy private insurance but didn�t control the cost of that insurance and set no minimum standards for coverage. Included in the bill was a fund for homecare workers’ health benefits�to be administered by SEIU.

�SEIU played the leading advocacy role and ultimately the lead compromise role on that bill,� California Nurses Association staffer Michael Lighty recalled. “Stern went behind the back of the California State Fed to cut the deal. But it didn’t even pass in the state senate. It lost the backing of labor. It could not withstand the scrutiny.�

In Massachusetts, SEIU affiliates have done little or nothing to build Mass-Care, the main single-payer advocacy organization. Instead, the union worked with Ted Kennedy, then-Governor Mitt Romney, and the coalition known as Health Care for All to enact the state system of mandated private insurance that became the model for the Affordable Care Act.

As one labor friend of Mass-Care notes, �SEIU has been completely absorbed with Romneycare. For them, it�s all about hospital financing, never about changing the system itself.�

Similarly, SEIU helped run interference for the Obama administration when it was working to keep single payer�and ultimately, any public option�off the table in 2009-2010.

Working with liberal foundations and other labor groups, SEIU helped raise $40 million for a group called Health Care for America Now. As David Moberg from In These Times reported, HCAN�s spending swamped that of single-payer groups, while �promoting a strategy closer to Obama’s proposal that would include employer-provided or individually purchased private insurance.�

In 2009, SEIU operatives even intervened at community forums in New Hampshire held to discuss the Affordable Care Act: they tried to prevent local PNHP supporters from distributing pamphlets on single payer.

SEIU�s Man with a Plan

Further fueling suspicions about SEIU�s intentions in Vermont are the multiple hats worn by recently arrived national staffer Matt McDonald. His past assignments have included trying to keep 45,000 Kaiser Permanente hospital workers from fleeing SEIU in California and joining the National Union of Healthcare Workers. In 2010, McDonald was part of an organizing team that engaged in so much misconduct that the National Labor Relations Board overturned the results of that election.

McDonald set up Vermont Leads from scratch, made himself a board member, and hired Sterling as its director. Meanwhile, he is also masterminding SEIU�s attempt to create the new statewide bargaining unit for personal care attendants, an effort that wisely includes wooing advocates for the elderly and disabled who receive such services. (For details on AFSCME�s homecare worker organizing in Vermont, which started before SEIU arrived, see here.)

In response to an email seeking details on SEIU�s homecare organizing plans and the about-to-be-unveiled Vermont Leads, McDonald replied that the questions �threaten the dual goals of creating a single payer system here in Vt., and the eventual unionization of thousands of workers.�

Scramble for New Members

A slugfest between SEIU and AFSCME in Vermont would be a throwback to the frenzied spending contests waged by the same two unions over home-based workers in 2004-2005. In the process of obtaining �organizing rights� deals in Illinois for both childcare and homecare workers�and prevailing over AFSCME there�SEIU became labor�s biggest funder of Rod Blagojevich, the Democratic governor whose illegal �pay to play� schemes landed him in jail for 14 years.

As similar homecare or childcare units unravel in several states under hostile GOP governors, SEIU is now increasingly desperate for new members. A union that was growing by 100,000 annually in 2006-2008 has hit the wall, due to external enemies and its own internal dysfunction.

In 2011, SEIU registered a net gain of only 7,000 members and agency fee-payers, as compared to 59,000 the previous year. So 5,000 new dues payers in Vermont have become a more tempting prize than before, even if they require a costly brawl with an AFL-CIO union that already represents other public workers in the state.

For budgetary reasons, Vermont�s Democratic-controlled legislature balked at creating a new statewide bargaining unit for publicly funded day care providers earlier this year. This was a major, but hopefully not permanent, setback for the Teachers (AFT), the state�s largest AFL-CIO union.

But Shumlin�s passive role and the opposition of key Democratic legislators doesn�t bode well for AFSCME or SEIU doing much better in homecare, as long as the two unions remain divided.

Price of a Relationship

The prospect of a homecare union war is not appealing to others in Vermont labor, for multiple reasons.

�In my opinion, SEIU seems to be cultivating a direct relationship with our governor by loyally supporting his health care plan�including all the expected compromises and retreats that may lie ahead,� says Traven Leyshon, secretary-treasurer of the Vermont AFL-CIO. �This will create real problems for any of us pushing for a stronger, more progressively financed single-payer system than Shumlin favors.�

Ellen David Friedman, a founder of the Vermont Progressive Party and past organizer for the National Education Association in the state, agrees. �SEIU makes very short-term and opportunistic calculations,� David Friedman said. �They will help Shumlin get re-elected in exchange for legislation authorizing homecare unionization. My guess is that his position on single payer really doesn�t matter much to them, since they�ve never really fought for it anywhere else.�

State Senator Anthony Pollina, a Progressive Party leader, worries that the wrong kind of pro-single payer �air war,� funded and directed from out of state, may �encourage right-wing groups to come in and spend even more money.�

According to Pollina, �things could escalate into a media campaign that leaves citizens on the sidelines, just like past single-payer referendum campaigns that were lost in Oregon or California.� Like the Workers� Center, he believes that �progressive grassroots activists can �out-organize� the opposition on the ground but SEIU�s invasion could end up undermining this good work.�

Richter and Oxfeld both insisted they would never let this happen while they served as Vermont Leads board members. �Vermont is a small place,� Richter said. �If it turns out SEIU is trying to push us in a different direction, they won�t have the ground troops to pull it off.� According to Oxfeld, �if they really try to get in the way, I don�t see anyone on the board going along with it.�

Health Care History Repeats?

Three years ago, Michael Lighty from the CNA predicted that creation of a publicly funded model plan, providing universal coverage in an American state, would �move us closer to a single-payer solution� than the �public option� that labor wanted in the Affordable Care Act until President Obama nixed it.

But Lighty warned that �if you pass a plan that�s watered down and bad, you�ve squandered the political moment. You�re going to fuel the cynicism and distrust so many people already have in what can be accomplished in Washington.�

Health care reformers in Vermont are concerned that SEIU will eventually play the same role locally that it did nationally in 2009-2010. If that results in another squandered political moment�this time leaving Vermonters cynical and distrustful about what can be accomplished in Montpelier�the repercussions will be felt in every other state capital where progressives still hope to improve on the Affordable Care Act.

Steve Early is a labor journalist who started writing about Vermont politics when he was a Middlebury College student in 1968. He spent three decades as a New England representative for the Communications Workers, assisting members in Vermont and other states with strikes, contract negotiations, organizing, and health care reform activity. He is the author, most recently, of The Civil Wars in U.S. Labor, from Haymarket Books, and a longtime supporter of the Vermont Workers� Center.

Beacons lead healthcare quality 'revolution'

"We are really at a tipping point here; providers and patients alike have come to realize that the modernization of healthcare is long overdue and that we all have a role in its broad adoption."

So said Jason Kunzman, project officer for the Office of the National Coordinator for Health Information Technology, as he moderated the "Beacon Communities: Leveraging Health IT to Fuel the Quality Revolution" education event at the recent HIMSS 2012 Virtual Conference and Expo. 

The session featured presentations by officials from two Beacon Communities: Southeastern Minnesota (SE MN) Beacon Community and the Keystone Beacon Community of central Pennsylvania. They grappled with the "tipping point" referenced by Kunzman: how has health IT been fueling the quality revolution? Especially, how has it benefited these spotlighted health systems?

Southeastern Minnesota Beacon Community

Chris Chute, MD,, a principal investigator for the SE MN Beacon Community, discussed the IT running through the Beacon system. 

The unique peer-to-peer HIE integrated throughout the community has been central to the community's infrastructure, he said. "This is distinct from most health information exchanges where the health information is the central hub and people subscribe to it. What's different about Southeastern Minnesota Beacon is that we have open-source software – the ONC-provided NwHIN-connect software – that is deployed in each and every provider," Chute said. 

This diversion from a hub-and-spoke model ensures communication and engagement across providers, and the leveraging of a national model: "When we talk about provision of care in Southeastern Minnesota, we are really talking about an integrated network," he said, "and Beacon is the integrating element where all care providers are coordinating and engaged."

Along that strain, the community's public health providers utilize the Public Health Documentation System (PH-Doc) "that is an electronic medical record of public health services," Chute added. PH-Doc integrates information from public health services into the HIE network to outline "community views of ideal health information."

Running parallel to SE MN Beacon's HIE is a comprehensive CDR, said Lacey Hart, program manager for the SE MN Beacon Program. The depository allows for the tracking of clinical and population metrics in the area. To that end, researchers are able to monitor the community workflow and analyze where impacts are being seen. 

Hart stressed data gaps, too, as a key aspect of area metrics highlighted by the advanced repository. "We looked at our data early on - before the repository - and now the data repository is really an excellent way to hone in on where the data gaps exist."

One timely example: SE MN Beacon has been monitoring asthma and diabetes trends, and outlining the clinical measures used to counter the disease. Using the CDR, however, researchers snagged a data hole; "…One of the things we were missing was the patient data," said Hart. Using metrics from the CDR, the Beacon team developed patient centric data gathering tools. The data exchange is now integrated with information on patient lifestyles

Keystone Beacon Community

Like its sibling in Minnesota, the Keystone Beacon Community of Central-PA is using IT to drive care improvements. 

Geisinger Health System, a Pennsylvania-based health services organization, heads the Keystone HIE. The exchange connects 13 member facilities throughout the area. 

The HIE began as a pilot system with three organizations, said Geisinger Health System IT Director and Keystone HIE Director Jim Younkin. It's now linked between 34 organizations. "The services that are being provided through Keystone Beacon include the EHRs being connected," he said. "EHRs now have the ability to publish and consume documents directly from the health information exchange." 

The HIE includes patient and provider portal applications, and supports three distinct models of health exchange: the "pull model," the "send model," and the "push model," said Younkin. 

"We started with the pull model, which is really just using the portal to do a look-up of information," he said. It hinges on "the idea of having a centralized data repository for access by members of the community."

The direct mode allows messaging between site clinicians and patients. 

The push model will be rolled out this month, said Younkin: it allows clinicians "to subscribe to a patient through the health exchange, and then as activity occurs for that patient we can deliver alerts and notifications to those clinicians to inform them of certain activities."

With these various models and the portal applications supported by the Keystone HIE, Younkin says care capability is expanding in central Pennsylvania. 

Similarly, IT has been catalyzing patient provision in the SE MN Beacon Community through HIE and CDR technology. 

IT critical to achieving quality

The communities highlighted in the HIMSS virtual education event only strengthen the case for IT's critical place in fueling the quality revolution, said Kunzman. It's the essential ingredient, he said, in driving providers over that "tipping point" and in the right direction. 

"We are at the end of year two in a three-year journey. Our Beacon Community grantees have made great achievements," said Kunzman. "They've enhanced the role that safety-net providers play in the overall continuum of care, Beacon communities and technology vendors have formed new collaborations in order to introduce efficiency in bringing the most important functionalities to market…"

Vendor Notebook: AeroScout and Futura Mobility partner for RTLS

Futura Mobility has partnered with AeroScout to provide real-time location system (RTLS) technology to hospitals. With the partnership, officials say Futura Mobility will leverage AeroScout’s real-time asset management solutions that deliver location and status of mobile assets and equipment. Key components of the collaboration include temperature and humidity monitoring, patient flow and safety.

Allscripts announced that Summit Medical Group, the largest physician-owned multi-specialty practice in New Jersey, has signed a long-term contract for managed IT services. With Allscripts Managed Services, Summit will focus on its core mission of providing world class patient care while using IT to improve clinical, financial and operational outcomes, officials say.

HID Global announced the production release of its next generation EDGE EVO and VertX EVO controller platform that brings intelligence and decision-making to the door for advanced and highly customizable networked access control solutions. EDGE EVO and VertX EVO offer an open and scalable development platform for the deployment of a wide range of access control functionality, including remote management options, real-time monitoring, report generation and more.

triCerat unveiled the beta version of its Scanect software, a remote scanning technology for healthcare settings that speeds scanning without sacrificing quality or security.
 
SRS announced that Pittsburgh Bone & Joint Surgeons has selected the SRS EHR and PM to replace the system it originally purchased for its seven physicians. PBJS provides high-quality orthopaedic care to the Greater Pittsburgh area of Pennsylvania.

Allscripts announced that Evangelical Community Hospital, in Lewisburg, Pa., has selected its Sunrise EHR system. The hospital already uses Allscripts solutions for its outpatient electronic health record. The addition of the Allscripts Sunrise Clinical Manager solution will help the Hospital migrate its inpatient data and information to an electronic format and provide a seamless and integrated electronic information solution across the hospital, officials say.

Press Ganey Associates and the American Medical Group Association announced the launch of a survey designed to help accountable care organizations (ACOs) and high-performing health systems identify opportunities for improving both efficiency and quality. The AMGA-Press Ganey Coordinated Care Solution, assesses a patient’s entire episode of care and enables better management of population health to create positive patient outcomes and maximize shared savings.

Get Real Consulting announced the launch of the AARP Health Record. The application architected and developed by Get Real, is a secure web based solution designed to empower people over age 50 to manage and improve their own health. This application allows users to enter, store and edit their personal health information in a central location and to selectively share it with caregivers, family members, doctors and other healthcare providers.

InterSystems announced that it has entered into an agreement with Missouri Health Connection for InterSystems HealthShare to be the technology foundation for Missouri Health Connection’s (MHC) statewide health information network. MHC is the state-designated entity chartered to oversee development of Missouri’s statewide health information network.
 
Availity announced the launch of its suite of expanded clinical documentation capabilities, and that four major health plans, seven vendor partners, and multiple physician groups and hospitals are live and successfully utilizing these solutions across its network. The solution suite automates the costly, manual exchange of clinical information needed to support the revenue cycle, as well as emerging value-based payment models and quality improvement programs.

Outcomes Health Information Solutions announced the launch of MA365, a solution that actively drives quality results for Medicare Advantage plans year-round. Launched from a single data platform, MA365 is an integrated suite of solutions that identifies and resolves disparities in care for Medicare Advantage members with the goal of getting needed care for members while also impacting a Medicare Advantage health plan’s Star quality ratings.

MedeAnalytics announced the launch of its Employer Reporting Resource Center. As healthcare expenses have outpaced inflation and revenue growth, companies have struggled to understand the value of their relationships with full-service health plans. Created in response to growing interest by health plans looking to better serve their group and administrative services only (ASO) customers, this resource center has been created to serve as an educational service to the healthcare industry.

Pegasystems announced its next-generation product development and management solution that enables health plans to better meet industry and customer needs by reducing time to market for new insurance and wellness products amid growing healthcare complexity. Pega Product Composer System provides a customer-centric approach to developing and managing innovative healthcare products, supporting product design, approval, operational readiness and implementation.