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November 6, 2006

Washington Health Policy Week in Review Archive c825e055-396f-4b82-a230-5fe8842f3bf0

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A Major Milestone on the Path to Health Care Information Technology?

By John Reichard, CQ HealthBeat Editor

October 31, 2006 -- Saying it has reached a major milestone in the effort to harness the vaunted power of health information technology, a public–private advisory group announced an agreement Tuesday on standards for maintaining personal health data, transmitting clinical lab results, and managing disease outbreaks.

"Standards" are the key to realizing the potential of health IT to make a variety of medical data widely and easily accessible, easy to use, and understandable and to prompt physicians to use up-to-date treatments that provide superior care.

Agreeing on standards will allow doctors around the country to speedily access a patient's medical history, thereby avoiding faulty diagnoses and the expense of ordering duplicative tests. It will keep doctors from prescribing the wrong drugs and dosages, remind them to order preventive care and help them adhere to the most up-to-date guidelines for treating a wide variety of diseases.

It will allow proliferating medical information systems to "talk" to each other so data can be widely and easily shared—and so that hospitals and doctors will be willing to invest in them.

The standards accepted on Tuesday by the advisory group—known as the American Health Information Community (AHIC) —deal with only a slice of health IT's uses. However, their development established a process that will speed agreement on health IT standards in a wide variety of other areas, said John Halamka, chairman of the panel that forwarded the lab, personal data, and biosurveillance standards to AHIC.

AHIC's formal action on the standards Tuesday was to agree that they should be forwarded to the Department of Health and Human Services for consideration. President Bush issued an executive order in August that will require providers doing business with Medicare and other federal health programs to have health IT systems that meet such interoperability standards.

The standards mark "a small step in the total number of standards that need to be considered, but a very large step . . . in movement toward interoperability," said John Loonsk of the Office of the National Coordinator for Health Information Technology at an AHIC meeting on Tuesday.

Agreement on the standards represents "the essence of what the community is here to do," said its vice chairman, Dr. David Brailer. It "represents an enormous amount of work." Added AHIC Chairman and HHS Secretary Michael O. Leavitt, "I don't have words to tell you how profoundly important this is."

The effort to identify standards for clinical lab results transmission, maintaining personal health data, and conducting biosurveillance was carried out for AHIC by another public–private group, the Health Information Technology Standards Panel (HITSP), chaired by Halamka.

The panel identified some 30 standards it said should be used in the three areas after reviewing 700 possible standards developed by 261 organizations. Volunteers worked a total of 12,000 hours in assisting the effort.

The standards agreed to for reporting clinical laboratory data will make it easier to understand those results and thereby avoid duplicative and unnecessary testing, HITSP said. The standards also will make it easier to add lab results to electronic health records designed to record the entire medical history of a patient.

Other standards agreed to apply to "personal health records," which are under a patient's control and include only a subset of the data in an electronic health record. Personal health records are in part designed to make it unnecessary to fill out the clipboard of forms patients often encounter with each new visit to a doctor's office.

"Going to the doctor or hospital frequently requires filling out multiple forms," HITSP noted in a report forwarding the recommendations. "These forms collect information such as name, address, insurance, medications, allergies, etc. Then, when an individual requires laboratory work or other testing, the same information has to be collected again. A single electronic registration will make it easier for individuals to give their information and for clinicians to use it."

The standards also should ease inclusion in the personal health record of an up-to-date history of a patient's medication use. Most patients "do not know the specific medications and the exact dosages that have been prescribed to them, and often do not know their allergies," HITSP noted.

"In addition, clinicians do not always have consistent prescription information about the same individual nor do they have easy access to medication information directly from the patients. Too often, this results in errors or unnecessary treatments."

The biosurveillance standards are designed to foster use of systems to quickly detect and monitor disease outbreaks and to rapidly respond to them. They are intended to ease rapid transmission of disease data from emergency departments, doctors' offices, and clinics to public health departments.

AHIC also heard Tuesday from speakers who discussed how health IT could be used to disseminate advances in diagnostic testing and treatment based on the explosion in knowledge about "genomics"—the role of genes in triggering disease.

Electronic health records could be the pathway for introducing such medical advances, said Gregory Downing of the National Institutes of Health. Gene-based tests would enable predictions of the risk of developing a disease and develop genetic profiles that could be used to ensure that only highly effective treatments are used, he said.

But Alfred Berg of the University of Washington School of Medicine noted that primary care doctors, who would be a key force for incorporating the use of such tests in medical practice, are "relentlessly empirical."

Prompts to doctors in electronic health records to use such tests would have to be based on evidence that they improve clinical outcomes compared with current tests, he said. But clinical data linking the tests to better outcomes is lacking, he said. "The quantity and quality of information has been disappointing," Berg said. Although genetic testing holds "great promise," Berg said, "there will likely be few examples of genetic tests that meet standards for common use in typical practices in the next three to five years."

But other speakers emphasized that understanding a patient's genetic makeup is key to safe and sound diagnosis and treatment and that genetic testing is already a part of medical practice today. At Leavitt's prodding, AHIC agreed to form a work group to review standards in this area that would foster the inclusion of gene-related data in electronic medical records.

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Hospitals Praise But Cardiologists Pan CMS Regs

By John Reichard, CQ HealthBeat Editor

November 2, 2006 -- Hospitals gave a big smooch Thursday to the final version of outpatient payment provisions announced by the Centers for Medicare and Medicaid Services (CMS) late Wednesday, but otherwise industry reaction to regulations released by the agency was strongly critical.

Cardiologists, for example, warned that provisions in the final rule cutting physician payments 5 percent next year would slice their payments even more deeply than that, undermining care to heart patients.

Winning praise from the American Hospital Association was a provision of the outpatient payment rule that delays until 2009 a reduction in payment updates for that type of care if a facility fails to report data on quality of care.

CMS "has correctly given hospitals ample time to implement a reporting system for hospital outpatient services," said AHA Executive Vice President Rick Pollack. He also praised the agency for deciding to develop quality measures "specifically for the outpatient setting."

But AHA did not miss an opportunity to declare that "the entire outpatient system is underfunded." Hospitals receive "only 87 cents for every dollar of outpatient care they provide to America's seniors," it said.

The American College of Cardiology (ACC) said the physician payment rule delivers "among the largest cuts the cardiovascular community has ever had to face. In fact, they are so severe that many practices may have to limit the services they provide and even close their doors to Medicare patients altogether."

Although the rule provides for a 5 percent across-the-board cut to doctors, the actual reductions vary because of changes in "work values" assigned to different specialties. Those changes mean primary care physicians fare better under the rule than other doctors, but their relatively favorable treatment had to be offset by deeper reductions to other doctors under budget-neutrality adjustments in the regulation.

In addition, cardiologists were hit by provisions contained in the rule that carry out cuts in imaging ordered under the budget savings bill (PL 109-171) that was signed into law in February. Those cuts "will be severe for cardiology practices that perform their own cardiovascular imaging studies," ACC said. "For example, Medicare payment for the nuclear myocardial perfusion imaging study that allows cardiologists to assess damage to the heart muscle from coronary artery blockages will be cut by 14 percent."

The combined impact of the 5 percent cut and the adjustment to improve the payment picture for primary care doctors "will reduce Medicare payment for placement of an intracoronary stent by 9 percent," ACC said. Another effect of the rule is to reduce payments over time for certain expenses associated with running a cardiology practice. The revised practice expense formula "will cut payment for Doppler color flow echocardiography 22 percent in 2006 and 72 percent by 2010," the cardiology lobby said.

The American Health Care Association (AHCA) noted that the doctor payment rule ironically requires doctors to order and certify the medical necessity of each "finger stick" blood glucose test for diabetics just as the nation is observing National Diabetes Month.

"The new rule for individually authorized finger stick tests for diabetic patients puts paperwork ahead of quality patient care," said Bruce Yarwood, AHCA's chief executive officer. "Many patients and residents in our nation's long-term care facilities require up to four blood tests a day to properly manage their diabetes and placing restrictions on this essential test is inconsistent with accepted best practices for diabetes management."

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Lessons from Abroad: Advanced IT Doesn't Always Hinge on Government Funding

By John Reichard, CQ HealthBeat Editor

November 3, 2006 -- One reason U.S. primary care physicians trail their counterparts abroad in the use of information technology (IT) is they need help paying for it, health care analysts say. Yet government funding for IT is a factor explaining high use rates in only five of the 10 nations whose IT use exceeds that of the United States and Canada, according to study results released Friday at an international health care conference on Capitol Hill.

The 10 countries in the study were Denmark, Scotland, New Zealand, Sweden, England, the Netherlands, Australia, Norway, Austria, and Germany.

Canadian researcher Denis Protti, who conducted the study, spoke on the third day of the three-day conference sponsored by the Commonwealth Fund and the nonpartisan Alliance for Health Reform.

Protti, a professor of health information science at the University of Victoria in British Columbia, said Denmark is by far the most advanced nation among the 10 in physician use of IT. But neither Denmark nor four other nations among the 10—Austria, Germany, New Zealand, and Norway—have reached their advanced status because of government funding, he said.

Denmark was particularly noteworthy among the 10 because of its pace-setting performance and its self-financed IT purchases among general practitioners (GPs). "There has been no direct funding to GPs investing in electronic medical records and electronic communication," said Ib Johansen, deputy manager of MedCom, the public–private entity in Denmark responsible for promoting use of IT by the nation's physicians.

The use of IT by physicians in Denmark historically has been voluntary, with use of computers mandated for the first time only two years ago, Johansen said. Ninety-nine percent of general practitioners in Denmark have computer systems now, but use of IT is not a recent phenomenon. According to the data presented by Protti, more than half of Danish general practitioners in 1994 were using electronic medical records.

"Virtually all GPs and specialists use a secure, national communications network to electronically send and receive clinical messages such as prescriptions, lab results, lab requests, discharge summaries, referrals, etc.," Protti said.

GPs enter prescriptions electronically, in most cases getting "decision support" in terms of warnings if a prescription might cause an adverse reaction because of another drug the patient is taking or warnings not to prescribe a drug if a patient is pregnant.

Once the doctor decides on a prescription, he or she "selects that patient's pharmacy from a pull-down menu," Johansen noted. The prescription then is sent electronically to the specific pharmacy.

Both providers and patients can see lab results online over the Internet, he added. They also can see a list of medications the patient takes, get information on waiting lists at various facilities, schedule appointments, renew prescriptions, and communicate by e-mail.

Why are doctors willing to foot the bill for IT? Efficiency, higher revenues, and peer pressure are all factors, Johansen said. "The major reason Danish physicians use their computer is because of the communication benefits it brings them," Johansen said. Instead of waiting five days for test results from a hospital, "they now receive them almost as soon as they come off the equipment," he said.

They also receive automatic notifications when a patient is registered in an emergency department. Hospital reports on discharged patients arrive within two days rather than four weeks or more. Prescription refills can be ordered quickly. "A process that used to entail having to pull charts and handwrite a [prescription] now takes 10 seconds."

Peer pressure enters into acceptance of IT, Johansen added. GPs meet regularly in "clubs" they form to discuss issues relating to medical practice and the talk creates pressure to become more efficient through use of IT, he said.

But if GPs aren't getting direct aid to buy technology, they do receive other government assistance. Doctors can bill for treatment of more patients because they can include e-mail consults. "On average, GPs have experienced a 20 percent increase in the number of consultations after beginning use of electronic medical records and electronic communications," Johansen said. And data consultants funded by local jurisdictions help doctors integrate IT into their practices.

Other outcomes of wider IT use are lower costs and saved lives, he added. IT has fostered greater use of lower-cost medications and a reduction in cervical cancer deaths because of greater screening efficiency, Johansen said. Deaths from the disease have fallen by more than half between 1988 and 2004, he said.

One of the factors easing patient worries about the privacy of their data is they are able to see on their computer screens which providers access their medical records, Johansen said. Protti said another reason IT has caught on so well among Danish doctors is its first applications were specifically those that benefited physicians, such as provider-to-provider communications. And privacy worries aren't as great because medical data—imaging results and prescription drug data, for example—are in different databases and not all in one electronic health record.

The move from "electronic medical records," in which data may be in different places, to electronic health records, in which it is all in one place, will lead to greater privacy worries, he suggested.

Protti said there is no single reason why the 10 countries have such a high use of IT. Requirements or incentives for electronic billing were "an influencing factor" in five of the 10. And government financial support to buy IT did play a role in half of the countries, but varied from modest one-time grants in Australia to programs in Sweden and Scotland where the county—equivalent to a province—"pays for everything."

"Clearly the role of government health policy played a part in most of the countries," Protti added. Financial incentives to automate as distinct from direct payments for purchases also were a factor. Accreditation of vendor systems, common IT standards, and consulting support to GPs also were important factors, he concluded.

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Study Finds Facilities Hard-Hit by Proposed Medicaid Cuts

By Mary Agnes Carey, CQ Health Beat Associate Editor

October 31, 2006 -- Texas, Louisiana, and California would be among the hardest hit states if the Bush administration implements its proposal to cut $12.2 billion in Medicaid funding over the next five years, according to a new report.

The study, compiled for the American Health Care Association (AHCA), which represents long-term care providers, said the proposal would reduce by $104 million federal spending for intermediate care facilities for individuals with mental retardation or developmental disabilities. The cuts, the group said, are slated for implementation in the coming weeks, "perhaps even the day after the November elections."

In a statement, Bruce Yarwood, AHCA president and chief executive officer, said the proposed reductions "pose a direct and immediate threat to our nation's citizens with developmental disabilities who are cared for in these facilities."

The proposals include limiting payments to providers, reducing the allowable provider tax rate from 6 to 3 percent, and other Medicaid spending curbs. Limiting the extent to which states can tax providers, such as nursing homes, hospitals, and facilities for the mentally disabled, would in turn reduce federal Medicaid matching payments.

In June, 44 senators asked Department of Health and Human Services Secretary Michael O. Leavitt to not make the spending cuts, stating that the reductions would reduce funding nationwide for long-term care by $1.6 billion, forcing some rural nursing homes to close and limiting services to the mentally disabled as well as harming some hospitals. In May, 82 House members also asked HHS to not make the changes.

According to the report, compiled by the firm ElJay LLC, intermediate care facilities for individuals with mental retardation or developmental disabilities in Texas would lose $38.1 million in federal Medicaid funding if the administration's cuts were put in place, while Louisiana would see a $14.6 million reduction. Such facilities in California would see their Medicaid payments reduced by $13.7 million and Illinois would see a $9.8 million drop, according to the report.

HHS spokeswoman Christina Pearson said the agency continues "to support the president's proposal, which helps alleviate significant tax burdens on health care providers for obligations to the Medicaid program that are otherwise the responsibility of the states."

Separately, AHCA also has compiled a list of what the proposed changes to Medicaid would mean for nursing homes. Overall, nursing homes would lose $1.54 billion, with Pennsylvania nursing homes losing $167 million in federal Medicaid funding; California nursing homes would lose $125 million and New York facilities would see $114 million in cuts, the group estimates.

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Study Predicts Medicare Drug Plan Gap Harder to Fill in 2007

By Mary Agnes Carey, CQ HealthBeat Associate Editor

November 1, 2006 -- Coverage to close the Medicare drug benefit's "doughnut hole" will be harder to find and cost more in 2007, according to a Families USA report that the Centers for Medicare and Medicaid Services labeled "a distorted and incomplete picture" of coverage choices offered to beneficiaries.

The report, released on Wednesday, concludes that in 13 states no drug plans will offer "meaningful coverage" in the "doughnut hole," the gap in coverage in which beneficiaries must pay costs out of pocket when their drug costs total between $2,251 and $5,100, after which catastrophic coverage begins.

The report defines "meaningful coverage" as coverage for a list of 25 drugs most commonly prescribed to seniors in 2004 in a Pennsylvania pharmaceutical assistance program, some of which are listed twice but by different dosage amounts. The analysis states that of the 25 drugs, 18 are not available in a generic form, and therefore are likely not covered because most plans that offer coverage in the gap cover generic drugs, not brand-name drugs.

The report predicts that the number of beneficiaries without access to "meaningful" coverage in the gap will rise from 375,000 this year to 6.6 million in 2007—an 18-fold increase. The figures include all Medicare beneficiaries with drug coverage as of June 2006. Not included are two groups who do not face a coverage gap—"dual eligibles," or beneficiaries who qualify for both Medicare and Medicaid but now receive their drug coverage in the Medicare drug benefit, and beneficiaries who qualify for the low-income subsidy.

"Drug plan coverage in the doughnut hole will be much scarcer in 2007, and, in those states where such coverage continues to be available, it will be far more expensive," said Ron Pollack, the executive director of Families USA. "This coverage gap never made sense, and now it is getting worse for seniors who take multiple prescription drugs."

Where comprehensive gap coverage is offered, premiums for the lowest-priced Medicare drug plans will increase by 87.4 percent, from a median monthly price of $55.08 in 2006 to $103.20 in 2007, Families USA researchers conclude.

In a statement, acting Centers for Medicare and Medicaid Services Administrator Leslie V. Norwalk said that "all Medicare beneficiaries in all 50 states have the option of an affordable drug plan" offering some or complete coverage in the gap in 2007.

Norwalk also said that beneficiaries in the majority of states "are seeing no change in the number of plans offering coverage of brand-name drugs in the gap" and that the report does not acknowledge cost savings from the use of lower-cost generics and therapeutic substitutes.

Mohit Ghose, a spokesman for America's Health Insurance Plans, faulted the study for not analyzing the coverage that Medicare Advantage plans provide to beneficiaries. "Any comparison and any study of the Part D program and the ways in which beneficiaries can access drug coverage must include a discussion of all types and all programs available, including Medicare Advantage plans," he said. Medicare Advantage plans cover both prescription drugs and other health services.

House Minority Leader Nancy Pelosi, D-Calif., said the Families USA study "provides new evidence that under the confusing Republican prescription drug bill, the number of seniors at risk of falling into the doughnut hole will skyrocket next year."

Without referencing the consumer group's study by name, Senate Finance Committee Chairman Charles E. Grassley, R-Iowa, issued a statement defending the Medicare drug plan against "partisan attacks in Iowa and elsewhere."

While the program "may not be perfect," Grassley said, "beneficiaries now can get affordable prescription drug coverage and they can choose a plan, including a plan with gap coverage, that best meets their needs."

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U.S. Primary Care Underdeveloped in Some Respects

By John Reichard, CQ HealthBeat Editor

November 2, 2006 -- Is the U.S. the puny kid on the primary care block? Whatever the disadvantages of health systems abroad, a lack of health information technology among primary care physicians does not appear to be among them. Neither does a lack of access to primary doctors outside of normal working hours nor the use of teams of physicians to better coordinate the care of patients with chronic diseases.

Those are among the findings of a new survey that assesses how primary care in the U.S. stacks up against six other nations: the United Kingdom, Canada, Australia, New Zealand, Germany, and the Netherlands.

Despite U.S. per capita outlays for health care of almost twice that of any of the other six countries, U.S. primary care practices "are more limited than the leading countries in information capacity, provide less patient access outside of 'normal' work hours, and are among the least likely to use teams or to receive financial rewards for quality," said the study, led by Commonwealth Fund Senior Vice President Cathy Schoen. Overall, U.S. primary care has "less capacity to ensure accessible, high quality, or patient-centered care," concludes the study, which was posted on the policy journal Health Affairs' Web site Thursday.

IT's Better Abroad
Researchers conducted surveys of primary care doctors in the seven countries from late February though July of this year to draw comparisons. While only 28 percent of U.S. physicians said they use electronic medical records in their practices, 98 percent of doctors in the Netherlands said they did so, as did 92 percent of doctors in New Zealand and 89 percent of doctors in the United Kingdom.

Ninety-three percent of Dutch doctors said they receive computerized prompts or alerts about a potential problem with a drug dosage or adverse drug interaction, compared with 23 percent of U.S. doctors.

Fifty-three percent of British doctors said they receive computerized alerts to provide patients with test results, compared with 15 percent of U.S. doctors.

Ninety-three percent of doctors in New Zealand and 83 percent of doctors in the United Kingdom said they use computer systems to send patients reminder notices for preventive or follow-up care, compared with 18 percent of U.S. doctors.

Eighty-two percent of doctors in New Zealand and 64 percent of doctors in Germany said it was easy for them to generate lists of patients who are due or overdue for tests or preventive care, while 20 percent of U.S. doctors said so.

Altogether, 87 percent of doctors in New Zealand and 83 percent of doctors in the United Kingdom said they had computerized systems to perform seven or more functions assisting them with clinical care, compared with 19 percent in the U.S.

Health IT is more concentrated in larger physician practices in the U.S., but less so in a number of the other countries. In four of the seven countries, user rates for electronic medical records and electronic prescribing are high in both solo and larger practices, while those rates were low in small practices in the U.S. and Canada.

"The data show that U.S. primary care doctors find it difficult or impossible to perform tasks that doctors in other countries find easy; they also practice without basic decision supports that could improve health outcomes and reduce costs," Schoen said.

Instructions and Teams
In Germany, 63 percent of the doctors said they routinely give patients with chronic diseases written instructions about how to manage their care at home, compared with 33 percent in the U.S. and 14 percent in Canada. In the United Kingdom, 81 percent of doctors said their practices routinely used multidisciplinary teams to coordinate the care of the chronically ill, compared with 29 percent of doctors in the U.S.

Eighty-five percent of doctors in the Netherlands and 80 percent in Germany said they offered office hours before 8:30 a.m., compared with 40 percent in the U.S. Seventy-four percent of doctors in Germany said they offer office hours after 6 p.m., compared with 38 percent of doctors in the U.S. But those early risers in Holland close up shop early; only 4 percent said they offer hours after 6 p.m.

Ninety-five percent of Dutch doctors and 81 percent of Australian doctors said their practices have an arrangement where a patient can see a doctor or nurse (not at the emergency room) if the practice is closed, while 40 percent of U.S. doctors did so.

But the U.S. outdistanced the competition when it came to waiting times for diagnostic tests and hospital care. Only 9 percent of U.S. doctors said their practices often had long waiting times for diagnostic tests, compared with 57 percent of doctors in the United Kingdom and 51 percent in Canada. And only 9 percent of U.S. doctors said they often had long waiting times for elective surgery or hospital care, compared with 85 percent in New Zealand, 69 percent in Australia, and 62 percent in the United Kingdom.

U.S. doctors also didn't have to wait long to receive reports from hospitals on their discharged patients. Half or more of doctors in Canada, Germany, the Netherlands and the United Kingdom said they had to wait 14 days or longer for those reports, while 40 percent or more of doctors in the United States and New Zealand said they received those reports within four days.

Overall, the study highlights a number of areas where the U.S. can improve, the study said. "Cohesive, broad-based policy changes" could lead to improvement, the study found. The U.S. lags in health IT in particular because, unlike the other nations, it lacks a national implementation plan, the researchers said.

A number of other nations excel in health IT because they have national health systems and "strong central leadership," Stephen Schoenbaum, the Commonwealth Fund's executive vice president for programs, said in an interview. "They are much more centrally controlled."

The Bush administration "has made significant efforts to develop standards," but significant issues remain in making sure that systems work together and are "interoperable," he said. "We are at an early stage, and we are behind the curve."

The U.S. could get on a better track through "even stronger leadership that does need to be national," Schoenbaum said. However, "that doesn't mean we end up with a national system," he added. It means better incentives akin to those that increased reporting by hospitals on quality of care to include virtually all hospitals, when just a few reported such data initially. Higher Medicare payments did the trick in that sector and a similar approach could work in primary care, Schoenbaum suggested.

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