The number of patient-centered medical homes recognized by the National Commission on quality Assurance is rising

The number of patient-centered medical homes is growing. They are being recognized by the National Commission on Quality Assurance and are just one part of the innovation of the American healthcare system.

EMR vs. EHR

Do you know the difference between an “electronic medical record” (EMR) and an “electronic health record” (EHR)? There is a common misconception that these terms are interchangeable, and many people today could not tell you if there is a difference between the two terms, let alone what that difference is.

An EMR is essentially the equivalent of a paper chart for a patient that is filled out by providers within an individual healthcare delivery organization (e.g. hospitals, physician’s offices), and is a legal record owned by that organization. EMR computer software is sold by enterprise vendors to hospitals, clinics, and other care delivery sites.

An EHR is a subset of EMRs that contains patient information from different healthcare delivery organizations. These records are owned by the patient or stakeholder, and the information can be shared through an EHR network. Unlike EMRs, electronic health records are interactive and the patient can access and supplement the information contained in the file. EHRs connect different healthcare organizations and may contain more detailed information about a patient’s demographics, medications, medical history, etc.

So, in order to utilize EHRs and for them to be effective, EMR software must be adopted by healthcare delivery organizations. Based on an HIMSS Analytics report published in 2006, the majority of hospitals have begun to implement EMRs, but at that point were not beyond the earliest stages. Since then both EMR systems and EHRs have grown in utilization and popularity, considering the potential for the easy sharing of patient information between healthcare organizations. A 2011 presentation by HIMSS shows that in 2011 more hospitals are developing their ability to use EHRs.

Both EMRs and EHRs are clearly an area of high potential for the healthcare industry. As the systems are more widely adopted and developed further at various organizations, the added ease of access and quality of health information will ideally help care provider organizations provide better treatment for patients. There are potential worries related to privacy and security with this type of information being transmitted electronically, however that is an entirely different issue that I will leave to be discussed at another time.

 

Author: Jamie Notaro

Edited by: Ken Chiang

 

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HHA Workers get OT and Minimum Wage

I recently came across an interesting article regarding proposed regulations for home health workers. Sometimes, it is the little things that are not dramatic that can affect our clients’ plans.

As described in more detail in the article below, On Thursday December 11, the Obama administration proposed regulations to give the nation’s nearly two million home care workers minimum wage and overtime protections. Those workers have long been exempted from coverage.  Home healthcare aides are not protected under the Fair Labor Standards Act.  Therefore, their employers are not subject to minimum wage or overtime regulations.

NY Times Article

As home healthcare aides are a rapidly growing work force, raising their wages and providing for overtime could represent a significant increase in financial responsibility for their employers.  One result might be that home health agencies may be forced to cut hours for their workers.  Also, the agencies may not have the financial resources to hire additional aides. In a slowly recovering economy, this would be an unfortunate result for both home healthcare agencies and their workers.

Another result might be that fewer patients may receive home health services or patients may not receive all of the care they need.  Patients might be required to pay more for the home health services they do receive.  Another result might be that home health workers might not be able to make as much as they do now as overtime hours are cut.

            Requiring an increase in wages could slow the growth of the industry, despite the projected significant increase in the need for home healthcare over the next 15-20 years. Slowing the growth of the home healthcare industry could lead to a decelerating rate of growth in the demand for many home healthcare products. If the availability of home healthcare services is curtailed, might that lead to an increase in direct and indirect healthcare costs?  For example, limiting access to home healthcare could encourage the use of more costly providers or an increase in negative outcomes as patients go without the care they need.

Now, what are your thoughts? 

Medicare Reductions — Real or Imaginary?

The Obama administration is expected to release a report today that indicates that healthcare reform will reduce Medicare spending by $575 billion over the next 10 years, starting with an $8 billion savings in 2011.  This could add 12 years of solvency to the program’s trust fund.

As with any partisan government report, we need to evaluate the accuracy of the numbers and the underlying assumptions.  Does it present a realistic and complete assessment?  Will the savings be used to solidify the Medicare trust fund, reduce premiums for our nation’s seniors or for another purpose?  The report indicates that Medicare spending cuts will help to lower seniors’ monthly premiums by nearly $200 annually by 2018.  For the moment, let’s assume and hope that the estimate is accurate and will be used to solidify the trust fund and reduce premiums for seniors.  These are all good outcomes and well worth pursuing.

One approach to generating the above savings is to implement price controls.  Medicare spending will keep increasing, only not as fast. Under the law, spending will rise by 5.3% a year on average over the next decade, compared to 6.8% without the cuts.  

The biggest portion of the Medicare cuts is from reductions in projected payment increases to hospitals and other providers over the next 10 years. The second biggest portion is reductions in payments to Medicare Advantage plans.  Cuts to Medicare Advantage plans start right away. The report says Medicare Advantage cuts account for $5.3 billion through 2011, more than 60% of the total estimated two-year savings of $7.8 billion.  An analysis by the Kaiser Family Foundation earlier in 2010 suggests that reductions in payments to Medicare Advantage would amount to $130 billion by 2019.  The reason for these reductions, per some analysts, is that the Medicare Advantage plans are overpaid when compared to the cost of care in traditional Medicare.  

As we’ve written before, price controls produce unintended effects.  How will hospitals and physicians react to a reduction in spending?  Will they sacrifice the quality of care?  Will they provide fewer services?  Will seniors realize $200 reductions in premiums but a greater reduction in services and quality?  Is that constructive? 

The insurance industry says the cuts will mean steep premium increases for millions of seniors in the plans. That could trigger an exodus, with seniors returning to traditional Medicare.  Is this the effect the government intended?

Unintended effects also is one of the reasons that a national health plan, so seductively attractive in many ways, was not implemented.  Monopolistic, or near monopolistic control, can yield arbitrary strategies and tactics that are not beneficial to Medicare beneficiaries and providers.

More effective than using the stick (ie, payment reductions) to force providers to become more efficient is to first provide incentives to drive quality and efficiency.  For example, a program to reduce hospital readmissions due to preventable infections and other problems is estimated to save $8 billion over 10 years. And projects involving the patient-centered medical home (ie, a new, team-based approach to providing medical care for seniors) is estimated to save $5 billion over the same period, by keeping patients with chronic health problems healthier and avoiding hospitalization.

The incentives in place in our healthcare delivery system often discourage cost-effective, high quality care.  Instead, these programs encourage more cost-effective care by removing wasteful care from the system.  These programs encourage higher-quality care.   

Revising incentives, gaining consensus and support and implementing new programs takes time and investment.  While better in the long run, the issues facing Medicare and the healthcare system overall are pressing.  Therefore, the carrot (ie, programs that drive higher-quality, lower cost care) cannot be the only approach that is used.  The stick also must be used to gain short-term improvements.  Unintended effects will need to be managed. 

My suggestion is that the proportion of stick to carrot needs to be constructive.  The current approach relies heavily on price controls (ie, the stick) and experiments to a limited degree with quality-improvement programs that drive lower cost.  The ratio needs to be changed to a more even balance between the two approaches.  That will yield longer-term benefits and reduce the impact of unintended effects.

Electronic Health Records — A Key to Progress

Electronic health records are a key to the advancement of the healthcare system.  Having medical records that follow patients across the continuum of care will enhance outcomes as all providers share a complete set of data.  Also, fully shared data will help reduce costs by eliminating redundant diagnostic evaluations and unnecessary prescribing of medications.  Electronic health records will facilitate the development of new models of care, such as the patient centered medical home.

However, only 20 percent of doctors and 10 percent of hospitals use even basic electronic health records according to Kathleen Sebelius, secretary of health and human services.

As reported by the New York Times yesterday (http://www.nytimes.com/2010/07/14/health/policy/14health.html?_r=1&hpw), the federal government issued new rules Tuesday that will reward doctors and hospitals for the “meaningful use” of electronic health records, a top goal of President Obama.  The rules significantly scale back proposed requirements that the health care industry had denounced as unrealistic.

The main criticism of the rules proposed by the Obama administration in January was that they took an “all or nothing” approach. Doctors could not have received any federal bonus payments unless they met 25 criteria, or objectives, and hospitals would have been required to meet 23.

Standards in the new rules are less demanding and more flexible. Doctors will have to meet 15 specific requirements, plus 5 chosen from a list of 10 objectives. Hospitals will have to meet 14 requirements, plus 5 chosen from a menu of 10 goals.

Doctors, for example, will have to use electronic systems to record patients’ demographic data (sex, race, date of birth); their height, weight and blood pressure; their medications; and their smoking behavior.

To meet the new standards, doctors will have to transmit 40 percent of prescriptions electronically. Under the proposal, 75 percent of prescriptions had to be sent electronically.

The Department of Health and Human Services said doctors and hospitals could receive as much as $27 billion over the next 10 years to buy equipment to computerize patients’ medical records. A doctor can receive up to $44,000 under Medicare and $63,750 under Medicaid, while a hospital can receive millions of dollars, depending on its size.

Sometimes, small steps are better than no steps at all.  Moving physicians and other providers to communicate with each other at all sometimes seems a big enough challenge to patients.  Anything that helps a patient not have to repeat the same story to each physician is a significant accomplishment.  Therefore, not only will the system reduce costs and improve the quality of care, patients will have fewer headaches just from accessing the system.

A few years ago, I was speaking with a leading researcher at the Commonwealth Fund.  He suggested that it might take 20 years to implement a fully-functioning electronic health record.  With the current administration’s financial support and guidelines for the initiative, we might achieve that goal in that timeframe.  However, a great deal can be accomplished through the “baby steps” proposed under the relaxed guidelines. 

For example, entering demographics and utilizing e-prescribing allows basic checks of appropriateness of the prescription.  It also reduces the opportunity for over-prescribing or duplicate prescribing of pain killers and other potentially abused medications.

The final rules do not guarantee that doctors and hospitals can electronically exchange clinical information on patients. The rules do require health care providers to work toward that goal, widely seen as a way to improve the coordination of care and avoid the duplication of tests. 

Of course, this is where the rubber meets the road.  Enhancing longitudinal and intra-practice communication is a significant step forward.  Using electronic health records to compare prescribing and treatment patterns to generally-accepted practice standards and algorithms will help improve the quality of care.  But a significantly increased return on investment will occur when the systems can communicate throughout the continuum of care.  The next step is for the healthcare and information technology communities to set data layout standards that will make this possible. 

Co-operation?!  What a novel concept!