Wednesday, April 29, 2009

The Federal Urge to Spend: The Comparative Effectiveness Institute

Washington is thinking of spending tens of billions of dollars on a Comparative Effectiveness Institute, based on a concept borrowed from Great Britain (The National Institute for Health and Clinical Excellence). However Great Britain has adequate primary care. We do not. And Great Britain has put a dollar limit on a newer drug or procedure regardless of its potential for benefit for that particular individual, while the U.S. Congress has rightfully ruled that out for our citizens.

The biggest flaw in the need for the Institute is the assumption that American doctors do not know how to practice medicine that delivers value for the dollar, and that information on this subject does not now exist. This idea is categorically false! Physicians know very well from many existing studies when further critical care will not be beneficial, when cardiac catheritization and stenting is not warranted, when multiple transfers from nursing home to hospitals will not benefit the patient and so on. I am not discussing debatable situations, rather situations that are manifestly obvious.

It is not a lack of knowledge underlying the cause for all this inappropriate care. The culprits have been previously discussed on this blog, for instance: perverse financial incentives including excessive reimbursement for technology, inadequate primary care, fear of legal consequences, and lack of national medical standards. If you want to read up on it, get a copy of The Dartmouth Atlas of Health Care: Regional Disparity in Medicine.

On this blog I have proposed multiple steps to more effectively deal with these problems:
1) Through the Federal Health Care Clearing House and Bank, prospectively verify the benefit of newer therapies via funding of their confirmatory research through the National Institutes of Health before they are approved for general use. This information would be generated via well-performed excellent studies reported without bias.
2) Use of my new admitting form that clarifies that only beneficial care can be delivered.
3) Physician review through Appropriate Care Committees to guarantee as much as possible that care will be beneficial and uniform throughout the country.
4) Amendments to the Patient Self Determination Act, the Americans with Disabilities Act and the Emergency Medical and Active Labor Act to include the phrase, “within acceptable medical standards.”

We can provide universal coverage and decrease our percentage of gross domestic product devoted to health care. If other industrial nations throughout the world can it, so can we. And we can do it without spending billions to study this, that, and the other, when the information is already out there. However, the sense from Washington is that we have to spend many billions more before we can reduce spending. I completely disagree!

A congressional budget office 2008 report quoted in the April 7, 2009 Annals of Internal Medicine states that a Comparative Effectiveness Institute in the United States would reduce health care spending by less than one tenth of one percent. There is no doubt in my mind that my plan is far superior. Do you agree?

Tuesday, April 14, 2009

The Electronic Medical Record: Must it Cost Billions to the Tax Payer?

According to a Dow Jones article the U.S. government plans to spend 20 billion dollars in five years to achieve a 12.6 billion dollar savings in ten. It is just me, or is there something bizarre about these numbers? The expenditure estimate is from an interpretation of the latest U.S. government spending plans, the savings estimate from the Congressional Budget Office. These numbers are quite approximate and may vary, but the main point is clear: electronic medical records are a good idea for coordinating patient care, but are not a tool for significant cost savings.

Is there an alternative that will provide the benefits of the electronic medical record and not require spending billions of our government’s dollars? Yes there is, with a little imagination and Congressional action. This plan calls for Congress to create a Federal Health Care Clearing House and Bank (see posting The Bank). The Bank’s first function would be to create a computer based national clearing house for patients’ billing and medical records. Many large information technology corporations (i.e. Google, Microsoft and others) have created comprehensive computer programs that can interact with various other hospital and outpatient data systems. The “Bank” would use standard federal government procedures for bidding and selecting the program/s and site/s for maintaining this medical record and billing system. This medical information would be kept in a central location/s with other sites for backup. The key aspect of this proposal is the centralization for maintaining electronic medical records, thus greatly lowering costs.

The central computer would receive billing and patient records from every hospital and medical entity in the land. All hospitals have most if not all their patient records on computer at this time. The “Bank” would charge the hospital, insurance companies and other medical entities a fee for each transaction. These fees would be calculated to support the computer system and would be quite modest for each entry. Keep in mind that there are millions of hospital-patient interactions and many millions of other medical transactions each year. Doctors would access the central computer, enter their information and would also be charged a much smaller fee. Pharmacy and other services would do the same. Patients would be able to access their own medical record free of charge.

There would be multiple levels of computer security, but with an additional caveat. As access to computer records can be traced more accurately than with paper systems, violators can be determined with greater ease. Congress when creating the “Bank” would also mandate heavy fines for unauthorized access, thus helping to ensure confidentiality.

I believe this is a workable and cost saving idea. I welcome your comments about this concept.