It is obvious that the plans for reform proposed in the House will not make it through the Senate (even using the nuclear option). A form of incremental reforms may be the best chance going forward. A combination of Health Insurance Co-Op which provides universal coverage while also throwing a bone to conservatives on tort reform seems like something that might make it to the President's desk before Thanksgiving.
I know many of you may think I have gotten overly pessimistic, but I think I am being quite realistic.
At an MIT Roundtable this past June he gave this excellent lecture below:
“We think with our eyes…
Vision is the locus of every profound kind of problem solving.”
Patrick Henry Winston
Electronic Health Records do not do much good if they are trapped in disparate silos that are unable to communicate with each other. To have 'meaningful use' of and Electronic Health Record (EHR) we need to develop Health Information Exchange (HIE). HIE will provide the capability to electronically move clinical information among disparate health care information systems while maintaining the meaning of the information being exchanged. The goal of HIE is to facilitate access to and retrieval of clinical data to provide safe, efficient and effective, timely, and fair, patient-centered care. HIE will also be useful to Public Health authorities to help in analyses of the health of the population.
The Nationwide Health Information Network (NHIN) is being developed to provide a secure, nationwide, interoperable health information infrastructure that will connect providers, consumers, and others involved in supporting health and healthcare. A key aspect to health IT implementation will be ensuring that State and regional efforts to achieve health information exchange are aligned with the national health IT agenda. The recent announcement of funding for state and regional HIE efforts puts some real flesh on the bones of these plans.
In Oregon this past year major state health reform was passsed with House Bill 2009. Withe this bill the Oregon Health Authority has been created and Dr. Bruce Goldberg has been appointed by Governor Kulongoski as its Director. HB 2009 also established the Health Information Technology Oversight Council (HITOC). The HITOC will coordinate Oregon's public and private statewide efforts in electronic health records adoption and the eventual development of a statewide system for electronic health information exchange.
In our area we are creating Gorge Health Connect (GHC) composed of area healthcare stakeholders including La Clinica del Carino Community Family Health, Mid-Columbia Medical Center, Oregon North Central Public Health District, Mid-Columbia Center for Living. Some of our goals are regional adoption of health information technology and an interoperable health information exchange. We want to enhance the health of all citizens, creating a health information system that supports provider management of chronic and complex conditions across all sites of care, increases consumer resources to more effectively manage their health, and improves coordinated care and the timely reporting of communicable diseases.
One example of a successful community HIE is HealthBridge, a not-for-profit HIE serving Greater Cincinnati and surrounding areas. HealthBridge is one of the four organizations highlighted in a national report "Migrating Toward Meaningful Use: The State of Health Information Exchange" released by eHealth Initiative,(on Twitter @eHealthDC) a national nonprofit organization dedicated to improving health care through information technology. They will also be in Spokane Washington September 10-11 for the Northwest Medical Informatics Symposium. Spokane is also on of three Consumer Managed Health Record Bank pilot projects in Washington. I have written about Health Record Data Banks, but we are unsure in the gorge area of which model for HIE we will use. NMIS looks to be an exciting conference, but unfortunately I will be unable to attend (I will be in Washington D.C. at the Gov 2.0 Summit)
To see exciting developments check out the CONNECT Community Portal, an open source gateway to the NHIN. The CONNECT Seminar 09 was a great success this year. Conference speakers included Aneesh Chopra, the White House CTO, R. Scott Gould, Deputy Secretary, Veteran’s Affairs, Dr. David Blumenthal, the National Coordinator for Health IT, Vish Sankaran, FHA program director, Wounded Warrior advocate Sarah Wade, and Brian Behlendorf, an authority on the open source community. Videos from this event can be found at: CONNECT Seminar Videos
Health care co-ops are nonprofit, member-owned and member-governed organizations through which individuals and small businesses can buy health insurance and negotiate fees with physicians and hospitals. They operate as exchanges which are a structured marketplace where people can choose among health plan options. In the Health Affairs blog "What People Don’t Know About Health Insurance Exchanges" by Peter Lee and John Grgurina, they make the case that a sustainable insurance exchange would:
- need to consider requiring individuals and very small groups (10 or fewer employees) to use the exchange
- be a dual market, we need to make sure there is a "level playing field" between the exchange and the market outside of the exchange
- need to be monitored closely, looking at how exchanges are run and ensure responsiveness and accountability
In a recent New York Times article Anne Underwood draws a sharp distinction between insurance co-ops and health insurance purchasing co-ops. She makes a case that only a public option will control costs, and co-op insurance exchanges would do no good. Dr. Jost in another article states that the only way cooperatives aimed at bending the cost curve and driving quality system-wide could succeed is with a strong national organization.
The leading advocate of the co-op concept in Congress is Kent Conrad, a Democratic senator from North Dakota and a member of the Gang of Six, the coalition of 3 Republicans and 3 Democrats on the Senate Finance Committee who have resolved to work out health reform on a bipartisan basis. The Six reaffirmed that commitment during an August 21 conference call, pledging to focus more closely on cost and financing issues that many find troubling.
The benefit of co-ops as a way to broaden access to health insurance might be that they are intended to become self-sustaining and not require ongoing government involvement and control. According to Senator Conrad, start-up money would be made available to capitalize them, but they would transition to self-sustainability through the member premiums they collect. Conrad also stresses they would be run by members and not by federal or state governments. They also would be required to take everyone regardless of pre-existing conditions, and could be formed at the state level or regionally.
Conrad told the Wall Street Journal that the current co-op proposal under negotiation in the Senate Finance Committee version of the health reform bill (which has not yet been released for Congressional debate or public scrutiny) would establish co-ops with a minimum of 500,000 members to ensure critical mass for effective provider bargaining. The federal government would offer interim start-up expertise and financing to the tune of $6 billion. The goal would be to help co-ops rapidly enroll 12 million members, which would make them the third-largest player in the US health insurance market.
Senator Conrad's office refers questions to his Web site, where the co-op FAQs provide a cute co-op acronym (Consumer-Owned and -Oriented Plan) but not much insight into the details of the plan. One FAQ statement seems to imply that healthcare providers would not be direct participants: "The Consumer Owned and Oriented Plan would allow for the creation of not-for-profit cooperatives that would provide affordable health insurance by creating a pool of consumers who could then negotiate with providers for health care."
The FAQ cites the Group Health Cooperative as an example of "a large health insurer in the Pacific Northwest." Tis does not quite tell the whole story. Pam MacEwan, executive VP for Group Health public affairs, told the WSJ that Group Health enjoys pricing leverage. But she said that relies on the 600,000 members in the co-op, along with its in-house network of doctors, hospitals and clinics built up over 62 years. "You can't get a lot smaller than that," she said..
So where did the healthcare co-op idea came from? Cooperative businesses and organizations are a pervasive part of the US economy, according to the National Cooperative Business Association. Current co-ops include Fortune 500 companies such as Land O' Lakes and the Associated Press. There are also over 900 rural electric cooperatives that own and maintain almost 50% of the electric distribution lines providing electric service to 37 million people. Cooperatives are all over the place. It is at least worth exploring the idea theymay be helpful in healthcare.
Since there are only 40 Republicans in the Senate, the Democrats would actually only be going nuclear on themselves. Reconciliation lets the Senate pass some measures with a simple majority vote, but non-budget-related items can be challenged. This could knock many provisions from the healthcare plan. Democrats could submit one big bill and fight to keep as many provisions as possible from falling victim to a 60-vote requirement. They could split the bill in two parts - one part dealing with spending questions, would go under reconciliation rules. The other part would still require 60 votes, but it would be subject to Republican amendments. You could actually lose provisions such as protecting people with pre-existing conditions, and the public option for health insurance. Any nuclear attempt is certain to further erode the effectiveness of health reform, and would make Republican gains next year almost certain in conservative areas currently held by Democrats. Remember what happened after 1994 with the "Contract with America" and the subsequent loss in the mid-term elections?
Going nuclear would allow some form of health reform to get through (albeit a watered down and neutered version) but it could also guarantee electoral losses and make Congress even less effective over the coming months. I still believe the best hope for meaningful health reform is to slow down and craft a bill with broad support. Give the American people time to understand what is in it, and try to get something done by the end of the year. Trying to hurry this through could backfire...
The first two HITECH priority grant programs, funded through the Recovery Act, support the national implementation of electronic health records (EHRs) initiative.
Approximately $598 million is being made available through the Health Information Technology Extension Program (Extension Program), to ensure that comprehensive support is available to health technology users.
Under the State Health Information Exchange Cooperative Agreement Program $564 million will be awarded to support efforts to achieve widespread and sustainable health information exchange (HIE) within and among States through the meaningful use of certified Electronic Health Records.
State Health Information Exchange Cooperative Agreement Program
The State Health Information Exchange Cooperative Agreement Program will help States and Qualified State Designated Entities (SDEs) to develop or align the necessary policies, procedures and network systems to assist electronic information exchange within and across states, and ultimately throughout the health care system. A key to this program’s overall success will be technical, legal and financial support for information exchanges across health care providers.
Health Information Technology Extension Program
The Extension Program will provide grants for the establishment of Regional Health Information Technology Extension Centers (Regional Centers) that will offer technical assistance, guidance and information on Electronic Health Records best practices.
The Extension Program also establishes a national Health Information Technology Research Center (HITRC), which will gather relevant information on effective practices and help the Regional Centers collaborate to identify and share EHR adoption, effective use, and provider support.
Grants under the Extension Program will be awarded on a rolling basis with:
- An expected 20 grants awarded in the first quarter of FY2010,
- Another 25 in the third quarter, and
- The remaining awards in the fourth quarter of FY2010.
The funding support continues for four years, after which the program is expected to be self-sustaining. Of the total federal investment, $50 million is dedicated to establishing the national HITRC, and remainder is set aside for the Regional Centers.
- The HITECH Act amends Title XXX of the Public Health Service Act by adding Section 3012, Health Information Technology Implementation Assistance. This section provides supportive services for the rest of the HITECH Act. Section 3012 (a) establishes the Health Information Technology Extension Program (Extension Program).
- The Extension Program provides grants for the establishment of Health Information Technology Regional Extension Centers (Regional Centers) that will offer technical assistance, guidance and information on best practices to support and accelerate health care providers’ efforts to become meaningful users of Electronic Health Records (EHRs). The consistent, nationwide adoption and use of secure EHRs will ultimately enhance the quality and value of health care.
- The Extension Program will establish cooperative agreements through a competitive process to support an estimated 70 (or more) Regional Centers each serving a defined geographic area. The Regional Centers will support at least 100,000 primary care providers, through participating non-profit organizations, in achieving meaningful use of EHRs and enabling nationwide health information exchange.
- The Extension Program will also establish a national Health Information Technology Research Center (HITRC), funded separately, which will gather relevant information on effective practices from a wide variety of sources across the country and help the Regional Centers collaborate with one another and with relevant stakeholders to identify and share best practices in EHR adoption, effective use, and provider support.
- The HITECH Act clearly prioritizes access to health information technology for historically underserved and other special-needs populations, and use of that technology to achieve reduction in health disparities. The HITRC will assemble and disseminate materials to support and address the needs of all prioritized providers, including but not limited to materials addressing the unique needs of providers serving Native Americans, persons with limited proficiency in the English language, persons with disabilities, and other historically underserved populations, as well as those that serve patients with maternal, child, and behavioral health needs.
- Grants under the Extension Program will be awarded on a rolling basis with an expected 20 grants awarded in the first quarter of FY2010, another 25 in the third quarter and the remaining awards in the fourth quarter of FY2010. The initial funding includes approximately $598 million to ensure that comprehensive support is available to providers under the Extension Program beginning early in FY2010, with an additional $45 million available for years 3 and 4 of the program. Federal support continues for four years, after which the program is expected to be self-sustaining. Of the total federal investment in this program, about $50 million is dedicated to establishing the national HITRC, and $643 million is devoted to the Regional Centers.
- The law requires that Regional Centers be affiliated with a U.S.-based, nonprofit institution or organization, or an entity thereof, that applies for and is awarded funding under the Extension Program. The program anticipates that potential applicants will represent various types of nonprofit organizations and institutions with established support and recognition within the local communities they propose to serve.
- The performance of each Regional Center will be evaluated every two years by a HHS-appointed panel of private experts, none of whom are associated with the center being evaluated. Continued support for the Regional Center after the conclusion of the second year of performance will be contingent on the panel’s evaluation being, on the whole, positive and on HHS’ determination that such continued federal support for the center is in the best interest of the program.
- The Regional Centers will focus their most intensive technical assistance on clinicians (physicians, physician assistants, and nurse practitioners) furnishing primary-care services, with a particular emphasis on individual and small group practices (fewer than 10 clinicians with prescriptive privileges). Clinicians in such practices deliver the majority of primary care services, but have the lowest rates of adoption of EHR systems, and the least access to resources to help them implement, use and maintain such systems. Regional Centers will also focus intensive technical assistance on clinicians providing primary care in public and critical access hospitals, community health centers, and in other settings that predominantly serve uninsured, underinsured, and medically underserved populations.
- The Regional Centers will support health care providers with direct, individualized and on-site technical assistance in:
- Selecting a certified EHR product that offers best value for the providers’ needs;
- Achieving effective implementation of a certified EHR product;
- Enhancing clinical and administrative workflows to optimally leverage an EHR system’s potential to improve quality and value of care, including patient experience as well as outcome of care; and,
- Observing and complying with applicable legal, regulatory, professional and ethical requirements to protect the integrity, privacy and security of patients’ health information.
- The Extension Program expects all Regional Centers to be operating at full capacity by the end of December 2010. In addition, it is expected that by the end of December 2012, the Regional Centers will be largely self-sustaining and their need for continued federal support in the remaining two years of the program will be minimal.
Additional information is available at http://healthit.hhs.gov/extensionprogram
Below are Meeting Materials:
- Update on HIT Policy Committee and its Workgroups
- Meaningful Use Grid
- Report on Clinical Quality Workgroup
- 2011 Measure Recommendations
- Report on Clinical Operations Workgroup
- Report on Privacy and Security Workgroup
- Privacy and Security Standards Applicable to ARRA Requirements