More on Medicare
Not long ago, a reader commented, “don’t you have more important things to do than write a blog.”
I have much to do, but I enjoy writing and appreciate the comments you make. However, the person raising questions about my blog time may feel better because I haven’t posted for a while. My absence was not intentional but last week was a whirlwind. Hopefully this week will be better. I’m actually traveling for a couple of days. I’ll be in Georgia, Kansas, Utah and Nevada. Nights in hotels seem to be good for my blogging regularity.
I want to stay with a Medicare theme today. In my last posting, I mentioned a “trigger” contained in the Medicare Modernization Act of 2003 which requires Medicare Trustees to notify Congress and the President if more than 45% of the Trust Fund comes from general revenues, two years in a row. That happened last year.
The warning “triggers” provisions of law that call for the President to send Congress legislation to bring the percentage back under 45%. Last week, the President delegated that responsibility to me and I sent actual legislation to Congress, which has a duty to act within a short time.
I’m pleased the provision is there. We need to respond. While I have little optimism the Congress will act, it is important to keep the discipline of a warning voice and the expedited procedure should at least generate some debate.
The proposal is solid. I’m simply going to link you to information about it (letter transmitting legislation to speaker of the House; summary of legislation). Remember there are two problems we’re dealing with. The big one is Medicare going broke in 2019. Frankly, responding to the trigger does little about that.
The second problem is the one the trigger is focused on. The problem is we are using more and more regular tax dollars, those usually used on other parts of the budget, to pay for Medicare. So, if you worry about education, you should worry about Medicare. Because, Medicare will get its money before education does. Likewise, if you want good roads, you should worry about Medicare. If you think medical research is an important priority, you should be worried about Medicare. Health care costs paid by the federal government are eroding our capacity in other important areas.
Claims Data from Medicare
The proposal I made last week is also relevant in another way. A couple of commenters asked about a lawsuit involving the use of Medicare claims data by people outside of government.
Brian Klepper said: “On Friday the Memphis Business Journal reported you saying that we ought to have ‘a Travelocity for health care’ that would ‘give a quality grade for doctors and show how much they charge for services.’ I'm wholeheartedly with you on this. But how do you square this proposal with the fact that, though you're the nation's largest payor, you acquiesced to the AMA's interests and then refused to release physician data?
Can you please explain these discrepancies?”
Michael Millenson of Highland Park, IL agreed with Brian. He said, “It's past time for HHS to be an aggressive, whole-hearted mover towards release of more information and more timely information. Meanwhile, one easy, no-cost step would be for Secretary Leavitt to use his bully pulpit to call for states to collect ‘all payer’ data. It sounds like a technical issue, but what it will do is allow valid national comparisons of quality of care, as well as enable better state efforts. A local/nation win-win.”
I want to use Medicare claims data for this purpose. And I have been advocating the states provide their data for this purpose. However, I have a problem. A federal court in Florida, some years ago, prohibited HHS from publicly disclosing certain Medicare claims data. Specifically, HHS was prohibited from disclosing annual Medicare reimbursement rates for individually identifiable physicians.
A few months ago, another federal court — this time in D.C., ruled the opposite — that I must provide the data to a specific party. This leaves me sandwiched between two differing courts.
We are working to develop a solution. However, the real fix will need to be legislative.
In the Medicare trigger legislation I sent to Congress, I have included language that would allow HHS in a thoughtful, consistent way to enhance quality improvement efforts in our Chartered Value Exchanges with physician performance measurement results. This needs to happen. I think there is a potential for bipartisan action on at least this part of the legislation I sent up.
Michael and Brian, take a look at the legislation linked above and tell me what you think.
Posted on February 22, 2008 in Medicare
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I think the person who wondered if you "have more important things to do" has ever thought that stakeholder relationship building was important. Perhaps he'd rather you spend all your waking hours in meetings, and to hell with attempting transparency and building relationships. Perhaps he wants you to go back to being an old-fashioned bureaucrat.
Posted by: Peter Stinson | February 22, 2008 at 01:10 PMFinally a courageous reader questions the desire of our government to communicate with it's citizens. Information directly from the leaders without filters from PR people or media will destroy this nation I tell you. Go back to your smoke filled rooms and get things done. I don't need explanations of policy or how a Cabinet member crafts legislation. Just to do and don't talk about it.
Posted by: Bob DeGol | February 22, 2008 at 04:20 PMI cannot understand Brian and Michael's fascination to get to what doctors bill Medicare. Since Medicare only pays the price it fixes, how does it matter what claims come into Medicare, when prefixed amounts are being paid? Mr. Secretary, could you please clarify this to the average reader?
As far as more Govenment dollars going to Medicare as compared to buildng roads or libraries or schools, please look at the population demographics. Even an illiterate person would understand that the fastest growing segment of our populatoin is the Medicare-eligible segment (apart from the 80-plus year-olds). So why is it surprising that larger portions of government dollars are going to Medicare funding? Just a commonsense assesment would be - we could pay for most of Medicare's growth if we took half of what we are spending in the war in Iraq. Somehow, this concept does not resonate with our "leaders" in D.C., Mr. Secretary.
Posted by: Arvind Cavale | February 23, 2008 at 01:20 PMThe CDC should revisit the entire Case Notification program. It is a waste of tax payers dollars in its current state.
Posted by: | February 25, 2008 at 07:52 AMI just read where the FDA approved Avastin, at $8000 a month, for metastatic breast cancer because it caused tumors to shrink for a while. It did not make patients feel better, and, in fact, its unpleasant side effects were specifically mentioned. It didn't make patients live longer. It make its manufacturers happier, because they get to sell more obscenely priced drug. It makes the oncologists happier, because they get to continue to pretend that temporary tumor shrinkage is a worthwile goal, despite the fact that neither quality nor quantity of life is improved. Maybe issues like this would make appropriate targets for a Dept of HHS that really wants to see Mediare survive a little longer.
Posted by: David Tribble, MD ABHPM FAAFP | February 25, 2008 at 05:06 PMMike Leavitt,
Please do the right thing & increase your budget proposal for 9/11 first responders.
These brave men & women from all 50 states served our country & deserve respect & proper care.
Sincerely,
Posted by: Paul Tarantino | February 27, 2008 at 08:11 PMPaul Tarantino
Mr. Levitt,
Posted by: jz-md | March 05, 2008 at 01:21 PMThe major problems with health care in this country are accessibility and affordability. In comparison, performance or "quality" is fantastic.
Your trials to define and reimburse "performance" is off the mark, and is just a thinly-veiled ruse to cut reimbursement. "Performance" indicators will incentivize MDs to fire their poorly compliant patients. These are the low-income patients.
Secretary Leavitt
I was privileged to ask you the second question from the floor after your enthusiastic presentation at HiMSS08. My question had to do with: Telemedicine, pending shortages of Medical personnel, the aging population, and CMS payment policy for Telemedicine. In this vain I would ask you to read the following:http://www.healthcareitnews.com/story.cms?id=8803
Gingrich, Center for Health Transformation push value of telemedicine
Telemedicine can improve access, lower costs and enhance the quality of healthcare and government should do more to remove barriers to its use, according to a new paper by the Center for Health Transformation.
On a parallel track, the VA is struggling to meet the needs of returning service men with PTS. Here again, I believe Telemedicine can move to the front by enlisting non VA
Psychologist, and Psychiatrist. Arizona has had a successful Telepsychiatry program for ten years. Please see :http://www.telemedicine.arizona.edu/updates/page4.htm Arizona is National Leader in TeleBehavioral Health
In support for your leadership for PHR/HER and ePrescribing I believe you will find the following informative:
Excerpted from: http://www.healthcareitnews.com/story.cms?id=4910
Dell has offered personal health records to its employees since 2004, but the employees had to fill in the information themselves, a time-consuming task, said Kathleen Angel, director of Dell Global Benefits.
Posted by: Ralph A Gierish | March 10, 2008 at 11:33 AM“The tool we’re announcing today is to be populated on a regular basis from claims data,” Angel said. Dell teamed up with WebMD to develop the tool.
Respectfully,
Ralph A Gierish
Member
Arizona Telemedicine Council
I am currently a MRSA patient, I have been fighting this for 6 months now. I work at the Grayson County Jail in Texas as a medic. for the inmates. MRSA is rampant in our jail, we have so many outbreaks that we wind up treating and dressing open MRSA riddled abcesses daily. To this day I am at home with a PICC line in my arm and unable to return to work because now after all of these months "I have a infectious disease" (strait from my supervisors mouth. Of course I didn't get it there even though I have never had anything like this before and am constantly in contact with it at the jail. Oh yea did I mention that they do not supply hand soap for us either, we supply our own. (this is our county HEALTH DEPARTMENT!)Scary huh! That's only the tip of the iceberg. I am so frustrated both mentaly and phisicaly because everybody scratches each other's back's here and you are left on your own to suffer and deal with it the only way you can. Workman's Comp. would be the first thing any normal person would think of, maybe I can turn to them and get some justice. (WRONG!) I see inmates suffer and they are treated with destain from the medical staff, this is a very painful problem and they are given ibuprophen for their pain only. I have tried to turn to OSHA but you see they don't govern counties and theres nothing they can do. These people don't even follow what common sence would tell you but the medical biohardous waste disposal guidelines. The biohazardous waste with MRSA wound drainage and sometimes even human flesh is just thrown away in the regular trash. How long do you think it would take for anyone to realize that all of the hands (inmate hands and public servant hands) it has to go through before before it get's to the landfill? How many other people are going to be infected with their reckless, careless ways before someone finally does something? I have nowhere to turn and nobody is listening! All I am asking for even if it doesn't benefit me it could the next person down the road is to please HELP US! Thanks For Listening, Angel
Posted by: Angel DeFratus | March 11, 2008 at 04:14 PMI think it's completely refreshing to see someone in your position who actually will listen to what others have to say. While your position requires a lot of hard work and time, your true connection to the people can be seen on a blog such as this. Please keep up the good work! Thank you.
Posted by: William | March 14, 2008 at 12:17 PMhttp://www.cube3design.com
Thank you for writing a very informative blog......it would be great to have more members of the administration write blogs to keep the American people informed
Posted by: Vectorpedia (Rick) | March 16, 2008 at 10:04 AMDear Secretary Leavitt,
Not knowing me, I feel it important to let you know that individuals you are familiar with, Dr. Mike McCoy, previous CIO UCLA, now with J. Marc Overhage and the Indiana Exchange, are both gentlemen in recent weeks familiar with the following information and very supportive.
IT systems in all the other vertical markets have only ever delivered (few exceptions)one significant value proposition to the user that in return supports adoption and generates a return-on-investment to justify paying the IT provider. That one thing has been a productivity improvement to the user and therefore a savings to the organization.
A CCHIT Certified EHR, which we are one of many who have that classification, will continue to suffer from lack of adoption resulting in unsustainable systems and failures we can all read about daily with 19% of the EHR systems being deinstalled in the ambulatory setting.
It seems the most valuable data in an EHR or PHR to healthcare providers and Medicare is the patient prescriptions and lab orders with the associated results. It is also where a significant portion of the $'s are spent. Prescriptions and labs are ordered in ambulatory care almost exclusively during the physician/patient encounter.
You may remember the name RX Connect. It was launched by PacifiCare prior to their Bank Call and becoming today United Healthcares PBM. The system was created and taken to PacifiCare by David S. Grant who was hired to lead the launch. Curiously it never suffered from adoption as it only takes a physician 4.5 seconds to e-prescribe and 1.5 seconds to reorder. The physician cannot write the labs and scripts that fast on paper not to mention that all background tasks are automatically incorporated. The system is point to point and can populate automatically the physican's EHR, the patients PHR or the community CDR like the Indiana Exchange approach. Medicare was incorporated in the original launch as a Payer.
The value proposition to the Payer that the system generates is mind boggling. In 90 days the empirical results of the PacifiCare launch proved the following:
1. The Insurer experienced a 35% overall savings in drug spend not including rebates.
2. 41% behavioral shift to lower cost alternatives at an average savings of $18.38 per shift to generic that the specific Payer preferred.
3. 37% Net-New mail order enrollment and utilization improving adherence while reducing costs
4. Full automated formulary management system.
5. 26% shift in compatible formulary agents yielding a significant increase in PBM manufacturer rebates.
6. 40% improvement in operational fulfillment efficiency to retail and mail pharmacies.
7. 11% reduction in potentially catastrophic errors due to ADEs. (TREND DATA ONLY). The Key is ADOPTION because you don’t avoid ADEs or acquire these results if the physician won’t use the system.
8. Reduction in hospital bed days and ALOS due to ADEs. (Analytics done by PacifiCare).
9. 4000% great adoption even in 2003 versus the nation's largest health plan sponsored initiatives. (Our information when broken down to average new orders per day from a leading ambulatory care EHR provider was, average order/day/Doc = 0.56 versus this system’s average of 11+/day see
10. 2500% greater adoption than current industry adoption metrics for e-prescribing.
11. Significantly improved Rx reconciliation due to accurate Provider data from the source. Rx-Hub has the same issue as SureScripts because the pharmacy adjudication systems loose a lot of SIG data.
12. Direct and indirect benefit to Medicare and commercially at risk patients.
13. Significant tangible and intangible social benefits and soft savings for the Provider in productivity improvements.
PacifiCare had a $2.0B drug spend in 2003. When extrapolating the data PacifiCare's savings approached $700M on only a $2.0B drug spend.
Success in your current deployment of funds from Medicare is our concern. We fear similar results will only continue without a practical solution to improve the physician's workflow during the ambulatory encounter. Note that the CEO's of RxHub and SureScripts have left to build a similar application although it may not incorporate Medicare/PBM requirements as EZRx, designed outbound originally with PBM requirements that generated the above empirical results but it substantiates the same topic.
As a 37 year successful IT supplier to the top 50 companies in the country, consider, if Microsoft's Word or Wang's original word processing system was less productive for your assistant than the original IBM Selectric Typewriter, you would still be using the Selectric Typewriter.
I am reaching out to you here as I know no other way but felt it important that you were personally aware that the technology exists and is already proven.
If we can help, how best can we do that?
Sincerely
David
Posted by: David G. Wallace | March 17, 2008 at 06:03 PMthe medicare Plan D Law is not working, you can't get medication that is not FDA Approved for what you take it for. and you can't get it from the drug company because I get 100% of the LIS which is the Low Income Subsidy and Extra Help. So what good is a Law that takes medication away from people. you won't post this because it will make you look bad.
Posted by: Jackie Hansen | March 18, 2008 at 08:37 PMSecretary Levitt, I hope you keep up the blog - I read it avidly. You've done a superb job at describing our healthcare predicament in a way that actually makes sense to a level that I can begin visualizing solutions. I like your proposed tactics on modernizing medicare through transparency. I've heard it said that we're handing the medicare problem onto our children... I'm beginning to feel like I am one of the children and the problem is already here. At 31 I sense that healthcare will by one of my generation's largest challenges. Ever think of running for President?
Posted by: Ryan | March 20, 2008 at 01:15 AMI appreciate your blog very much. This is he wave of the future whether people accept it or not. I appreciate you connecting with the regular folks. I think you will find that if a relationship is created with people this way, you will have very strong advocates when needed. Angel, MRSA is everywhere and I agree there is not enough information out there. I also deal with inmates and their belongings. I never touch the inmates just their property..and I have gotten it too. I think that it will be a full blown horrible epidemic before anything is done. My only take on it is that as long as its in the jail and homeless, no big deal will be made about it..but let someone of any stature , and they will get it and all hell will break loose! Hang in there, and use raw honey on your wounds...
Posted by: Carri Frederick | March 26, 2008 at 06:02 PMI had a bad experience with 2 hospitals. The 1st was is St. Mark's, they gave me morphine, I had a bad reaction to it and instead of helping me, they treated me badly. I went home sicker then when I came to them for help.
The second one is IHC. They had been good to me in the past. However, when my doctor went to the new facility, I was told to call her office for my medications and treatments. The doctor never got my messages. The secretary told me that her office does not do this anymore. Instead I was left out in the cold without a doctor and my medications. As a result I had to get another doctor, however, I can not see her until the end of August. So, I am doing without my medications and treatments.
I did a lot to get that facility built when I was a State Representative. It is a slap in the face at how horrible I was treated by some of the employees at that IHC. They owe me an apology.
Posted by: Loretta Baca | June 19, 2008 at 04:35 PMDear Secretary:
Posted by: PC | July 06, 2008 at 02:12 AMI am a 69 year old recently retired college administrator. I have had Blue Cross Blue Shield health insurance for years. When I retired this past January, I learned that I had to take Medicare as my primary and keep Blue Cross-Blue Shield as my secondary insurance. When I tried to make an appointment this past week with my physican of 8 years, I was told that the clinic is not making any appointments for Medicare patients because Medicare has not made payments to the clinic in several months. I have several serious chronic health conditions that need to be monitored. I don't know that to do. I do not want to change doctors, and I am afraid that another doctor will not take me because I would be a Medicare patient. This is very disturbing. I have worked for 40 years and contributed and now it appears that I am left in the lurch!
I think the entire Case Notification program should be revisited. It kinda seems like a waste as it is now.
Posted by: Robby | December 22, 2008 at 02:33 PM