In Support of Senator Tom Harkin (D-Iowa)

“The Affordable Care Act, the health care law of 2010, created a Prevention and Public Health Fund.
The fund is an unprecedented investment in promoting wellness, preventing disease, and protecting against public health emergencies.
Much of this work is done in partnership with states and communities, which are already using Prevention Fund dollars to help control the obesity epidemic, fight health disparities, detect and quickly respond to health threats, reduce tobacco use, train the nation's public health workforce, modernize vaccine systems, prevent the spread of HIV/AIDS, increase public health programs’ effectiveness and efficiency, and improve access to behavioral health services.
…..
With this investment, the Affordable Care Act helps states and the nation as a whole focus on fighting disease and illness before they happen.” – HHS.gov

Sounds magnificent, doesn’t it? Section 4002 of the Affordable Care Act (ACA) authorized the appropriation of $15 billion over ten years to be used for public health by the Secretary of Health and Human Services (HHS), and last year a third of that was taken away during budget negotiations to support other unrelated worthy endeavors. During 2010 and 2011, the Fund spent $1.25 billion on various public health activities, including $198 million on additional primary care residencies and physician assistants training. In 2012 the Fund allocated approximately $1 billion to various community efforts ranging from early childhood obesity prevention to Alzheimer’s education and support. For 2013, the Fund is planning on spending half that much on prevention and public health, while diverting $453.8 billion to CMS to assist with enrollment in the new health insurance exchanges. So out of the original $15 billion allocated to public health and prevention, only a fraction will go to its intended purpose, unless of course the Republican sponsored Helping Sick Americans Now Act defunds the entire thing through 2016 to replenish the stopgap Pre-Existing Conditions Insurance Plan which ran out of money earlier this year.

The public health fund from its inception was just an effort to make communities where most Americans live and work more conducive to healthy lifestyles through a variety of small investments in infrastructure improvements, services, education and research. There is quite a bit of health IT in the Fund, but instead of the sexy fly-by-night EHR type of IT that gets all the media attention and all the money we don’t have, the Fund is supporting electronic infrastructure for immunizations, infection prevention and surveillance, data collection and analysis of health indicators for various purposes. The Fund was a long term proposition and it was never clear how businesses profit directly from its moneys, if at all, thus it came under attack almost immediately when in September 2010, Republicans proposed to defund it to pay for things that would save real dollars to the business community in the here and now. In some circles the Fund was referred to as a “slush fund for jungle gyms”, because obviously playgrounds for children are much inferior to proper pharmacotherapy for the next generation of obese diabetics.

But the Fund had many Democrat champions who (almost) consistently, and selflessly, went to bat for the wellbeing of future generations. For example, in April 2012, shortly after shaving off one third of the Fund’s money to pay for the payroll tax cut extension package, Democrats made a stand and refused to allow others to join in the pillaging of the same Fund, this time to pay for a student loan interest reduction program. In a brilliant strategic move, Minority Leader Nancy Pelosi, surrounded by an all-female legislative chorus, called the Republican bill a "continuation of the assault on women's health" and suggested that student loan interest reductions should be paid by taxation of oil companies. This of course, had nothing to do with the Presidential election and the gender issues carefully cultivated to defeat a slew of idiotic Republican candidates taking turns at making the most medieval statements about 50% of the electorate.

In the past, all attempts to take money out of the Fund somehow required Congressional approval, but in a recent development it seems that the administration that created the Fund, and valiantly defended it over the years, can now freely treat public health as a true “slush fund”, and quietly divert as much funding as it deems appropriate to other activities without an up or down vote in Congress. Obviously this does not qualify as an “assault on women’s health” because most women, and men, are not aware that hundreds of millions of dollars are proposed to be diverted from public health to paying “navigators” for the new health insurance exchanges. And as the Secretary of HHS, who is able to do what an elected Congress cannot, pointed out, the money will still indirectly support preventive care because the navigators will help Americans to enroll in health plans that give them preventive benefits.

Until now, most people were able to purchase health insurance without hiring a consultant, but it seems that the new health insurance exchanges, that were meant to simplify the process, require that the government provides us with personal shoppers to expedite the transfer of taxpayer subsidies to big corporations. And since the government is buying us preventive care, such as screening for obesity and diabetes (but not necessarily treatment for either one), we don’t need to actually prevent obesity and diabetes by building sidewalks, playgrounds or gardens in our communities. Makes sense, doesn’t it?

It didn’t make much sense to Senator Tom Harkin, who is not running for any more reelections, so is now free to stand for principles. In a seemingly unrelated move, Mr. Harkin chose to block the nomination of Marilyn Tavenner to head the Centers for Medicare and Medicaid Services (CMS), until the Obama administration is willing to negotiate its private raiding of the Preventive and Public Health Fund. The former champions of the Fund seem a bit irked by Mr. Harkin’s position, particularly because the nomination of Ms. Tavenner was a rare moment of bipartisan support (most likely because she is not seen as an obstacle to privatizing Medicare and Medicaid), and like a typical battered spouse, the Democratic Party is desperate to enjoy this brief moment of validation from its abuser.

You will not win this one, Mr. Harkin, and any “negotiation” on the amounts stolen from public health this year will be more than made up for after you retire, but sometimes making a stand on behalf of the people is more important than winning the battle, something this administration never understood, and watching an elected official represent the interest of the public instead of private or party interests, may very well affect public health infinitely more than the moneys currently at stake.
So stay the course Mr. Harkin, and let Mr. Harry Reid file cloture if he must, and let this be a lesson in integrity for future generations. Godspeed and thank you!

Fast Medicine

How are you feeling today? Do you feel a bit under the weather? Maybe you have some aches and pains, or a miserable flu, or maybe you have some chronic condition like diabetes or asthma, or some other ailment. Perhaps you could benefit from medical attention, but then again getting medical care is so darn inconvenient and expensive and time consuming, and everybody knows that our health care system is broken, and that health care is full of carelessly infected people, who waited many months just to be pushed around, maimed and exploited by arrogant doctors who never wash their hands, before being packed onto jumbo jets that fall out of the sky on a daily basis. Obviously, something must be done, and soon, or we are all going to crash and burn, or worse, go bankrupt.

Fortunately the uniquely American entrepreneurial spirit of innovation, fueled by unimaginable advances in technology, is finally galvanizing its efforts to fix the American health care tragedy, just like it fixed finance, food, retail, transportation and all sorts of other industries, to our utter delight and immense benefit. It’s also nice to see that in the spirit of global cooperation, our friends across the pond are pitching in with innovative ideas of their own. In the April issue of Health Affairs, two top shelf researchers from England are informing us that a “A Key To Slower Health Spending Growth Worldwide Will Be Unlocking Innovation To Reduce The Labor-Intensity Of Care”. Observing that labor costs are the largest contributing factor to the rising costs of health care, the authors reach the inescapable conclusion that “there is great potential to reduce costs while preserving the quality of care by experimenting with delivery models that require a less costly skill mix”, and they have plenty of examples to support this theory. In Mexico, for instance, people “pay $5 per month to access a health advice hotline before setting foot in a physician’s office” and in India, “assembly line–style eye surgery has dramatically reduced cost without sacrificing quality”. The idea is to utilize technology and innovative labor arrangements to deploy health workers with limited formal training “in a variety of contexts”. “Deployed in low- and middle-income countries to address labor shortages, they could also be used in developed countries to reduce the need for the most highly skilled clinicians”. The main epiphany for me here was that poor countries, with billions of unemployed starving people, can have “labor shortages”!!

But other than that, America is way ahead on this one, and since primary care is, well, primary, it is also the primary place to begin the cutting of “highly skilled clinicians”. The latest buzz comes from Walgreens’ announcement that its NP staffed retail clinics will now begin diagnosing and treating chronic disease, thus reducing the need for the highest skilled clinicians. The prices are advertised, of course, and look pretty reasonable at between $79 and $122 for an established patient exam, excluding tests, procedures and complicating factors. To illustrate our savings, the Medicare Physician Fee Schedule for an average established patient visit (CPT 99213) is currently $72.81 (national average). For the most complex office visit for an established patient (CPT 99215), Medicare pays doctors $142.90 on average. Convenience is of course priceless, but some caution is necessary because Walgreens may not be willing to “care” for you after all.

In the same issue of Health Affairs, several folks employed by Walgreens are exploring another technology driven, cost-reducing innovation. Using data analytics and health risk assessments ($89 at its retail clinics), Walgreens is introducing the concept of “impactibility modeling” to be layered on top of predictive risk-stratification analytics in order to identify patients who “may not be amenable to the proposed preventive intervention”. So “[a]lthough certain subpopulations are at high risk, they may be denied preventive care because they are not expected to respond to it”. Basically, why spend money on lost causes, “such as people with cognitive or other mental health disabilities and those who have language barriers. Or an organization may exclude all of the very highest-risk patients, because such patients are sometimes regarded as being less amenable than others to preventive care”. Following a convoluted attempt at explaining the ethical aspects of this innovation, the authors recommend that more data should be collected, that “there should be appropriate ethical reviews” and that some pilots be initiated.

Now that we’re pretty much done with primary care doctors and really sick individuals, perhaps we can take our savings up a notch. Health Affairs seems to be a veritable treasure trove of innovation these days, and in its February issue, we find an article from Health Partners in Minnesota reporting $88 savings for each simple episode of care administered by their Virtuwell platform. I have to admit that the logic behind their savings calculations escapes me, but their exquisitely high tech platform is the epitome of labor intensity reduction. You go online, provide a valid credit card number, fill out a bunch of forms answering questions about your condition and medical history (perhaps Barton Schmitt, or something similar), and in 30 minutes or less you receive your diagnosis and plan, from an NP somewhere, including prescriptions and referrals if necessary, for a flat fee of $40. You may call if you must, and you will receive an electronic message in a few days to make sure all is well. This is way better than the Mexican hotline model as far as eliminating skilled jobs, and with some more intelligence injected into the protocols, perhaps a little Watson style analysis, we could probably get rid of the NPs altogether.

A small step in this direction can be found at Walmart, CVS and Safeway, where SoloHealth is deploying their health assessment stations which provide “free and convenient access to healthcare”. You can screen your vision, blood pressure, weight, body mass index and as many ads as will fit in 7 minutes or less. All for free. This is not really treatment of disease just yet, but the potential is certainly there. Perhaps you can talk to the Station for 7 minutes, then go shopping, and come back in 30 minutes to get your Virtuwell diagnosis and script, and 30 minutes of shopping, particularly with pediatric patients in tow, could be worth enough to the hosting retailers to be able to share a portion of earnings with the Virtuwell platform owners. Isn’t it amazing how innovations can feed of each other to generate cheaper and more convenient innovations?

If you’re still not convinced, here are a couple more things to consider. First, the fee-for-service issue is automatically resolved by switching health services venues, because retail is one of those more advanced “other industries” and therefore perfectly fine with fee-for-service. Second, everybody wins because retail health care, other than being free and very convenient for shoppers and retailers, has a built in operational feedback loop. You go to a convenience store, load up on soda, Cheetos, Doritos, gummy bears and 50% off holiday candy, screen yourself online, go buy some smokes to alleviate the tension, get diagnosed with diabetes amenable to care, get your prescription filled, and on your way out pick up some of the stuff mentioned on the screening station screen, or recommended for purchase on your patient education handouts, and some beer to go with the smokes and the generic Metformin (it’s not like the machine can tell, right?). Rinse and repeat every three months or sooner if you start experiencing chest pain. They do treat cardiovascular disorders too. And don’t worry; you will get plenty of proactive outreach reminders if you forget your next appointment, from the retailer, the various ad sponsors and your dedicated zero-skills care team. How much more convenient can it get? Problem solved.

Game of Interoperabilities

In 2004 President Bush created the Office of the National Coordinator for Health Information Technology (ONC), introducing the notion that Health Information Technology (HIT) should be nationally coordinated. One of the first endeavors of ONC was the planning and design of a National Health Information Network (NHIN) as a means to facilitate the exchange of electronic health information among providers and Health Information Exchange (HIE) entities. This was, and still is, a grand vision of an interconnected health care ecosystem, inclusive of all governmental agencies and all stakeholders who in any shape or form make a living or a profit from servicing the health care needs of the nation (see image below).

To prime the pump for enough electronic information to be exchanged, the new ONC made grants to the American National Standards Institute (ANSI) for the creation of a Health Information Technology Standards Panel (HITSP) to assemble standards for the exchange, and to RTI to create the Health Information Security and Privacy Collaborative (HISPC) to work with business stakeholders at a State level. Both these committees are defunct now, but HITSP had a very productive and highly visible lifespan, attracting sponsorship from government contractors and trade associations. In addition, ONC also awarded a grant to a new entity, the Certification Commission for Health Information Technology (CCHIT), which was pulled together by the American Health Information Management Association (AHIMA), the Healthcare Information and Management Systems Society (HIMSS) and the National Alliance for Health Information Technology (NAHIT). Both AHIMA and HIMSS are flourishing these days, but NAHIT voluntarily dissolved itself (and removed its website). The funding for CCHIT was aimed at creating a certification program for Electronic Medical Records (EMR), including interoperability capabilities. In 2006, CCHIT began certifying EMR software and was the sole government designated Recognized Certification Body (RCB).

(click image to enlarge)
Source: CONNECTing to the Nationwide Health Information Network (NwHIN): The Road Ahead

In 2009 President Obama injected much needed stimulus dollars and empowering legislation into the ONC. The HITECH Act opened a new era of prosperity for all things HIT. The prolific HITSP and the less stellar HISPC were replaced by two brand new Federal Advisory Committees, an HIT Policy Committee and an HIT Standards Committee to make recommendation to the reinvigorated ONC in its efforts to implement the Meaningful Use incentives program. CCHIT lost its unique certifier position and became just one of several government sanctioned certifiers of Meaningful Use compliant Electronic Health Records (EHR). The NHIN, now part of the Federal Health Architecture (FHA), acquired a new open source gateway called CONNECT first deployed in 2009 to connect the Social Security Administration (SSA) and MedVirginia for the processing of electronic disability claims. But the NHIN, with its stringent requirements for blessings from the Federal Bridge Certification Authority (FBCA) and a rather uninviting CONNECT gateway, was judged to be a bit too heavy and slow to provide instant gratification. So in 2010, NHIN was given a new smaller and nimbler sibling, aptly named NHIN Direct, intended to facilitate health information exchange through something as simple and as ubiquitous as email attachments (encrypted, of course).

For one reason or another, NHIN changed its name to the much hipper NwHIN (Nationwide Health Information Exchange) and NHIN Direct dropped its NHIN name affiliation to stand on its own as the Direct Project. The ONC then initiated a major push to have its various grantees (e.g. State HIE, Regional Extension Centers, and Beacon Communities) exchange health information through the Direct Project flavor of secure email. Most HIT vendors complied and implemented the Direct Project specifications in their products. In 2011, the ONC created the Standards and Interoperability (S&I) Framework, “a collaborative community of participants from the public and private sectors who are focused on providing the tools, services and guidance to facilitate the functional exchange of health information”. Started with three initiatives, the S&I Framework now includes dozens of projects and workgroups, managed by government contractors presumably on a volunteer basis, and the Direct Project has been folded into this new framework, and shortened its name to Direct.

In the meantime outside the confines of ONC, interoperability players can trace their pedigree to 1997 when HIMSS and the Radiological Society of North America (RSNA) created an organization named Integrating the Healthcare Enterprise (IHE) to develop frameworks and specifications (profiles) for health information exchange. IHE has been very active and very prolific over the years. In 2011, the EHR/HIE Interoperability Workgroup (IWG), a consortium of States and HIT vendors, with a goal of “increasing the adoption of EHRs and HIE services”, was created by the New York eHealth Collaborative (NYeC), an organization with extensive ties to ONC, founded in 2006 to facilitate HIT adoption and health information exchange in the State of New York. Leveraging IHE work, the workgroup created guidelines and specifications “to promote a scalable approach that allows for rapid deployment at an affordable price, thereby expanding market opportunities for vendors”. Around the same time, Mayo Clinic, Geisinger, Kaiser Permanente, Intermountain Healthcare and Group Health formed the Care Connectivity Consortium (CCC) to “demonstrate that effective and timely health information exchange using the latest national IT standards is possible in a secure environment and among geographically disparate health care providers”. Things were beginning to heat up.

In May 2012, the ONC requested public comments on its strategy for governing health information exchange through its NwHIN. The ONC envisioned a set of Network Validated Entities (NVEs), similar to the Direct email intermediaries, Health Internet Service Providers (HISPs), specifically built for, or specializing in, the exchange of health information, and it outlined policies and regulations to be adhered to by participants in information exchange as “conditions for trusted exchange” (CTE). By October 2012, the ONC decided to transition the NwHIN community management to a new public-private entity named Healtheway and rename it eHealth Exchange. Almost immediately, Healtheway formed a Coalition with the NyeC spawned IWG to combine harmonization of standards and market share. The next step was an announcement that the Coalition selected CCHIT to “certify that the interfaces between the HIT and HIEs are consistent across multiple states and systems”. 2012 also saw the creation of DirectTrust, an entity whose goal is to “to develop, promote and, as necessary, help enforce the rules and best practices necessary to maintain security and trust within the Direct community, and to foster widespread public confidence in the Directed exchange of health information”. In December, ONC announced its intention to provide grant funding to “entities already involved in governance of health information exchange” and forgo its own regulatory plans.

During the 2013 HIMSS season, the Coalition announced a collaboration agreement with the CCC to take advantage of the CCC “advanced services that address the complexities of patient matching, consent management and, eventually, population care”, and CCHIT announced three new certifications, one for EHRs connecting to HIEs, one for HIE to HIE connectivity and one for Direct users. Across town, DirectTrust, in partnership with the Electronic Healthcare Network Accreditation Commission (EHNAC), announced its Direct Trusted Agent Accreditation Program, DTAAP, for HISPs, Certificate Authorities, and Registration Authorities, which may or may not be EHR or HIE vendors. Also at the HIMSS extravaganza, a new Alliance, consisting of several very large EHR vendors, named CommonWell entered the interoperability fray, announcing its plans “to promote and certify a national infrastructure with common standards and policies” and to “ensure that products that display the CommonWell Health Alliance seal have been certified to work on the national infrastructure”.

It is important to note that, all the organizations described here (except the government, of course) are not for profit corporations and most are supported by government grants to certain degrees.  They all charge, or plan on charging, some sort of membership and/or subscription fee, and by my last count at least three of them plan on offering, and charging for, certifications of software products used to exchange health information in any way. Also interesting is the fact that HIT vendors are participating in multiple organizations, so for example an EHR vendor can be part of both the Coalition and the Alliance, or part of none. Fortunately though, most leaders of these new entities, are currently, or were in the past and presumably will also be in the future, involved in the various ONC regulatory and technology specification activities.
The factions described here are by no means the only actors in the health information exchange game. Such revered standards organizations as HL7, NCPDP and ASC X12, who have been supporting practically all health care interoperability efforts on their own for many years, or the various international open standards groups, or the hot new BlueButton initiative, are not really contenders for what’s at stake here, but should be acknowledged for completeness sake. 

So last week, ONC picked its favorites and granted less than half a million dollars, split between DirectTrust and the IWG, and their partners, to bolster their existing attempts at governing the national exchange of health information. Congratulations to both.

What does this all mean? I am not sure. Season 13 looks promising, and your guess is as good as mine. I just like watching the cute little flame-throwing dragons…