Friday, January 16, 2009

Stimulate this: Part 2

As I noted in yesterday's blog, the House of Representatives soon will be taking up a massive economic stimulus package.

I am still making my way through the massive proposal. (It takes awhile to digest $850 billion in new federal spending!) My initial reaction is positive, in that the proposal would fund some of ACP's top priorities: making health information technology more available to clinicians; training more primary care doctors; funding comparative effectiveness; ramping up the overall federal investment in health sciences research; and helping states maintain Medicaid coverage.

Still, I have some early questions:

Will the money on health information technology be spent wisely?

There are skeptics. Charlie Baker writes in the Health Care blog that HIT hardly meets the definition of "shovel-ready:"

"To put this in 'shovel ready' terms, if someone decides to put a new kitchen in their house, or a new bathroom, or a new bedroom, they usually put together plans that outline their end game before they begin. States that build roads, or renovate schools do the same thing. Plans, drawings, blueprints - call them what you will - but they lay out, in advance, how the goals and aspirations of each project are supposed to be achieved. Putting billions into Health IT without putting the plans together first - which is, in fact, what health care reform is all about - seems exactly backward to me."

ACP, in its own letter to HHS nominee Daschle, urged that HIT funding be prioritized and distributed to support applications that will help physicians achieve the capabilities to provide patient-centered care through a medical home.

Will the funding for primary care training result in Congress declaring victory - when there is so much more that will need to be done?

It is good to see that the bill proposes to spend $600 million to train more primary care clinicians through the National Health Services Corps (although it's not clear how much of this will go to physicians versus other professions). By itself, though, expanding the NHSC will not be enough to address a primary care workforce crisis that is spinning out of control. Just last week, the Institute of Medicine reported that 16,261 additional primary care physicians are now needed to meet the demand in currently underserved areas.

To be clear, I think it is good thing that the stimulus bill recognizes the importance of primary care and health information technology. And the provisions to help states maintain their safety net programs and to assist people who may lose health insurance are essential.

I also think though that the HIT funding needs to be targeted to do the most good. And a heckuva lot more is needed to save primary care - including raising primary care payments so they are competitive with other specialties.

Today's questions: Do you support the priorities in the stimulus bill? Would you spend the money differently or better?


Steve Lucas said...

Not being a doctor I offer a bit of an outside view. First, $600M for physicians is a large amount of money, but is not $20B, and less than half the fine Lilly will pay for Zyprexa problems.

With the proposed increases in insurance coverage we will need more physicians. Sorry, but this becomes a bodies calculation, just to service the influx of new patients, and that is without any changes in service standards. I would like to see physicians spending more time with patients and the new patients will require a great deal of time.

We as a society are facing a great issue with the cost of education, starting at the undergraduate level. Simply put, many students are not attending the college that matches their ability due to cost and we are thus loosing not only doctors, but lawyers, engineers, and basic scientist to high tuition prices. This is being seen in state supported university's where presidents with multi-million dollar contracts main function appears to be to secure muti-billion dollar endowments.

The government does have experience with large distributed computer projects and the results were fraud, over billing and kickbacks. A number of years ago at the beginning of one such project my attorney wife was called into her bosses office where her boss and a 25 year old computer guy spoke and told her she had to go since she would ruin their "deal." My wife was then put in a corner with no duties while the computer project continued.

The "deal" was vendors would develop a module for the project in one state, and then export it to other states, and bill all those involved full price. The computer people racked up large over time bills while having pizza and enjoying outings to sporting events and leather jackets. In the end people resigned and a great deal of political currency was used to cover the whole thing up. Nobody was prosecuted.

I am sure the $20B figure received a great deal of support from some very major corporations. My inclination would be to hold off on spending this money, instead funding a tightly controlled pilot project that could then be exported to the various uses with all of the major flaws identified and resolved.

I view our major problems as cost of education for all professionals, combined with producing a viable work environment and a fair compensation system. Throwing $20B into the shark tank will not accomplish this goal and I do not know that $600M will solve our doctor shortage and compensation issues.

Steve Lucas

furrydoc said...

This one takes some thought. I might wonder why $0.6B to bring a lot more healing hands and redistribute talent but twice that sum, $1.1B for many fewer people to tease out what the primary physicians and their consultants actually did to move their patients ahead. And how does one accomplish all this research without siphoning medical school alumni away from direct patient care?

What this really looks like is a giant financial trough that can accomodate a lot of hungry snouts, each interest wanting to take its own gobble from the monetary slop. That would include us physicians and let's not forget a few morsels to the failing insurance industry that once cheated us and encouraged our medical students to take specialty residencies or a boost for COBRA and Medicaid in case people still don't have jobs when all is said and done.

rich the furrydoc