Thursday, February 12, 2009

Urban myths about the stimulus bill

Within the next day or so, Congress is expected to give final approval to the stimulus bill. I have not yet seen the final language that House and Senate negotiators signed off on yesterday, but it appears likely that it will include three of ACP's top priorities: funding for health information technology, training of more primary care clinicians, and research on comparative effectiveness.

Some ACP members, though, have told me that they are concerned - as one long-time ACP member in California described it - that the bill will "allow the government to track everything we do for our patients and dictate the care we provide." The source of his information was a widely-circulated commentary by Betsy McCaughey, a fellow with the Hudson Institute and a former lieutenant governor for New York State.

Ms. McCaughey says that "Your medical treatments will be tracked electronically by a federal system ... One new bureaucracy, the National Coordinator of Health Information Technology, will monitor treatments to make sure your doctor is doing what the federal government deems appropriate and cost effective [which] would allow the government to track the care that doctors provide to patients."


The legislation codifies the role of the National Coordinator of Health Information Technology (which, by the way, was created by the Bush administration). The National Coordinator has absolutely no authority to require that physicians submit treatment data to the federal government. Instead, it will work with the private sector to make sure that electronic health records (EHRs) meet standards of usefulness and interoperability - something most physicians and patients should welcome.

The bill also gives physicians the opportunity to apply for Medicare payment subsidies - as much as $40,000 per physician - to help them buy a certified EHR. If a physician chooses to accept the incentives (it is voluntary, after all), he or she will have to agree to use the technology for meaningful uses that will improve patient care and provide some documentation that this really is the case. Meaningful purposes will be defined in more detail later on, but will be things like using the EHR to generate reminders that a patient is due for preventive screening, or making it possible for physicians to electronically participate in quality measurement and reporting programs. This in turn will create market incentives for EHR manufacturers to make sure that their systems actually have the capabilities needed to support such "meaningful purposes" that contribute to better patient care.

Think about it this way. Would you want taxpayers to subsidize EHR systems that don't have the functions needed to help clinicians make meaningful improvements in patient care? Why would physicians want to buy such systems? And what physician wouldn't want to use their EHRs to making meaningful improvements in patient care, as long as the EHR has the necessary capabilities?

It is true that physicians will eventually be subjected to Medicare payment cuts if they don't have a certified EHR. ACP has expressed concern about the penalties, and will work to assure that a number of pre-conditions are met - like true interoperability, affordability and functionality of EHRs - before any penalties could go into effect.

Finally, there is nothing in the legislation that gives the federal government the authority to mandate plans of care. The funding for comparative effectiveness research will go to two well-respected research entities, the National Institutes of Health and the Agency for Healthcare Research and Quality, not some new regulatory super-agency. This is what the Senate Finance Committee has to say:

Q: Can the government use the results of this [comparative effectiveness] research to tell me, or my doctor, what tests and treatments I can or cannot have?

A: Absolutely not. In fact, the Senate bill specifically prohibits the government from making any coverage decisions based on this research, or even from issuing guidelines that would suggest how to interpret the research results. The sole aim is to disseminate the results of the research to the public, so that patients and their doctors can make the best decisions for their specific situations, together.

It is one thing to make a philosophical argument against the government subsidizing things like EHRs, primary care, and comparative effectiveness. It is another thing to make wild exaggerations that have little or no basis in fact.

Today's question: What do you think of Ms. McCaughey's claims and my response to them?


Jay Larson MD said...

"Paranoia - a disturbed thought process characterized by excessive anxiety or fear, often to the point of irrationality and delusion"

Ms. McCaughey's commentary seems to meet this definition. Bob's response is right on target.

james gaulte said...

It will not matter if the CER does not have regulatory power,(if anyone figures out what the bill says in its final form) if CMS decides to use the panel's various findings to make care limiting decisions and cut costs.

Steve Lucas said...

Stepping into the world of business, an early concept taught in economics is that money can be made in chaos. The best example is war. Bombs and bullets are used with no residual value all for the sake of right vs wrong.

In medicine we are reaching the point where therapies can be tested against each other, or at least tracked, and when a preferred treatment is found, we will have a level of certainty regarding effectiveness and cost, thus eliminating the sales of products that have faired only slightly better than placebo.

Various entities in medicine see this possibility, and will use all of their past successful spin systems, to try and eliminate this potential loss of income. Fear of the unknown or contrived government scenarios are only two tools in this arsenal.

My reality is that the gravy train in drugs is over. The pantry is bare as there are no new blockbusters on the shelf. Device makers are falling under increased scrutiny for a number of reasons, and failures, and the list goes on.

The Friday night PBS show Nightly Business Report featured a short seller who was betting against the medical field. Quoting the often heard 16% of GDP, and our less than stellar results, he stated the obvious that people will not continue to pay this price in an economic downturn.

I feel much of the noise about CER is about preserving a dysfunctional financial lucrative system, not about preserving personal choice or patient need.

Steve Lucas