Tuesday, August 31, 2010

Whatever happened to the Patients' Bill of Rights?

One of the more surprising twists and turns in the continuing debate over health care reform is that many physicians who now object to the Affordable Care Ac t (ACA), were, just a few years back, advocates for more federal regulation. In fact, in the early 2000s, more than 200 "provider" and consumer groups - including many state medical and national medical specialty societies that now oppose the ACA because of concerns about "excessive regulation" - were among the fiercest champions of federal legislation to mandate that health insurers comply with a Patients’ Bill of Rights. A bipartisan bill introduced by Senator John McCain (R-AZ) and the late Senator Ted Kennedy (D-MA) would have ensured that patients have the "right" to appeal insurance company denials to independent reviewers, to choose a specialist of their choice, and to access emergency room services when needed. This effort to enact a federal Patent Bill of Rights failed, because of opposition from the insurance industry and President George W. Bush.

I bring up this history lesson because most of the key provisions in the McCain-Kennedy bill are now the law of the land, thanks to the Affordable Care Act. Yet instead of applauding the new protections, many of the same physician organizations who called for a federal Patients' Bill of Rights now want to "repeal" the same consumer protections established by the ACA.

I understand that times, circumstances, and opinions change. It is not unreasonable, for instance, for physicians who advocated for the Patient Bill of Rights to now object to a almost one trillion dollar price price-tag associated with the coverage provisions in the ACA.

But the history of the Patient Bill of Rights is illustrative in one very important sense. It shows that physicians (like most of the rest of) have not held consistent views on the question of whether we need more or less federal regulation of health care. When the issue was in opposition to insurance company "gatekeepers" that limited access to specialists, most physicians were quite willing to have the federal government prohibit such practices.

Similarly, a staple of mainstream conservative thought is that the federal government should not pre-empt state "rights"- but not always. For instance, when it comes to medical liability reform, most conservatives (including right-leaning doctors) favor enactment of a federal law to impose limits on non-economic damages on states that do not have such caps.

I also don't know of many physicians who would repeal Medicare, or the Food and Drug Administration, or the National Institutes of Health.

My point is that Americans - including most physicians - accept the idea that the federal government has a responsibility to regulate health care, and even the most conservative doctors have championed MORE federal regulation (e.g. in the case of the Patient Bill of Rights and tort reform) when it has been in their interest. The debate, then, should be over how much federal regulation is needed, instead of oversimplifying the issue as one of being "for" or "against" federal regulation.

Today's questions: How much federal regulation of health care is needed?

Friday, August 27, 2010

Are doctors too cozy with drug companies?

The public thinks so, according to a new survey. The Consumers Report health blog writes that:

"More than two thirds, or 69 percent, of consumers surveyed said they think drugmakers have too much influence on doctors' decisions about which drug to prescribe. Half of those polled said they feel doctors are too eager to prescribe a drug rather than consider alternate methods of managing a condition. And 47 percent said they think gifts from pharma companies influence doctors to prescribe certain drugs, with 41 percent saying they think doctors tend to prescribe newer, more expensive drugs.”

The medical profession has taken steps to reduce financial practices that influence physicians' prescribing practices. A new voluntary code by the Council of Medical Specialty Societies (CMSS) has won praise in some circles including from the American College of Physicians.

Some purists would completely sever the link between physicians and pharmaceutical promotions, including banning any industry support for continuing medical education. I wonder, though, if an outright ban would have unintended adverse effects on patients. For instance, as this commentary points out, without pharmaceutical grant support, CME programs would likely have to charge higher registration fees to cover their costs, which likely could cause some physicians to forgo CME altogether, and reduced external funding could adversely affect the quality of CME.

Discussions of a ban on all drug company support for CME must address the competing public good of ensuring the availability of high quality and affordable CME and reducing undue industry influence over physicians. In my mind, the CMSS code strikes the right balance.

Today's questions: Do you think drug companies have too much influence over physician prescribing? Do current voluntary codes, like CMSS', go far enough?

Thursday, August 19, 2010

A "Home Grown" Rocky Mountain High

Writing for Kaiser Health News, reporter Bill Scanlon recounts the remarkable success Grand Junction, Colorado has had in improving health outcomes and saving money. He writes that Grand Junction has adopted five key reforms:

"Health Partnerships. Grand Junction's doctors, hospital and the dominant insurer, Rocky Mountain Health Plan, work together on patient care, with many of the doctors on salary rather than being paid for each procedure they do.

Primary care. The Grand Junction health system highlights disease prevention and management of chronic conditions to reduce expensive hospital visits, an emphasis that is also a key component of the new health law.

Treatment protocols. The local physicians and health plan have agreed to guidelines in terms of treating common problems, such as diabetes and lower back pain, based on best practices.

Electronic medical records. Doctors and medical facilities in the area use a region-wide electronic medical records system. It also means a physician's peers can see what he is doing and evaluate his style of care.

Medical homes. Nearly all patients here have a personal doctor who oversees primary care. Such 'medical homes' are also being advocated in the health overhaul."

This isn't the first time that Grand Junction has been featured as a poster child for a better health care system. The Los Angeles Times published a fascinating five part series on Grand Junction, also authored by Scanlon.

Can Grand Junction's approach be replicated? On this, there is less agreement, although many health policy experts believe that the key elements described above can be successfully adapted elsewhere.

Congress clearly believes so. The new health reform law, the Affordable Care Act, provides for a substantial investment of federal dollars to promote accountable care organizations (similar in concept to Grand Junction's health partnership), pilot-testing of alternatives to fee-for-service, new models to train and compensate primary care physicians, adoption of evidence-based treatment guidelines, and rapid expansion of patient-centered medical homes. The federal government also plans to spend billions of dollars to encourage clinicians to adopt electronic health records.

But as the federal government should heed another lesson from Grand Junction: let the doctors and hospitals decide. Scanlon quotes Dr. Michael Pramenko, a primary care physician and leading advocate for Grand Junction's reforms, on the importance of letting communities do their own thing:

"Pramenko says the beauty of the co-op is that the community can make its own rules. That lowers the tension in the public vs. private health-care debate, he asserts. 'If government makes the law that says doctors have to do this, they will get resistant,' he says. 'But if it's home-grown and if we make the rules together and we're all in this together, there's much more buy-in by the local physicians.'"

So my unsolicited advice to CMS Administrator Berwick is this: yes, the federal government should provide seed money for physicians and hospitals to develop their programs to improve outcomes and reduce costs, modeled on the key elements that have worked in Grand Junction. But don't impose so many strings that it strangles home grown initiatives from taking root.

Today's question: What do you think is the "take home" messages from Grand Junction?

Monday, August 16, 2010

"If you are a physician, much has been given to you. What are you going to do with it?"

I am going to do something unusual today - reprint in its entirety, below, a commentary from a 4th year medical student, Jonathan. He posted it in response to comments from other readers to my blog about Dr. Berwick's commencement address to his daughter's med school class.

Just a few minutes ago, I tweeted about Jonathan's post, calling it a needed voice of idealism at a cynical time. This is what Jonathan had to say to his physician-colleagues:

"To begin, I am a fourth year medical student going into primary care and this directly applies to me ...

We have two options when reading this [Dr. Berwick's] address:

We can take, in my opinion, the weak road or the strong road. Our new generation, as well as the one that raised us, is one of apathy and selfishness. We are only concerned about how changes affect us. We have lost the sacrifice and the consideration of our patients and fellow staff. This address, no matter how hard your heart may be, springs up a humanism in you that is undeniable. You can choose to brush it off and make excuses about policies and money, or you can stand up and be the physician that is described. I agree that there are a lot of issues in medicine today (billing, paperwork, bureaucracy to name only a few). However, if those issues render you cold and uncaring, my friend, I strongly suggest you find another profession. This profession is one of nobility. It is one of selfLESSness. This is a high calling. A good book states, 'To whom much has been given; much will be expected.' Well, if you are a physician, much has been given to you. What are you going to do with it?"

Today's question: How would you answer Jonathan?

Wednesday, August 11, 2010

Dr. Berwick, in his own words, to his own daughter

Today, I came across an outstanding commencement address given by Dr. Don Berwick to his daughter's graduating medical school class. Read what he had to say to these newly-minted physicians, and tell me, do his words fit the description of the "rationer-in-chief" ascribed to him by his critics?

(Although I encourage you to read the address in its entirety, major excerpts are presented below.)

"Dean Alpern, Faculty, Families, Friends, and Honored Graduates ...

I don't have words enough to express my gratitude for the chance to speak with you on your special day. It would be a pleasure and honor at any graduation ceremony. But, I have to tell you, to be up here in this role in the presence of my own daughter on the day that she becomes a doctor is a joy I wouldn't dare have dreamed up. I hope that each of you will someday have the chance to feel as much gratitude and pride and love as I feel right now, joining you, and, especially, joining Jessica. Thank you very much. I am so proud of you, Jessica ...

... Let me read to you an email I received on Thursday, December 19, 2009. It came from Mrs. Jocelyn Anne Gruzenski - she goes by "Jackie." I did not know Jackie Gruzenski at the time; she wrote to me out of the blue. But I have since connected with her. And, she gave me permission to read her email to me to you. Here's what she wrote:

'Dr. Berwick,

'My husband was Dr. William Paul Gruzenski, a psychiatrist for 39 years. He was admitted to (a hospital she names in Pennsylvania) after developing a cerebral bleed with a hypertensive crisis. My issue is that I was denied access to my husband except for very strict visiting, four times a day for 30 minutes, and that my husband was hospitalized behind a locked door. My husband and I were rarely separated except for work,' she wrote. 'He wanted me present in the ICU, and he challenged the ICU nurse and MD saying ... 'She is not a visitor, she is my wife.' But, it made no difference. My husband was in the ICU for eight days out of his last 16 days alive, and there were a lot of missed opportunities for us.'

Mrs. Gruzenski continued: 'I am advocating to the hospital administration that visiting hours have to be open especially for spouses... I do not feel that his care was individualized to meet his needs; he wanted me there more than I was allowed. I feel it was a very cruel thing that was done to us...'

Listen, again, to the words of Dr. Gruzenski: 'She is not a visitor; she is my wife.' Hear, again, Mrs. Gruzenski: 'I feel that it was a very cruel thing that was done to us.'

'Cruel' is a powerful word for Mrs. Gruzenski to use, isn't it? Her email and the emails that followed that first one are without exception dignified, respectful, tempered. Why does she say, 'cruel'?

We will have to imagine ourselves there. 'My husband and I loved each other very deeply,' she writes to me, 'and we wanted to share our last days and moments together. We both knew the gravity of his illness, and my husband wanted quality of life, not quantity.'

What might a husband and wife of 19 years, aware of the short time left together, wish to talk about - wish to do - in the last days? I don't know for Dr. and Mrs. Gruzenski. But, I do know for me.

I would talk about our children. I would talk about the best trip we ever took together, and even argue, smiling, about whose idea it was ... We would have so much to talk about. So much. The nurses would pad in and out of the hospital room, checking i.v.s and measuring pulses and planning their dinners and their weekends. And none of what the nurses and doctors did would matter to us at all; we wouldn't even notice them. We would know exactly who the visitors were - they, the doctors and the nurses. They, they would be the visitors in this tiny corner of our whole lives together - they, not us. In the John Denver song it goes this way, '... and all the time that you're with me, we will be at home.'

Someone stole all of that from Dr. and Mrs. Gruzenski ... Someone who did not understand who was at home and who was the guest - who was the intruder ...

Of course, it isn't really 'someone' at all. We don't even know who, or what it is. Its voice sounds rational. Its words are these: 'It is our policy,' 'It's against the rule,' 'It would be a problem,' and even, incredibly, 'It is in your own best interest.' What is irrational is not those phrases; they seem to make sense. What is irrational is what follows those phrases, in ellipsis, unsaid: 'It is our policy ... that you cannot hold your husband's hand.' 'It is against the rules ... to let you see this or to let you know this.' 'It would be a problem ... if we treated you on your own terms not ours.' 'It is in your own best interest ... to miss your daughter's moment of birth.' This is the voice of power; and power does not always think the whole thing through. Even when it has no name and no locus, power can be, to borrow Mrs. Gruzenski's word, 'cruel.'

I want you to celebrate this day. I want you to experience all of the pride, all of the joy that it brings you to have reached this milestone. I am not telling you Dr. and Mrs. Gruzenski's story to sadden you. I am telling it to inspire you. I want you to remember it, if you can possibly remember anything I am saying to you at this chock-full moment of your lives, because that story gives you a choice.

You see, today you take a big step into power. With your white coat and your Latin, with your anatomy lessons and your stethoscope, you enter today a life of new and vast privilege. You may not notice your power at first. You will not always feel powerful or privileged - not when you are filling out endless billing forms and swallowing requirements and struggling through hard days of too many tasks.

But this will be true: In return for your years of learning and your dedication to a life of service and your willingness to take an oath to that duty, society will give you access and rights that it gives to no one else. Society will allow you to hear secrets from frightened human beings that they are too scared to tell anyone else. Society will permit you to use drugs and instruments that can do great harm as well as great good, and that in the hands of others would be weapons. Society will give you special titles and spaces of privilege, as if you were priests. Society will let you build walls and write rules.

And in that role, with that power, you will meet Dr. and Mrs. Gruzenski over, and over, and over again. You will meet them every day - every hour. They will be in disguise. They will be disguised as a new mother afraid to touch her preemie on the ventilator in the incubator. Disguised as the construction worker too embarrassed to admit that he didn't hear a word you just said after, 'It might be cancer.' Disguised as the busy lawyer who cannot afford for you to keep her waiting, but too polite to say so. Disguised at the alcoholic bottoming out who was the handsome champion of his soccer team and dreamed of being an architect someday. Disguised as the child over whom you tower. Disguised as the 90-year-old grandmother, over whom you tower. Disguised as the professor in the MRI machine who has been told to lie still, but who desperately needs to urinate and is ashamed. Disguised as the man who would prefer to know; and as the man who would prefer not to know. Disguised as the woman who would prefer to sit; and as the woman who would prefer to stand. And as the man who wants you to call him, 'Bill,' and as the man who prefers to be called, 'Dr. Gruzenski.'

Mrs. Gruzenski wrote, 'My husband was a very caring physician and administrator for many years, but during his hospitalization, he was not even afforded the respect of being called, 'Doctor.' Dr. Gruzenski wanted to be called, 'Dr. Gruzenski.' But, they did not do so.

You can. That choice is not in the hands of nameless power, not fated to control by deaf habit. Not 'our policy,' 'the rule.' Just you. Your choice. Your rule. Your power.

What is at stake here may seem a small thing in the face of the enormous health care world you have joined. It is as a nickel to the $2.6 trillion industry. But that small thing is what matters. I will tell you: it is all that matters. All that matters is the person. The person. The individual. The patient. The poet. The lover. The adventurer. The frightened soul. The wondering mind. The learned mind. The Husband. The Wife. The Son. The Daughter. In the moment.

In the moment, it is all about choice. You have a magical opportunity. You have the opportunity to decide. Yes, you can read the rule book; and someday you can even write the rule book. Decide. Yes, you can hide behind the protocols and the policies. Decide. Yes, you can say 'we,' when you mean, 'I.' Yes, you can lock the door. 'Sorry, Mrs. Gruzenski, your 30 minutes are up.' You can say that.

But, you can also unlock the door. You can ask, 'Shall I call you 'Dr. Gruzenski?' 'Would you like to be alone?' 'Is this a convenient time?' 'Is there something else I can do for you?' You can say, 'You're the boss.' You can say, 'Tell me about the best trip you ever took. Tell me about the time you saw your daughter born ...'

Decide. You can read the rules. Or, you can say, 'Pardon me.' 'Pardon this unwelcome interruption in your lives. Thank you for inviting me to help. Thank you for letting me visit. I am your guest, and I know it. Now, please, Mrs. Gruzenski, Dr. Gruzenski, what may I do for you?'

Congratulations on your achievement today. Feel proud. You ought to. When you put on your white coat, my dear friends, you become a doctor.

But, now I will tell you a secret – a mystery. Those who suffer need you to be something more than a doctor; they need you to be a healer. And, to become a healer, you must do something even more difficult than putting your white coat on. You must take your white coat off. You must recover, embrace, and treasure the memory of your shared, frail humanity - of the dignity in each and every soul. When you take off that white coat in the sacred presence of those for whom you will care - in the sacred presence of people just like you - when you take off that white coat, and, tower not over them, but join those you serve, you become a healer in a world of fear and fragmentation, an 'aching' world, as your Chaplain put it this morning, that has never needed healing more.


Today's questions: What is your reaction to Dr. Berwick's address to his daughter and her newly-minted physician colleagues? What do you think it says about the philosophy he brings to public service?

Monday, August 9, 2010

Guess what? CMS' actuary agrees health reform improves Medicare's outlook

Critics of the Medicare trustees' report on the positive impact of the Affordable Care Act (ACA) on Medicare's solvency, the subject of last Thursday's blog, have seized on an analysis by CMS's chief actuary, Mr. Richard Foster. It is true that Mr. Foster offers a more pessimistic "alternative scenario" of the impact of the ACA than the trustees used. But you know what? Mr. Foster agrees that that the ACA makes a "marked improvement" in Medicare's fiscal outlook.

Let me explain. Both the trustees and Mr. Foster agree that most of the improvement in Medicare's long-term fiscal outlook is due to changes in payments to hospitals and other non-physician providers under Medicare Part A. This improvement is unaffected by the Medicare SGR formula, which affects only payments to physicians. (I'll get back to the SGR later.)

According to the Congressional Research Service, Congress' decision to adjust Medicare payments to hospitals to reflect productivity gains is based on an analysis by the expert Medicare Payment Advisory Commission:

"Medicare's payment systems should encourage efficiency and Medicare providers can achieve efficiency gains similar to the economy at large. This policy target links Medicare's expectations for efficiency improvements to the productivity gains achieved by firms and workers who pay taxes that fund Medicare."

Where do trustees and Mr. Foster disagree? Mr. Foster doubts that hospitals and other non-physician providers will be able to achieve the required productivity gains, and he expects that Congress eventually will over-ride them. The trustees assume they will remain in place.

However, as Robert Greenstein from the Center on Budget and Policy Priorities points out, even if one accepts Mr. Foster's more guarded view of the ability of the health care sector to improve its productivity, the Medicare program is still better off.

"... even under the trustees' 'illustrative alternative' projection, which assumes that only 60 percent of the ACA’s savings are achieved in the long run (the scenario that Medicare actuary Richard Foster prefers), half of the long-term shortfall has been closed by this one piece of legislation."

On this, Mr. Foster agrees. He writes that, "In the likely event that the productivity adjustments are eventually overridden, the cost rate would be significantly higher than under current law. Even so, the alternative scenario projections would represent a marked improvement over the estimates in the 2009 report."

Now, let's get back to the SGR. I have covered this ground before, but the SGR cuts are not the result of the ACA. They were enacted by Congress and signed into law in 1997. The trustees' report only deals with the changes created by the ACA itself, not the inherited legacy of a law passed 13 years ago. The ACA didn't solve the SGR problem, but it sure as heck didn't create it or make it worse.

I've said it before, and I'll continue to say it until the cows come home. The SGR formula has to go. ACP will not rest until it does. And Congress and CMS will need to accurately account for the increased spending that will result.

But I stand by my view that the trustees' report - and Mr. Foster's "alternative scenario" - demonstrate that Medicare's fiscal outlook is markedly better because of the ACA. The only disagreement is over how much better.

Today's question: Do you disagree with the notion that the health care sector should "achieve the same kind of productivity gains by firms and workers who pay taxes to fund Medicare?"

Thursday, August 5, 2010

Good news for Grandma! Health reform to keep Medicare afloat.

One of the more effective criticisms of the health reform law (Affordable Care Act, or ACA) is that it hurts Medicare. It also is wrong.

Effective, in that it has been widely reported that seniors are more likely to express negative views of the ACA than other age groups. (Although the Kaiser Family Foundation's Drew Altman, citing the group's most recent tracking polls, writes that seniors' opposition to health reform "is at least somewhat over played.")

Effective, but wrong: the ACA actually helps Medicare in three important ways.

First, Medicare's trustees today confirmed that because of the ACA, the Hospital Insurance (HI) Trust Fund is now expected to remain solvent until 2029, 12 years longer than under earlier projections, and spending on Medicare Part B as a share of GDP over the next 75 years is down 23 percent relative to the costs projected in the 2009 report. The improvement is due largely to the reductions made by the ACA in the annual "market basket" updates to hospitals and other non-physician providers (productivity "adjustments" that by and large were agreed to by the affected industries), lower payments to Medicare Advantage plans, and increased tax revenue. The Wall Street Journal's health blog notes the report comes with a caveat: the trustees had to assume that Medicare will continue to pay hospitals and other providers under the reduced rates, which may be politically difficult to sustain over time. And the improvement in the Part B (physician spending) side doesn't take into account the costs that would be associated with repealing Medicare's sustainable growth rate (SGR) formula.

Second, the ACA helps Medicare because it adds more benefits, at little or no cost to seniors. Effective on January 1, Medicare will eliminate deductibles and co-payments for most preventive and screening services, and pay for an annual "well" physician examination. Starting this year the ACA begins to phase out the Medicare Part D "doughnut hole" until it disappears in 2012.

Third, the ACA will promote development and pilot-testing of new models of payment and delivery to improve payments for primary care, promote patient-centered care through medical homes, reduce preventable hospital admissions, and create incentives for physicians, hospitals, and other providers to deliver better care, more efficiently. For the most part, the Medicare trustees' did not include the potential savings from these changes in its report.

Of course, the ACA does not solve all of Medicare's problems. The program will still need to be reformed to fix the growing gap between the number of workers paying taxes into the program and the number of persons receiving benefits. This, plus rising health care costs, will continue to endanger its long-term solvency. Access will continue to be at risk until the Medicare SGR is repealed and doctors are assured a fair fee for their services.

Still, the bottom-line is that Grandma will get better benefits, starting now, and won't have to worry about the program running out of money for another two decades. The delivery system reforms from the ACA have the potential of improving outcomes and saving even more money, which could help the program staying solvent well beyond 2029. I'd say that's pretty good news for America's seniors.

Today's question: What is your reaction to the Medicare trustees' report that "The outlook for Medicare has improved substantially because of program changes made" by the Affordable Care Act?

Tuesday, August 3, 2010

Do non-citizen foreign medical graduates do it better?

Yes, according to a study in today's Health Affairs. (The full text of the study is available only to subscribers, but Kaiser Health News Daily has a good summary of its findings and links to other news reports.)

The study compares inpatient death rates and lengths-of-stay for patients with congestive heart failure or acute myocardial infarction when provided by U.S. citizens trained abroad, citizens trained in the United States, and non-citizens trained abroad. Treatment was provided by internists, family physicians, or cardiologists. The differences were striking, according to the authors:

"Our analysis of 244,153 hospitalizations in Pennsylvania found that patients of doctors who graduated from international medical schools and were not U.S. citizens at the time they entered medical school had significantly lower mortality rates than patients cared for by doctors who graduated from U.S. medical schools or who were U.S. citizens and received their degrees abroad."

It also found that board certification was positively associated with lower mortality and lengths of stay. Years in practice since graduation are associated with poorer outcomes. Self-designated cardiologists had higher mortality rates but lower lengths of stay than self-designated general internists and family physicians.

John Norcini, the study's co-author, tells Bloomberg news that "economics may help explain the gap in patient outcome." Because of lower pay relative to other specialties "primary care may not be getting the best and the brightest from U.S. medical schools," said Norcini. "Foreign students see primary care as a gap that they can fill and a way to practice medicine here." He calls non-citizen IMGs the "cream of the crop" because the ones who make it through are "highly desirable and motivated."

The study, if supported by other research, could have important public policy implications. One is that the that the public should have more confidence that the care provided by non-citizen IMGs (in general) is at least as good as U.S. citizens trained here, at a time when IMGs are likely to remain a critical component of a primary care workforce in shortage.

The idea that the U.S. is depending on the "cream of the crop" of non-citizen IMGs though, will add to concerns about a "brain drain" from less developed nations that have an even greater need for well-trained physicians. This concern was examined by the American College of Physicians in a 2008 policy monograph, which "cautions that the nation should not rely on IMGs alone to solve the shortage of physicians in the United States and that balance must be achieved between respecting the freedom of IMGs to migrate and fulfilling the needs of both home and host countries."

The study also speaks to the need for fundamental changes in payment and delivery models to once again attract the "best and the brightest" to internal medicine.

Today's questions: What is your reaction to the finding that non-citizens trained abroad do better than U.S. citizen IMGs or U.S. trained physicians? That board certification is positively associated with better outcomes, while years of practice since training are associated with poorer outcomes? What should policy-makers do with this information?

Monday, August 2, 2010

Is the pen mightier than the PC?

When it comes to prescribing, it appears so. A new report from the Center for Studying Health System Change finds that most physicians write their RX scripts by hand, despite financial incentives for physicians to adopt electronic prescribing. Even those who have e-RX systems do not always use them, and when they do, they may not to use the features that were anticipated to have the biggest impact on improving prescribing practices.

HSC's nationally representative Health Tracking Physician Survey finds that "two in five physicians in office-based ambulatory practice (41.9%) reported that information technology was available in their practice to write prescriptions in 2008 ... Moreover, physicians who had access to e-prescribing did not necessarily use it routinely. About a quarter of the physicians reporting availability of IT to write prescriptions (23.1%) used the technology only occasionally or not at all. So in 2008, about one-third of all physicians in ambulatory settings (32.3%) routinely used e-prescribing." Advanced features - drug information alerts and patient formulary information - were used even less frequently.

Primary care physicians were more likely than medical and surgical specialists to use e-prescribing, as were physicians in larger group practices.

The low adoption rates for e-RX suggests to me that financial "carrots and sticks" may not be enough to drive adoption of health information technology. Medicare will pay a 2% bonus of total allowed charge to physicians for use of e-RX systems through 2013, but penalties will go into effect in 2012 on those who do not. Even larger chunks of money are available for physicians who adopt "certified" electronic medical records for meaningful use (including e-prescribing).

I am not sure why more physicians aren't using e-RX systems. Is it because of cost? Force of habit? Or do the systems themselves lack user-friendliness and functionality?

Whatever the reasons, it doesn't bode well for the government's goal of getting a certified electronic health record in every practice. The HSC authors note, "the challenges to implementation of EMRs as a whole are substantially more complex than e-prescribing. And, EMR technology is much less mature, suggesting that policy makers should expect a substantially longer time horizon to achieve meaningful use of health IT than the five- to six-year horizon of the Medicare and Medicaid incentive programs."

Today's question: Why do you think physicians are slow to adopt e-RX, even with the government"s "carrots and sticks"?