$25 Billion (Annually) Changes Everything

Did you know that 19% of all Medicare patients entering the hospital will be back within 30 days, and 34% within 90 days, costing America $19B per year. In the private sector, tack on another $6B for readmission on key diseases including congestive heart failure, heart attack, and pneumonia, and you have $25B a year in spending.

But here's the change: starting with this fiscal year, as part of the Affordable Care Act of 2010, Medicare will start penalizing the bottom quartile of hospital with the highest 30 day readmission rates-- and penalize them a lot! If a hospital finds themselves in the lowest quartile (risk adjusted for age of populations and other metrics), they will loses 1% of their total Medicare and Medicaid revenues--and that's just this year. The bar will rise. 1% may not sound like a lot, but considering that most hospitals barely break even it's a lot of money. for a thousand bed hospital that has 50% of patients on Medicare of Medicaid, that could be $5M per annum--serious bucks. This is a risk transfer of money from the payers (medicare and Medicaid --or you) to the providers (the hospitals). They are going to be held accountable for the services they deliver. It's enough to have the CEOs and CMOs of every hospital worried.

Why? Well often, these hospital executives feel they can't control what happens when a patient leaves the hospital, so why should they be held accountable? Comments I have heard from very senior executives:

"I can't stop a patient if they eat Kentucky Fried Chicken on the way home from the hospital."

"Her husband won't stop smoking."

"I talk about exercise and it goes in one ear and out the other."

"They are so old i's not going to make a difference what they do."

Well, these are valid concerns, since personal responsibility has got to be part of the answer. But it's also shirking of responsibility on the part of the hospital. Study after study validates that there are important steps the hospital can and should take that when practiced consistently, reduce readmissions as much as 40%†

1. Expedite transmission of discharge summary to other health care professionals - Only 20% of the time does this happen in a timely fashion today, according to JAMA

2. Educate patients throughout stay - The current discharge process is on average 8 minutes. That's not enough time to educate the patients and their care givers if someone is sick enough to land in the hospital with a heart attack

3. Confirm medication plan - Only 37% of patient can state their medications and their purpose, according to Mayo Clinic Proceedings

4. Assess understanding with teach back - This means "don't talk at us: and then ask, do you understand? " Make the information available, with Q& A during and after the hospital stay

5. Make follow-up appointments - Patients should never leave the hospital without their follow up appointments. Usually a hospital will only schedule those related to their facility. But a patient needs their physical therapist, their primary care physician and other appointments scheduled too

6. Provide written discharge plan - w suggest giving it to family members, PCPs, and professional caregivers as well. It takes a village

7. Organize post-discharge services - Rides to hospitals, confirm pharmacies, telemetric equipment to be set up. It's all the hospital's responsibility

8. Assess patient risk - We know that some people can understand and take care of themselves better than others. If a patient is high risk, match the care levels appropriately. Make sure a case manager or social worker is involved. Yes, it costs more, but not as much as rehospitalization.

At Axial, we believe this is the standard of care that every hospital should practice. We've developed software that will enable hospitals, patients, and family members to help reduce readmissions.

Don't we all want to get better and reduce costs? NO Excuses, please!

†Estimates based on Project RED (Re-engineered Discharge), Dr. Brian Jack et al, Boston University, and Project Boost (Better Outcomes for Older Adults Through Safe Transitions), Dr. Eric Coleman et al, Society of Hospital Medicine studies

Doing The Right Thing

Having just returned from HIMSS, the Supershow of Health Information Technology, I'm trying to shake off the flashing lights, Health IT booth-turned-pub, the DeLorean silver car and other attention grabbers to see what the potential of $40B of our tax money to be spent on incentives means for improving the state of health care information technology in the country. The sad truth is not much. It's still really hard and really expensive to get clinical information from point A to B, (unless the same company is at both ends, and then it's just expensive) and to get well edited and timely information on mobile devices. These are basic fundamental needs that any other industry has, and yet the most curious thing to me is that there is no anger, no outrage, from the hospitals that are forking over the money, year after year. As a former CIO in two other industries, I know that until the clients start voting with their wallets, no change will be forthcoming.

Like any other industry where a lot of money is at stake, there are major companies that control a lot of the market. In our industry, these include well known names like GE, and, Siemens, and industry specific powerhouses like McKesson, Epic, Cerner and Allscripts. Historically, these companies have been selling primarily to hospitals, but with the new HiTech act of 2009, they are expanding their products to reach physicians as well.

It's been pretty clear for decades that these big companies' strategies include total ownership of the hospital's information. But health care never happens just in a hospital setting, and very infrequently in a single doctor's setting. There needs to be a simple, low cost way to get this information around--just like you can order on-line from multiple places and track your package on UPS, or go to a bank anywhere around the world and get cash.

So thought our government, when they spent 800+ pages detailing "Meaningful Use" for our country. To boil the law down to its essence, there are two parts to it; first, you must have an electronic system of record where patient information is kept securely in standard form. Second, you must make that information available electronically so a person or another system can use it. Pretty straightforward, right?

After two years of teeth gnashing and hand-wringing, led mostly by incumbent vendors, who led a charge to water down the requirements to meet them, I was eager to see our new, improved, interconnected world. As my grandfather used to say, "A leopard can't change its spots." What have these big companies done to help systems talk to each other? More of the same. It is still hard to communicate between systems, and if you insist on it, it will cost you a small fortune. Two software practices, bundling (making you buy a lot more than you wanted to get a specific feature), and forced upgrades seem to be the commercial methods in play if a hospital wants to achieve compliance.

As an experiment, I went to all six of the major vendors to see how we, a small company, could interface with their systems. This isn't a unique question, according to our government's tax roles, there are over 5000 smaller Health IT companies, devices, and system integrators that would like to make their systems work with the big systems.

"Oh yes, as soon as our mutual hospital client upgrades to our newest version, and then requests an integration specialist"--Upgrade cost? Over $10M dollars for a 500 bed hospital (assuming they already have paid tens of millions for the system). Three of the six gave a similar answer. Fine print--there are many other upgrades included in these new versions, but if you just want to be able to read/write HL7, you must upgrade)

"If our clients buy our whole system, they have no need to integrate with anything else." Really? Does your system links with PACs? "That's a special integration project." Labs? "Hospital labs are special integration projects." Mobile devices? "We have a Citrix client to display things on a browser." How much does your system cost? Anywhere from $30M to $250M dollars..."

Best answer, two of the six had a special HL7 services pack that was a separate module for purchase that didn't require a total system upgrade, (price not given), but the red tape, the information comes out standard in a pdf format, not machine format. Why not? "We believe our system should be the center of all the information for that hospital."

All these big companies have followed the letter of the law, not the spirit of the law. You still can't get a basic hospital system without spending tens of millions of dollars--going up to hundreds of millions for a full implementation. A hospital IT system is expensive, but these bundling and upgrade practices make simple interoperability very expensive.

And it's not like the costs of these systems are hidden costs--Moses Cone, a 500 bed hospital near us in Greensboro, chose the rip-and-replace strategy (taking out an old system and putting in a new one) had this in their newsletter...

"A team of more than 90 Moses Cone Health System employees will begin training in October on a comprehensive medical information system that will be built through a contract with Epic Systems Corp.

The Health System has committed more than $80 million for purchasing and installing the software and hardware, as well as more than $30 million in staffing costs related to the electronic health record over the next five years. The system, which will be in place in two to two and a half years, will result in integrated billing, registration and clinical software packages that seamlessly “talk” to each other."

To each other, yes, but not to anyone else.

Let's put this in some perspective. During that same time 2 1/2 year period, a 500 bed hospital will see about 250,000 emergency patients. About 25% of them will be uninsured and without primary care. At $80 per primary care visit, each patient could get to see a doctor 20 times for the same money. Ultimately, it's all the same pot of money a hospital has to utilize. Better continuity of care for uninsured patients, or a systems project that ultimately locks in the hospital to speak only with other physicians with the same system.

At Axial, we believe all health systems should speak to each other safely and securely at a fair price. To back that claim, we put our technology in the public domain. We are building a library of public "connectors" that will let any legacy system speak to another legacy system. I challenge hospital CIOs and CMIOs to demand open access to the information they've paid dearly for. I challenge anyone operating in Health IT to do the right thing. Charge for innovation and health improvement, not linking billing and clinical systems--something that every other industry did decades ago. We challenge the rest of the industry to follow our lead.

One Thing...

In the Classic Billy Crystal Comedy, City Slickers, Billy Crystal asks Jack Palance, who plays Curly, the crusty cowboy, what his secret to a good life is. Curly answers, "The secret to a good life is one thing" and holds up an index finger...and then he dies. We never know the answer.

Similarly, in getting to better health in this country, I've been trying to figure out what the "one thing" is that this country should be doing. Figuring out this one thing is important, because we have information overload. There's too much detail, too many problems with complex inter-relations, and therefore no one can act. A 1000 page national health bill was passed, and no one but a few paid experts actually knows whats in it--though the general agreement is that it about providing more access to doctors through changing eligibility and payments; not about a healthier America.

I think I have my answer, and the one thing we should do something about is food. It keeps us alive, it gives us great comfort and enjoyment, creates common ground and cultural history, but can also make us obese, trigger all kinds of disease because of chemicals and nutritional imbalance. And obesity is the number one public health crises in America.

But back to one thing. Food is an extremely complex subject, as I learned when I was ill and actually had to research what made a truly healthy long term diet. I guarantee you the answer is neither simple, nor is what most of us do every day.

In school lunch programs, which could be a major tool in combatting obesity; there are many studies about what is wrong and how to change. But theSchool Nutrition Association, a 55,000 person professional organization whose mission is to advance good nutrition for all children, Tom Baranowski, Professor of Pediatrics Baylor College, gave the following report cards to the efforts across the nation to promote positive change.

Report Card For School Health Behavior Promotors -

IOM Committee on School Nutrition

January 28 2009

Why? Why do all the well intended, well research change efforts fail so miserably? The best answer I can come up with was provided to me in an excellent book called "Switch - How to Change When Change is Hard", by Chip and Dan Heath. Their point is that you need one thing, that motivates both your brain and your heart--and it must be simple. They cite a public health experiment in West Virginia, in one of the most obese towns in the country, to improve diet and nutrition. For years, the town has been told how to eat right, given access to community health professionals, and nothing happened. But then, two researchers found that if you wanted to cut out half the saturated fat in our country's diet, you would cut out whole milk. That's right. I suspect most of my blog readers don't drink whole milk, but most of the country does. In fact, they think its downright healthy.

So they tried an experiment in this town. They showed pictures at all the grocery stores of one glass of whole milk on the left, an equals sign, and five slices of bacon on the right. This was followed by the instructions to buy 1% or fat free milk. Guess what happened? There was a 37% increase in the purchase of lowfat/nonfat milk, that lasted beyond the experiment date. This is a huge needle move for any public policy experiment. What does this prove? According to the Heath brothers, it shows an important truth. Its not that people don't want to change, its that they don't know how; there are too many options.

So for our country, I believe the one thing is food. But we need to find our individual "one thing" that we can do for ourselves and our kids. It has to be simple and irrevocable. For me, its no processed sugar (sugar feeds my chronic fungal infection and sets off my fibromyalgia attacks). That's kind of a big one, so for your family it might be no bleached flour, or no refined oils. Eating less sugar is not a valid option--because it gives you too much wiggle room. Your one thing must be binary. I think you'll find this "one thing" goal setting does lead to change, and then you can find your next "one thing". Diets don't work because there are too many options--too much too choose, too much behavior to modify.

I would be happy if the country replicated West Virginia's experiment. Its a place to start. Curly was a very wise man....

My Healthcare Obsession (Part 3)

It turns out that this blog has helped quite a few people find their way to the right doctor. Dozens of people have contacted me offline to tell me about their crippling struggles and lack of diagnoses. It definitely reminds me why I started Axial Exchange in the first place. So I will finish with my promise to tell you how I crawled back to health. I don't know why I put this off for so long, probably just because it makes me tired to think of everything I had to do (and still do), and because some of it sounds awful and scary. But I hope I can continue to help people who are going through some of the things I went through.

After my complete diagnoses, I started a regimen of anti-bacterials, anti-fungals, and numerous other pills. The first goal was to kill, or at least beat back the latent infections. I was told that I might experience the yeast die-off effect, which is your body's reaction as the anti-fungals begin to attack the yeast. If they were working, I would probably start to feel worse. Boy, did I! within four days, I was sick as a dog--room spinning toilet clutching nausea. This went on for about a month.

After the first two weeks, I started my intravenous vitamin supplements-three hours a day, twice a week, sitting with other patients in a room full of lazy-boy recliners, all of us hooked up to IVs, all looking pretty weak and sick. You signed an agreement saying you wouldn't ask anyone what was wrong with them, but week after week sitting with many of the same people, we started to talk. The diagnoses were all over the place. There were quite a few cancer patients that were seeking out ways to help their immune system through the debilitating phases of chemotherapy and radiation. There were people with all kinds of auto-immune issues, multiple sclerosis, Guillain-Barre, Chron's, lupus, rheumatoid arthritis. There were people with Lyme disease. We all had two things in common, we were quite ill, and the conventional medical system had failed us. Occasionally someone who was further along in the healing process would be there, and offer us all encouragement. I try and do that now when I go back for periodic IVs, as I had to do this year when I had my first major relapse since getting well.

Between the anti-fungals and the IVs, I was totally wiped out. Add to that continued physical therapy for short term pain management, and getting well was a full time job--and an expensive one at that. Other than the pharmaceuticals, nothing was covered by insurance. I was beyond my employer-capped physical therapy treatments. The IVs weren't covered. But at least I felt like I was doing something logical to attack a specific set of issues.

I'm not sure I can pinpoint exactly when this happened, but I'd say between six weeks and two months of these two therapies, I started to feel better. The first thing I noticed was that my mind was a bit clearer. I could actually string a sentence together. Then I noticed that my afternoon exhaustion "naps" were a bit shorter.

In addition, I was on a wide variety of medications, some prescription, some homeopathic, many of which I still take today. They include pills to manage the pain and the over-reactive nervous system, supplements to help rebuild my immune system, and extra vitamins and minerals because I will probably never absorb as many as I should through food due to the multiple years of strain on my digestive system. I had daily what I call my "Heath Ledger cocktail", which included a six or seven prescription medications. Anyone checking the literature would never mix these prescriptions together, and the automatic warning labels at the pharmacy kept getting longer, but they were the right mixture for me. (I later learned that the average number of prescriptions Fibro patients that have found relief take is seven.) I also take many supplements, including Vitamins B, D, magnesium, probiotics, and others I'm sure I'm forgetting. My only issue with suppplements is that you need to take so many, and the pills are usually large. At my peak, I was taking 25 pills/tablets, twice a day. I still take around 15 pills/tablets twice a day, and probably always will, though I try and getting off the prescription medications periodically. If I start feeling worse, I add them back.

Ah Sleep! Something that alluded me for four years. If anyone has ever dealt with chronic insomnia, I feel for you. To this day, what I cherish the most is a good night's sleep, which is still hard. The reason; in Fibromyalgia patients the sympathetic nervous system always is engaged, and you never enter REM sleep, thus sleep is light, you are easily wakened, and you wake up feeling exhausted. But guess what! Our moms were right! You need a good night sleep to get better. Once I gave in to my aversion of trying sleeping pills and started taking a time release formula that helped me stop waking every 90 minutes, I started to sleep, and the healing came faster.

The next phase was diet overhaul. Now let me begin by saying most people would have categorized me as a healthy eater before. No junk foods, lots of vegetables, generally good moderation. But the anti-fungal diet was in a class by itself. No sugar (not even fruit sugars), no gluten or any starch except quinoa, amaranth and buckwheat, and no dairy. What did I eat, you might ask. Not much. I lost a lot of weight, fast. That extra 25 pounds came off in a month, the same way I put it on. But the main reason for the diet had nothing to do with weight; it was to kill the yeast. Basically, the antifungal medications can knock the yeast back, but the slightest bit of fertilizer (ie anything that converts to sugar) will start the yeast regrowth. Trying to get rid of candida is kind of like killing weeds. You yank them out and they grow right back. But, ultimately, if you deprive them of sun and water for long enough, they will die.

This particular diet is called the Body Ecology Diet(http://www.bodyecology.com/), and though its difficult to sustain for most normal people, I highly advise it if you have been suffering from chronic disease for a period of time. It starves the bad stuff while encouraging your immune system to repair with lots of foods that provide immune system support. I was able to stick with it for about four months. Five days after starting this regimen, I experienced another really big level of improvement. Never before did I really understand the link between food and disease (a topic for a later column) until I saw how my health improved staying strictly on this diet. This blog is already too long to tell you the potions I made, my exercise regimens, my nutritional daily supplements, and the amazing machine that helps titrate my medicines, but I followed the instructions rigorously, and I continued to improve. I had to get over my aversions to taking any medications, and I had to relearn everything I had been taught about food and diet. It took me about 9 months to get about 50% well. It took me another six months to get to 90% well, where I remain today.

If anyone is still with me, my point in telling you all of this is that getting well is a process and a total commitment. You need to find the right caregiver, and realize that chronic illness doesn't happen in a month, and you won't get well in a month. But you can get better! I will always have Fibromyalgia and probably candida as well, but I can manage it. Its two years and three months since I started my get well routine, and I am running this company, I am a busy mother of two children, and I have energy again. I know what to do when I have flare-ups, as they're called, and how to recognize when I'm overdoing things. I have a healthier diet and exercise regimen than I ever had before I got sick, and that has to be good for the long run.

My Health Care Obsession (Part 2)

I'd like to dedicate this blog to Brant Walton, an exceptionally talented 34 year old Anethesiologist at Stanford who died way before his time, on December 31st of colon cancer. I only got to know Brant briefly, after he was diagnosed with Stage 4 cancer. A mutual acquaintance put us in touch; and even in his illness, Brant was a fighter. The cause of getting medical information together became hugely important to him. He couldn't believe, even as a doctor at Stanford, with insider knowledge and permissions, how long it took to get his information. In my sadness, I have found a renewed commitment to continue to work towards accessible health information for all.

http://med.stanford.edu/ism/2009/december/obit-walton.html

Since I wrote Part One of this blog, many people have been asking me what my health problem was and how I treated it. To pick up where I left off, I had been diagnosed with both a cervical herniated disc and Fibromyalgia, and packed off with pain pills and a self-help pamphlet. By October of that year, I decided I had to quit my job and focus full-time on getting well. I was dopey and still in pain, and my health continued to decline. Despite all I read about Fibromyalgia, that it wasn't a deteriorating illness, I was deteriorating. I couldn't walk up a flight of steps, carry a bag of groceries, or sleep. I was taking Lyrica, the newest "miracle drug" for Fibro. After six weeks, I had gained 25 pounds. Lyrica did help with some of the pain, but with no weight plateau in sight, my doctor took me off it. The next week was like heroin withdrawal, or what I imagine that would be like. Shaking, sweating, nausea, fevers/chills. Fatigue, no appetite and weight gain.

I was at my most depressed. Something else had to be wrong with me, but the doctors told me I had my diagnosis and I should make the best of it. I learned that 70% of Fibromyalgia patients cannot carry on full-time employment. was spending three mornings a week in physical therapy with muscle manipulation, heat, and electro-stimulation therapy, and that helped level off the pain, but I wasn't getting better. As a last resort, I set up an appointment with Doctor #10, John Pittman of the NC Center for Integrated Medicine. Having grown up around so many major medical systems, I was skeptical about "Alternative Medicine", but after trying so many doctors with no results, I felt I had nothing to lose. Dr. Pittman is an MD that uses both conventional presecription medications and homeopathic medications, and lots of tests. His results are based on scientific evidence.

Dr. Pittman was different from the outset. I wrote a complete medical history, and my initial visit was 3 hours. They asked me my health history going back to my childhood. The application asked my goal.. "To get my life back", I answered. At the end of the interview, Dr. Pittman said he was pretty sure he knew what was wrong with me(!!), but of course wanted the tests back for confirmation; that my pattern was quite familiar to what he'd seen in many other patients. The tests performed were basic blood and urine tests, but he asked for more detail than previous doctors had asked for.

Two weeks later, after two years of misery, I had my answer. I had a chronic fungal infection, generally known as Candida. If you think about your middle school chemistry, disease is either bacterial, viral, fungal, or parasitic. No doctor had tested me for the last two. My fungal level was "off the charts" literally, beyond the 99th percentile. What that meant was that for years, the fungus had been growing inside my intestinal tracts so that it covered it like kudzu. Over time, nothing could get in, or get out. As a result, by the time I was diagnosed, I measured in the bottom quartile of white blood count, red blood count, and all major vitamins and minerals, and in the bottom 5% of my B vitamins and D vitamins. With a chronic fungal infection, over time in order to function, your gut gets little holes in it where the food passes through, unfiltered. This lets in many bad things, including many toxins,. So not only were my essential vitamins and minerals and blood cells depleted, I had heavy degrees of toxic metals, especially mercury. In all, 10 of the 11 toxic metals I was tested for were evident in my blood system.

In addition, I had hypothyroidism (low thyroid) and abnormally low hormonal levels. As Dr. Pittman put it, my battery had "run down". Since my diagnosis I have learned that there is a 70% co-incidence with Irritable Bowel Symptom, Candida, and Fibromyalgia. Increasingly, doctors wonder if there is a chicken/egg syndrome. Does the fungal infection at some point trigger the auto-immune disease?

Dr Pittman told me that the treatment he recommended would take about a year. Based on his other patients, he felt there was a 75% chance I would feel substantively better, and that I would learn how to avoid major setbacks. He also warned me that most of the treatments he recommended were not covered by insurance. There were very few protocols approved for either Fibromyalgia or Candida other than pain pills and anti-fungals; neither if which he believed got to the root cause of the problem. He outlined a four step plan. 1) Aggressively fight the infection; 2) Immediately address the fatigue through intravenous supplements, since I wasn't absorbing what I needed through my digestive track, 3) Rebuild my immune system and digestive track so my body could filter and absorb normally and 4) have chelation therapy to remove the toxic metals.

I was so thrilled to have an answer and a plan. I wasn't going crazy; I was just very sick! But why had it taken so long to get a diagnosis? What was wrong with the conventional medical system? I took my test results back to my internist and other conventional doctors I had seen along the way, and they validated his diagnoses, though no one could explain why they hadn't found the issues or ordered the test. The problem in my opinion, is two fold. No regular doctor can spend enough time with you to figure out what is wrong if it is not glaringly obvious and the illness is systemic. Secondly, health information was not captured and stored for all the other doctors (or me) to evaluate.

In the next blog, I will tell you how I crawled back to health.

Build It and They Will Come

It is rare in the economic history of the United States that the Federal and State Governments moves faster than the private sector. But that's what seems to be happening in the field of Health IT, especially with respect to interoperability. You may well be familiar with some of the incentive money, but probably not with what is happening at the State level--and this could affect every American's ability to access information. So read on if you want to make sure your state does the right thing.

There are two big buckets of money in ARRA set aside for Health IT. The largest, by far ($36B gross, $19B net) is for hospitals and doctors to move from paper to electronic medical systems. These incentives come at the back-end of the Health Care provider's implementation project, in the form of multipliers to the reimbursement the practice receives from Medicare or Medicaid. Hospitals are gearing up to take advantage of these incentives, as it may mean somewhere between $2-$7M per hospital. However, the average doctor will receive $40,00-$60,000 over four years, not covering the cost of most implementations. Needless to say, the doctors are lukewarm to negative about this incentive package, and aren't rushing to the door to convert their practices.

There is a smaller bucket of ARRA money that doesn't get nearly as much press coverage, but may have a much bigger bang for the buck. That is money set aside for States to build Health Information Exchanges. These would be public "backbones" that will ultimately connect all the hospitals and physicians in each State. The announcement, made by Vice President Biden, and HHS Secretary Kathleen Sebelius on August 20th, set aside $564M for the States to build Health Information Exchanges. Because of the particulars of ARRA funding, States will have to respond and build quickly. The States submitted Letters of Intent on September 17th, and have to submit grant proposals by October 14th. Then, the Federal government will announce the grant recipients by December 1st. Having managed procurement for a major private institution, this is very fast turn-around indeed.

Here's the kicker. If the States want the Federal Government to pay their whole tab, then they must have their project completed within two years. After that time, State matching funds must apply to the project. Given the in-the-red status of most States, they will hurry, hurry, hurry.

That could be great, or it could be setting the table for failed implementations. A lot will depend on whether each state adopts four basic principles outlined below. If you want your state to provide a backbone for a health information exchange, feel free to cut and paste from this blog and send this to your State's Governor. Each state applying usually sets up some kind of Authority to manage the process (in my state, it is the NC Health and Wellness Trust Fund), but that Authority will be determined by the Governor.

1) Set up the State for easy Communication with the Federal Agencies at a low price


A state's Health Information Exchange's design should mirror the National Health Information Network’s open source CONNECT design. States should not recreate the wheel. Using the CONNECT design, the State will be able to seamlessly connect with Federal Agencies such as Medicare and Medicaid, the Department of Defense and the Veterans Administration. Additionally the flexible open source design keeps medical information resident in the existing systems within doctors and physicians’ practices and avoids the need for a statewide medical database--a fear for many citizens.


2) Keep Costs Low and Improve Interoperability by Mandating the Use of Data Standards by Companies involved with Health Care Information in the State


States should promote long-term sustainability by mandating that all companies doing business with the State, including laboratories, imaging centers, hospitals, and Physician offices make their results available in the ANSI-approved standards known as HL-7 (there are other relevant standards, as well). If a system is old or a vendor does not know how to do this, then they must put their interface technology in the public domain so that third parties can convert it to industry standards. We have learned from the 200 plus HIE's that were created and not sustained that the largest cost of both building and operating exchanges is due to proprietary, point-to-point non-standard connections between legacy hospital and lab systems.


3) Plan Personal Health Information to be the Centerpiece of the Exchange



A State should design its Exchange with the patient front and center. Currently, most HIEs are business-to-business, with only 2 HIEs making data available to the patient, though many have plans. We believe the key to getting long-term health care costs down is to educate patients. American consumers are very savvy, and they will learn what they need to in order to make good life decisions. They just need the information.

In addition to the broad principals, patient-centric records specifically will help patients with complex and chronic diseases make sure that all information is getting to every doctor and practitioner involved in their care. This is particularly useful for caretakers of sick children or aging parents.



4) Design For Public Health and Research Use By Building De-Identification Functionality into The Exchange


This same data can and should be repurposed for Public Policy Health Care, tracking of illness, and demographics. Often, Public Health Data comes from some other place or project that was financed independently of the Exchange (as most states have some kind of Public Health repository but may not have a Health Information Exchange). In addition to spotting key health rends like flus, the de-identification of data can be used to find clinical trial subjects, a costly and expensive proposition for Universities, Pharmaceutical companies, and Contract Research Organizations, ultimately bringing down the cost of getting new drugs and procedures to market.

Sometimes news that doesn't make headlines really matters. This is one of those times. You can make a difference in your state as well. If all 50 States followed these simple, logical design principles, we'd all be better off.

The Third Rail

I'm glad I'm not a politician, so I can speak the facts without getting booted out of my job. President Obama has rightly focused the country on Health Care, but the issues under debate are not the ones that will cure our woes. My problem with Mr. Obama's plan is that it doesn't touch the real issues. Getting people insured is a relatively safe political issue. Getting an industry up to modern communication standards and information sharing is a relatively safe issue. So I'd like to touch the third rail--managing Health Care costs and who pays for them.

Sure, it would be much better if we were all insured at a fair price. Believe me, I know how difficult that is. When I left Corporate America to start this company, and tried to get insurance, I was flatly turned down by three major carriers because of pre-existing conditions. Through months of perseverance, I was able to find some high-risk pools (even though my issues are not terminal nor do they involve hospitalization). For my family of four, we would have to pay $1800/month with a $12,000 deductible. That's $32,000 a year before any insurance kicks in. Its a pretty clear example of why many people are uninsured, or can't afford to give their employees health insurance.

And yes, our ability to take care of ourselves and the ones we love will improve dramatically with access to our own health information, and improved communication with providers. That's why we started Axial.

So fair insurance and health connectivity are important issues, but they are the tip of the iceberg. Here is the real problem.

A picture's worth a thousand words, so here it is:

This is the cost of our health care year by year, according to the Department of Health and Human Services in their 2007 report.

This data, is two years old, so now our costs are well over $2 trillion dollars per annum. The slope of the curve is pretty scary, isn't it? Especially when you consider that we rank 37th in Health Care effectiveness in the world, according to the World Health Organization.

And while having all people insured is important, it won't significantly drive the costs down. It is true the Emergency Room Visits are the most expensive types of visits, and what uninsured tend to use, but sending not emergency cases to Urgent Care facilities will still not dent this curve.

So what needs to be done?

First, we need to recognize the mathematical facts. Medicare in its current form for everyone over age 65 cannot be supported by our tax base. On average, a Medicare patient has 3.3 times as many medical expenses as a non-Medicare patient. Why? Simply because they are older, and more things go wrong as you age. 80% of your lifetime health care expenses happen the last two years of your life, and in this country on average, that means around 80 years old. So for fifteen years for each citizen, the tax base is paying for more of a patient's likely health care costs than that person had in the whole first 65 years of their life. Unless our working tax base grows at a rate we've never seen in all of US history, we will add to the deficit at an ever increasing rate.

We live longer, but with more disease, but have never changed the age at which people are eligible for Medicare. We need to increase the eligibility age to the point where there is a reasonable divide between benefits start and life expectancy. When Social Security started under FDR, benefits kicked in at age 65. Guess what the average life expectancy was? 64.

Secondly, while Medicare should provide a good floor for basic health care, it cannot possibly cover all expenses. If a 91 year old man or woman wants a hip replacement instead of a walker or wheelchair, should the taxpayers pay for it? Of course not, you may say--until its your parents and you see their misery. Multiply that scenario millions of times, and then you see the problem.

We need to start a system much like 401-Ks for Health Care savings. Medicare should provide the safety net, not full service care. We should all expect, as we do for retirement, that our medical costs should go up, and we can choose to receive baseline care or that for which we have saved.

The current cost controls squeeze the doctors--the ones providing the care. The reimbursement rates for Medicaid are so low that most doctors will not accept Medicaid. The same is starting to be true for Medicare. Well, you might ask, why can't the doctor take their Medicare, and bill them for the difference of their charges? Great question! But by law, the doctors cannot bill any additional amount. Why not?

Price transparency coupled with the doctors being able to set their own rates and collect the differences between insurance reimbursement and their bills would go a long way to settling supply and demand. Let's take two doctors. One is John Hopkins trained and has an impeccable surgical record as a neurosurgeon, with high survival rates, short hospital stays, and low post-care costs. The other doctor is a mediocre surgeon, with longer hospital stays, and an uneven recovery rate. Would you pay more for one of these surgeons than the other? You bet! But Medicare would pay the same.

Lest you think doctors are getting rich, you should know that most doctors are on a downwardly mobile path, unless they do cosmetic surgery or some other process not covered by insurance. The general reimbursement rate for a primary care physician or pediatrician is $30 a visit in the Research Triangle, and pretty similar in other major metropolitan areas. That's before they pay their staff, rent, or medical malpractice. Pediatricians have to see 30 patients a day to break even! 40 patients a day will earn them about $100,000, not exactly the bonuses in question at Citicorp.

Think its better for surgeons? Well, it depends on whether the see Medicare and Medicaid patients. At the time of this writing, a highly skilled neurosurgeon, gets reimbursed $600 to remove a brain tumor by Medicaid-- a 4-6 hour process for which he had to train 14 years post college. I just paid more than that to get new brake rotors and pads in my car. That will not even cover his cost of renting the operating room. For Medicare, that number is closer to $1000, but still slightly above break-even.

We need to empower our primary care system, which is decimated, by reimbursing more, not less. Right now, at best they are a triage team, because in eight minutes, the average time they can spend with a patient, what can you really find out about a patient? Unless you've got the flu or measles, they will need to send you to a specialist. Make time for the doctors to discuss all the issues, so less specialist care is needed. Make time to establish the fundamentals of good health, including diet and exercise. Reimburse Physicians assistants and nurses to discuss these preventative issues with patients.

People do get sick, very sick, and deserve compassionate and appropriate medical attention. But right now, we citizens get penalized very little if we lead an unhealthy lifestyle-overweight and lack of exercise. Your insurance premiums go up if you smoke, but that's it.

The slope of this curve will never change unless we take some drastic actions. Start benefits at a later age. Medicare should provide a floor, not total coverage for patients health. Citizens should have incentives to save, like 401-Ks to supplement Health Savings. Let free pricing prevail--along with price transparency and doctor's records. Focus on good health, not treating symptoms.

If I were a politician, I would be electrocuted by now; but if things are going to change, we all need to know the facts and be brutally honest about what needs to change.