Every now and then I like to follow-up on recent posts to highlight the fact that so many of the issues we address on Health Beat continue to develop after we write about them.  So, without further ado, some additional coverage of recent post topics:    

AHLTA

I’ve criticized AHLTA, the Defense Department’s computerized medical record system, in three separate posts. And with good reason: the troubled system will ultimately cost tax payers $20 billion, despite the fact that it processes data slowly, is prone to errors, is disliked by military clinicians, and is incompatible with VistA, the Veterans Administration’s successful health care IT program.

I’ll spare you a fourth AHTLA essay and instead direct you to an update by Bob Brewin of Government Executive magazine which ran a few days ago. 

Brewin reports that “AHLTA…poses safety risks…Medication reconciliation — a process that requires developing a complete list of patients’ medications and dosages — is key to ensuring patients are not prescribed drugs that don’t mix well. But, ‘AHLTA does not allow complete and uncompromised medication reconciliation [and] therefore remains a patient safety risk,’ said Lt. Col. Carter Hale…

“Army Lt. Col. Daniel Schissel, president of the Association of Military Dermatologists, reported that the application has decreased his productivity. He commented that before AHLTA, he was able to see 5,000 patients annually and record each encounter with excellent, albeit written, notes. Post-AHLTA, he sees 3,600 patients annually and describes encounters in electronic note templates that he says are so cryptic a follow-on provider would have difficulty visualizing where he had removed a spot of cancerous melanoma. It would be helpful to attach a photo, but Schissel said MHS [Military Health Service, the DoD section that manages AHLTA] clinicians now are discouraged from doing so, ‘as photos are difficult to load and consume large amounts of bandwidth.’

“Army Col. Barbara Crothers said deployment of AHLTA has cut back on
her time with patients…‘I spend more time with my computer screen than
actually viewing cases,’” said Crothers.

Brewin continues: “Given this body of evidence you would think MHS
would use the development of a supposedly-spiffy new architecture for
the next-generation electronic health record system as an excuse to
ditch AHLTA. But no. Last week Charles Campbell, chief information
officer at MHS, told me the architecture ‘is the framework, not new
applications. We are not planning to get rid of AHLTA.’

“Methinks this indicates MHS has become hostage to its software,”
concluded Brewin. “Instead of going in a new direction, the
architectural project looks like a way to dress up old code and loathed
applications with new buzzwords.”

It wouldn’t be the first time that the DoD has tried to ignore AHLTA’s
failings and present the system up as a success—despite the fact that
(as Brewin puts it, with tongue firmly in cheek) AHLTA has a “way to go
before it wins any prizes.”

Certificate of Need Laws

Last month I analyzed
certificate of need (CON) laws, which require that hospital developers
receive government approval to build new hospitals or acquire expensive
new technology, and found them to have a mixed record.

Unlike most CON skeptics, however, I don’t think that CON laws’ big
problem is that they restrict free market health care, but rather that
they perpetuate the emphasis on volume in medicine. Under the CON
process, facilities that hope to win approval for expanding must commit
to performing some minimum volume of services. To get approval for a
new MRI scanner, for example, a hospital has to promise to perform,
say, 200 scans a year. Essentially, the government orders providers to
prove that their services are needed by promising to perform them
often.

Given that CON laws were supposed to help control health care costs,
you can probably see the backwardness of a regulation that mandates
doctors to do more. Yet the issue of volume doesn’t get a lot of play
in CON discussions at the state level. Instead, CON concerns are
usually reduced to a question of free-markets versus protectionism.

Today, for example, the American Medical Association reports that the Federal Trade Commission and the Department of Justice have formally declared—for the second time since 2004—that
CON laws “undercut consumer choice” and “stifle innovation.” These
comments, directed at the Illinois Task Force on Health Planning
Reform—currently contemplating whether or not to reform or repeal the
state’s CON laws—indicate just how much free market enthusiasts despise
CON regulations.

Like the FTC and the DOJ, Illinois doctors think that CON laws are
overly-restrictive (not surprising given that that the absence of CON
laws allows for a greater explosion of profitable specialty services).
In contrast, the Illinois Hospital Association (IHA) feels that,
without CON laws, "profiteers can come in” set up free-standing
specialty surgical centers  that provide especially lucrative
procedures “and cherry-pick by engaging in only those services where
people can pay using private insurance. “ Such a situation “leaves
community hospitals with the burden of covering indigent and
uncompensated care, and it can undercut hospitals’ ability to subsidize
emergency or charity services…”

The IHA has a good point. But, as I said earlier, it would be wrong to
think that CON laws, as they currently stand, are as effective as they
could be—even if they do help some hospitals stay afloat. What this
discussion lacks is a deeper appreciation of how the absence or
presence of particular forms of regulation relate to providing the greatest number of people with the most appropriate care.
Are CON laws encouraging more procedures, even if they help states
resist building more facilities? Aren’t there better ways of
understanding medical need than the volume of services a facility
promises to provide before that service is even made available?  These are important questions that get to the heart of the real problem. 

But when the FTC chairman’s analysis of CON laws is reduced to parroting consumerist
mantras such as  "vigorous competition can promote greater access to
cost-effective, high-quality health care” you know that the debate is
likely to contour to conventional ideological fault lines. That’s too
bad—both for Illinois, and the future of discussions and debates
surrounding CON. 

Medicaid

Last week I wrote
about the many problems of Medicaid, one of which is the very low
reimbursement for doctors who take Medicaid patients. In the post, I
mentioned a 2007 story from Illinois where two clinics fought the state
Attorney General so that they could stop taking new Medicaid patients.
The two facilities employ more than 90 percent of the physicians in
Champaign County, Illinois—a county that has about 20,000
Medicare-eligible children and adults—and came under fire for refusing primary care in order to guide more patients to the emergency room, where reimbursement rates are higher.

Now from Virginia comes a report
of another hospital pushing back against Medicaid—except this time it’s
a doctor who’s under pressure. Dr. Phillip Hale was fired from his post
at Danville Regional Medical Center, where he worked for 14 years.
“[The firing] seems to be driven by (the hospital’s) bottom line
mentality without really looking at the big picture,” Hale told Danville News this past Friday.

Hale’s practice was a money-loser for the hospital, since he focused on
preventive care—which, if practices correctly, reduces the number of
patients who need more lucrative procedures. “If I took care of their
blood pressure and sugar, they wouldn’t be going to the emergency
room,” Hale said. “They wouldn’t be getting sick enough to be admitted
to the hospital.” He attributes his firing to Danville Regional’s
transition from a non-profit to a for-profit hospital in 2005: “I think
it goes back to when the decision was made to sell to a for-profit
hospital. The writing was on the wall then.”

This isn’t the first time a hospital has tried to get rid of a doctor
for providing appropriate care to Medicaid patients. In 2003, Dr. John
Chomer sued Logansport Memorial Hospital for firing him because he was
trying to make sure that Medicaid patients didn’t go to the emergency
room for routine care. According to the Indianapolis Star, Chomer claimed
that he told patients that it was “ ‘inappropriate’ for them to visit
the emergency room for colds and other minor illnesses”—to which Logan
Emergency Physicians President Lazo Krszenski supposedly replied,
"(you) are taking money out of (the hospital’s) pocket.”  The case is
still held up in court.

These stories are a vivid illustration of the perversity of Medicaid reimbursement: doctors are actually getting punished
for providing Medicaid patients with appropriate care. They’re being
encouraged to shunt patients to the emergency room for routine care—a
practice that, as I’ve noted in the past, has disastrous financial consequences for the system –and fails patients who truly need emergency care. 

Later this week, I’ll post on Medicaid reform that addresses both reimbursement and other issues that cripple the system.