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Report on Health Information Blocking

The Office of the National Coordinator for Health Information Technology (ONC)
Department of Health and Human Services, April 2015

Current economic and market conditions create business incentives for some persons and entities to exercise control over electronic health information in ways that unreasonably limit its availability and use. Indeed, complaints and other evidence described in this report suggest that some persons and entities are interfering with the exchange or use of electronic health information in ways that frustrate the goals of the HITECH Act and undermine broader health care reforms. These concerns likely will become more pronounced as both expectations and the technological capabilities for electronic health information exchange continue to evolve and mature.

Conclusion

The intent of the HITECH Act was to drive the rapid adoption of interoperable technologies and services to support the exchange of electronic health information to improve care and efficiency in the U.S. health care system. While this intent was and is clear to most stakeholders, based on ONC’s experience and available evidence, the developing market for health IT products and services has, in some instances, fallen short of this charge.

The precise nature and extent of information blocking remain obscured in large part by contractual restrictions that prevent the disclosure of relevant evidence. However, based on the evidence and knowledge available, it is apparent that some health care providers and health IT developers are knowingly interfering with the exchange or use of electronic health information in ways that limit its availability and use to improve health and health care. This conduct may be economically rational for some actors in light of current market realities, but it presents a serious obstacle to achieving the goals of the HITECH Act and of health care reform.

There are several immediate actions ONC, HHS, and other federal agencies can take to partially address some kinds of information blocking. In this report, ONC has outlined a number of targeted actions to deter and mitigate such conduct, within limited areas.

While important, these actions alone will not provide a complete solution to the information blocking problem. Indeed, a key finding of this report is that many types of information blocking are beyond the reach of current federal law and programs to address. Thus a comprehensive approach will require overcoming significant gaps in current knowledge, programs, and authorities that limit the ability of ONC and other federal agencies to effectively target, deter, and remedy this conduct, even though it violates public policy and frustrates congressional intent. For these reasons, in addition to the actions outlined in this report, successful strategies to prevent information blocking will likely require congressional intervention.

Information blocking is certainly not the only impediment to an interoperable learning health system. But the findings in this report suggest that it is a serious problem—and one that is not being effectively addressed. ONC believes that in addition to the actions described in this report, there are several additional avenues open to Congress to address information blocking and drive continued progress towards the nation’s health IT and health care goals. ONC looks forward to working with Congress to identify the best solutions.

http://www.healthit.gov/sites/default/files/reports/info_blocking_040915.pdf

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On July 21, 2004, David Brailer, the then National Coordinator for Health Information Technology, released a 178 page report, “The Decade of Health Information Technology: Delivering Consumer-centric and Information-rich Health Care.” Following is my comment on that date in response to his report:

A private health care information technology system

By Don McCanne, MD
Quote of the Day, July 21, 2004

The private, competitive market has produced for us computers that are powerful yet inexpensive. Software that is used widely is quite inexpensive, and that in the public domain is essentially free after the initial development costs. With inexpensive computers and software developed in the public domain, the cost of an integrated health care IT (information technology) system should be quite modest. And the return in error reduction and administrative efficiency would far more than offset any real costs.

The Veterans Administration is far ahead of the rest of the nation in developing and utilizing an integrated IT system. And this has been developed in the public (government!) sector. Many other nations with universal health care systems have also introduced integrated IT systems primarily through the public sector.

What has the magic of the competitive marketplace produced in the way of an integrated IT system to this date? High costs, very poor penetration, and system failures! Competitive market theory dictates that we should be leading the world with a high quality health care IT system at a low cost. What went wrong?

First of all, a fragmented system of multiple private plans, public programs and being uninsured does not provide an infrastructure that is very conducive to an integrated IT system. A single payer system, or, at minimum, a highly regulated system of universal coverage through multiple plans, would provide a framework that would ensure adaptability of an integrated IT system. Of course, a single, publicly administered system would be much preferred for an integrated IT system.

But the greatest difficulty with private IT solutions lies in the very nature of these marketplace models. Their goals are, above all, to maximize profits and to maximize the market price of their shares. To achieve those goals, corporate behavior varies from that of a public entity that has a simpler goal of establishing an effective and efficient high quality system that serves the heath care system and its patients well. The public system does not have to be concerned about being a successful business enterprise, but the private model does.

What might the private sector do that doesn’t serve our interests well? They will produce products that command the highest prices that the market will bear. They will design the products to provide a continuing revenue stream. Once gaining a significant share of the market, they will design incompatibility with other systems in an attempt to garner the entire market. They will design obsolescence into their systems to ensure future markets for their new innovative products. They will partner with and perhaps acquire other related entities that can expand profit potentials through greater control of components of the health care system which their products can influence. Although these are good business practices, they are terrible policies for our health care system.

The health information technology report released today should alarm us all. Although we all agree on the importance of an integrated IT system, the Bush administration is limiting the role of the government to being an enabler that encourages the private sector to develop a successful business model. Rather than higher quality at a lower cost, we’ll end up with mediocrity at a much higher cost, wasting even more of our health care dollars.

We desperately need strong leadership from our government in developing a health care IT system that will serve us all well. But based on the current leadership that has failed to address even the fundamental issue of adequate health care coverage for all, it is unlikely that we’ll see any enlightened leadership on this in the near future.

https://www.pnhp.org/news/2004/july/a_private_health_car.php

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Comment:

By Don McCanne, MD

Some say that my comments of over a decade ago were prescient. They were not. The current disarray of our health information technology system (HIT) was fully predictable.

There are times and circumstances in which the private sector sector serves us well, with appropriate government oversight, and there are times and circumstances in which the government serves us well, with appropriate private partnership.

We blew this one. We turned HIT over to the private sector while failing to provide adequate government oversight. We ended up with just what I predicted a decade ago, when David Brailer was predicting a decade leading to HIT nirvana.

Right now we have a much larger problem in our health care system with an imbalance between the private sector and government. We have turned much of our health care financing system over to the private sector, especially the private insurance plans, without providing adequate government oversight. Thus we have tens of millions of individuals without insurance, many more who are underinsured, many who have impaired access to their physicians because of insurer network restrictions, many who face financial hardship when medical needs arise, and an outrageously expensive system due to the profound administrative waste of the insurers and the burden they place on the health care delivery system.

Virtually none of these problems would exist if we had the government instead of the private insurers serving us as the health care financing authority. It should be the government rather than the private insurers that distributes the funds to the private and public health care delivery systems.

It is amazing that it has taken a decade for us to discover officially that placing control of HIT in the hands of the private sector is not serving us well. What is even more astounding is that, in over half of a century, we have not seemed to learn that lesson as it applies to our health care financing.

It is not as if we have not tried. PNHP has been preaching this lesson for over a quarter of a century, especially after it became obvious that the private insurers and their managed care revolution proved to us that they should no longer be stewards of our health care dollars.

The founders of PNHP were not prescient. The need was obvious. It still is.

Health Care Coverage and Access in the Nation’s Four Largest States

By Petra W. Rasmussen, Sara R. Collins, Michelle M. Doty, Sophie Beutel
The Commonwealth Fund, April 10, 2015

In this brief we use data from the Biennial Survey to examine differences in health insurance coverage, cost-related problems getting needed care, and medical bill problems and debt among adults ages 19 to 64 in the nation’s four largest states.

The four largest states in the U.S.—California, Florida, New York, and Texas—fall into two distinct categories. The first group is represented by California and New York, both of which are operating their own health insurance marketplaces and have expanded eligibility for Medicaid to adults who earn at or below 138 percent of the federal poverty level—about $16,000 for an individual or $32,000 for a family of four.3 Florida and Texas, the second group, are using the federal marketplace to enroll residents in health plans and have declined to expand Medicaid eligibility. In this new analysis of data from the Commonwealth Fund Biennial Health Insurance Survey, we find that, in 2014, there were larger shares of uninsured adults in Florida and Texas compared with California and New York. In addition, adults in Florida and Texas were more likely to report not getting needed care because of cost and to report having problems paying medical bills.

Percent of adults ages 19-64 who are uninsured

12% – New York
17% – California
21% – Florida
30% – Texas

Percent of adults ages 19-64 who experienced cost-related access problems

30% – New York
31% – California
43% – Florida
43% – Texas

Percent of adults 19-64 reporting medical bill problems or medical debt

29% – New York
24% – California
42% – Florida
41% – Texas

Conclusion

The analysis suggests that the health policy decisions made by state leaders matter. Of the four states studied, New York has had the longest history of legislation aimed at enhancing the availability of affordable coverage. California also implemented an early expansion of Medicaid eligibility and, based on federal survey data, both states began achieving declines in their adult uninsured rate earlier than other states. Both have taken advantage of opportunities granted by the Affordable Care Act to further expand the reach of coverage and access. Alternatively, Florida and Texas, while experiencing robust enrollment in private plans through the federal health insurance marketplace, have not expanded Medicaid eligibility and have made less headway in reducing their uninsured populations.

While there have been significant declines in the number and share of uninsured adults since the major provisions of the Affordable Care Act went into effect in 2014, coverage gaps are leaving millions uninsured and without access to affordable coverage. An estimated 3.7 million people have fallen into the Medicaid coverage gap in states that have not yet expanded eligibility for Medicaid.

In addition, the law does not provide access to any new coverage options for unauthorized immigrants. They are ineligible for Medicaid coverage and cannot purchase private plans through the marketplace, either subsidized or unsubsidized. The Congressional Budget Office estimates that by 2020, 30 percent of the remaining uninsured will be unauthorized immigrants, or about 9 million people. Another part of the law that is leaving people uninsured is the so-called “family coverage glitch,” which defines affordability—and eligibility for subsidies—based on the cost of individual, rather than family, coverage. Currently, an estimated 2 million to 4 million people are uninsured because of this issue.

The analysis also indicates that expanded coverage is necessary to improve access to care and reduce medical financial burdens among U.S. families. But the quality and comprehensiveness of coverage across all sources of insurance (marketplace plans, individual plans, employer-provided coverage, and Medicaid), will ultimately determine the degree to which these problems are lessened for U.S. families.

http://www.commonwealthfund.org/publications/issue-briefs/2015/apr/coverage-and-access

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Comment:

By Don McCanne, MD

New York and California have fully implemented the provisions of the Affordable Care Act whereas Florida and Texas have not. As a result, Florida and Texas have more people who are uninsured, more people who experience cost-related access problems, and more people with medical bill problems or medical debt.

Although the leaderships of Florida and Texas should be ashamed for failing to implement the programs that would ensure that more residents receive the health care that they need, the leaderships of New York and California should be ashamed as well for not demanding changes in our health care financing system that would ensure health care for everyone. The numbers in the tables above for these two “exemplary” states are disgraceful and would not be tolerated by any other wealthy nation.

Incremental patches are grossly inadequate. We need a single payer national health program.

Why the Private Health Insurance Industry Has to Go

By John Geyman, MD
PNHP Blog, April 8, 2015

The private health insurance industry in the U.S. has had a long run since shifting to medical underwriting and a for-profit status in the early 1960s. It finds itself increasingly dependent on the government as the costs and prices of health care have continued upward since the 1980s. Its many perks from government include tax exemptions for employer-sponsored insurance (ESI), privatized Medicare and Medicaid programs, and longstanding over-payments to Medicare Advantage programs. The Affordable Care Act (ACA) has added to these perks since 2010 with subsidized premiums through the exchanges, a “risk corridor system” to protect insurers from losses, and allowing automatic self-renewal for 2015 plans.

Incremental attempts to contain health care costs and reform the system since the 1990s have built upon our current multi-payer financing system. After five years’ experience with the ACA, we now know that insurers themselves are a major barrier to achieving the kind of access to affordable care that our population so desperately needs.

Here are some of the major reasons why private health insurers warrant no further bailout by government and taxpayers.

1. Continued discrimination against the sick.

Despite the supposed consumer protections in the ACA, a 2014 letter from more than 300 patient advocacy groups to the Secretary of Health and Human Services described continuing ways that insurers still discriminate against the sick, including benefit designs that limit access, high cost-sharing, restrictive drug formularies, inadequate provider networks, and deceptive marketing practices. A recent study by Kaiser Family Foundation found that only one-third of households with incomes between 100 percent and 250 percent of poverty have enough liquid assets to pay their deductibles, while only about one-half can meet out-of-pocket limits. As other examples, Wellpoint developed an algorithm to search its database for patients with breast cancer with an intent to cancel their policies, while many insurers place all drugs used to treat such complex diseases as cancer, multiple sclerosis and HIV in the highest drug formulary cost-sharing tiers, thereby reducing insurers’ costs but making the drugs unaffordable for many patients

2. Fragmentation, inefficiency, and exorbitant administrative overhead.

There are some 1,300 private insurers still trying to maximize their income by avoiding the costs of sicker patients. Their administrative overhead is more than five times higher than that of the single-payer program in two Canadian provinces; the overhead of private Medicare Advantage plans averages 19 percent vs. the 1.5 percent for traditional Medicare. Although the ACA set limits of 20 percent for overhead in the individual market and 15 percent in large-group markets, a recent study has found that those requirements had no effect on insurers’ overhead spending over the first three years of the ACA.

3. Increasing costs for less coverage

The ACA provided insurers with four levels of coverage—the so-called “metals”—with actuarial values (what insurers pay vs. what patients pay) ranging from 60 percent (bronze) 70 percent (silver) to 80 percent (gold) and 90 percent (platinum). Not content with those levels of coverage, the industry through its trade group, America’s Health Insurance Programs (AHIP), has been lobbying hard for copper plans with only 50 percent actuarial value. Silver plans have been the most popular on the exchanges, so that patients are left with almost one-third of their costs, plus the cost-sharing that was required to get and maintain their policies. All this has led to an epidemic of underinsurance, whether the plans are purchased through the ACA exchanges or through the private insurance markets. The ACA has made the mistake of focusing on raising the numbers of Americans with “insurance”, but has not been effective in containing prices or costs of health care, with the result that an increasing proportion of these costs are shifted to patients and families. One-half of bronze plans in seven large U.S. cities require enrollees to pay the deductible (often $5,000) before covering a doctor’s visit. 

4. Gaming the ACA for profits more than service to patients

There are many examples of this, starting with Medicare Advantage. Many insurers have been cited by the Centers for Medicare & Medicaid Services (CMS) for serious violations of Medicare’s patient protection requirements, including inappropriate denial of coverage and failure to consider physicians’ clinical information. Humana, one of the largest Medicare Advantage insurers in the country, is facing scrutiny from the U.S. Department of Justice for its risk-adjustment practices, which “upcode” the severity of patients’ illnesses in order to gain increased reimbursement, even as they lobby Congress for continued high over-payments. Meanwhile, some insurers are marketing short-term plans that last less than 12 months, evading any of the ACA’s requirements.

5. Private insurance has priced itself out of the market.

Premiums keep going up at rates much higher than the cost of living, with little or no containment by regulators. As examples, MetroPlus, a popular new entrant on the New York exchange in 2014, has requested rate hikes of up to 28 percent in 2015 for some of its enrollees, while Florida Blue, the state’s largest insurer, has announced an average rate increase of 17.8 percent for 2015. One can argue that the private insurance industry should be regarded as obsolete and not worth saving. However, the ACA has extended its life, including almost $2 trillion in federal subsidies over  the next ten years (if these subsidies survive a U.S. Supreme Court ruling on their legality in coming months). Insurers have focused on attracting enrollees with low premiums, high cost-sharing, and low levels of actual coverage. Large insurers such as Wellpoint (Anthem) and Humana expect to receive $5.5 billion in 2015 through  the ACA’s “risk corridor” provision that protects them from “losses.”

6. As their business plan dictates, insurers are leaving unprofitable markets without regard for patients’ needs.

Private health insurers are all about making money, so they leave unprofitable markets regardless of the public’s needs. A recent example is Blue Shield of California (which just lost its state tax-exempt status with a surplus of more than $4 billion), which withdrew from 250 zip codes in California throughout the state in 2014.

Based on the above, the time has come for us to replace private health insurers with a more efficient, not-for-profit single-payer financing system—national health insurance (NHI)—which could be enacted by passage of H. R. 676, Expanded and Improved Medicare for All.

Reference:  

Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single Payer Solution for All Americans. Friday Harbor, WA, Copernicus Healthcare, 2015, http://www.johngeymanmd.org

Other references are available at either link below.

PNHP Blog: https://pnhp.org/blog/2015/04/08/why-the-private-health-insurance-industry-has-to-go/

Huffington Post (Same article): http://www.huffingtonpost.com/john-geyman/why-the-private-health-in_b_7029594.html

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Comment:

By Don McCanne, MD

Those supporting further implementation of the Affordable Care Act (ACA) while rejecting more comprehensive reform are trying to make the overpriced and inadequate private health plans work for us. John Geyman reminds us of some of the reasons why the private plans are actually the cause of several of the problems we face today. We need to replace them with a single payer national health program.

Medicare fix needs fixing

By Theodore R. Marmor
philly.com, April 13, 2015

In recent weeks, reform legislation that proposes to change how Medicare pays physicians drew much attention. The prod to action was the imminent expiring of the present fee schedule.

For many years, Congress had failed to reach agreement about the rate of increase in physician payments under Medicare. This, in turn, prompted annual, ad hoc “fixes” while postponing decisions on how Medicare should operate as a “purchaser” of medical care.

The surprise of 2015 is that the House of Representatives did agree, in bipartisan fashion, on a remedy. After five years of persistent and contentious debate over the Obama health reform we now know as Obamacare, the sight of Speaker John Boehner (R., Ohio) embracing Minority Leader Nancy Pelosi (D., Calif.) over a health-care bill is indeed newsworthy.

But here, as in other instances, the problem is faulty reasoning from misleading assumptions.

Take the definition of what’s wrong with our current payment arrangements. Many lawmakers say that Medicare should reject the fee-for-service method, the mode Medicare has used since its inception — and the way many industrial nations pay their doctors.

Instead, these lawmakers argue, Medicare should reward doctors for the “quality” rather than the “quantity” of their work, and reward “value” over “volume.” Sylvia Burwell, secretary of Health and Human Services, has fervently embraced “value-based payment.”

This seeming agreement over the need to do away with fee for service has prompted much discussion of alternative payment models, such as “capitation,” “bundled payments,” and monetary incentives for exemplary physician behavior.

Sounds plausible, doesn’t it? But the problem is — as all other industrial democracies have learned in the last three decades — there is no single payment panacea. Each method of compensating doctors has the vice of its virtue.

If you pay physicians per capita — known as capitation, an annual or monthly amount for each patient signed up with a practice — the hope is that the doctors will care more about the health of their patients and less about the number of procedures they perform.

But there is little or no evidence to back up this hope. Many other countries use fee-for-service payments, but spend far less on health care than we do, and yet get decent results, without alarming problems of excess procedures.

Under Britain’s National Health Service, physicians were once paid almost exclusively by capitation, and it generally served them well. Now general practitioners get paid partly per capita, partly by meeting targeted actions, and partly by the equivalent of a “salary” for being available on weekends and evenings. They are experimenting with a mix of payment methods.

So the international evidence shows there is no one obvious way to pay doctors. How to manage sensibly the mix of methods is the important challenge.

The celebration of paying for “value over quantity” assumes we know how to identify value and pay for it. Yet, there is considerable disagreement in modern medicine about how much one way of working is better than another.

For example, an attempt to establish a standardized cost-benefit analysis of treatments for Medicaid patients in Oregon in the late 1990s fell apart upon implementation. There was no agreed-upon list of what treatments were more valuable on grounds of both cost and quality, and physicians were rightfully indignant when their professional knowledge about what was best for their individual patients was upended by a rulebook.

In reading the bill that the Senate will soon vote on, I can’t help but notice how the new prescriptions for physician behavior represent marketing jargon more than considered thought. For decades, one has seen prepaid group practice redefined as “managed care,” while actually what was going on were mostly efforts to reduce the costs of care.

We have now seen a whole series of reforms celebrated for giving the patient financial “skin in the game,” based on a vision of a medical-care marketplace where large deductibles force patients to make choices among goods and services that earlier forms of health insurance did not do.

As if these issues weren’t enough to abandon this bill and start over, there are a couple of specific provisions that represent a Trojan horse for the further undermining of traditional Medicare. One is the imposition of deductibles on Medigap plans that the majority of Medicare beneficiaries buy to help with cost-sharing, a reform that will discourage seniors from seeking needed care. The other is a measure that would require wealthier people to pay higher Medicare premiums — a measure that could further erode universal political support for the program.

The Senate should take this legislation back to the drawing board.

Ted Marmor is a professor emeritus of political science and public policy at Yale University and co-author, with Rudolf Klein, of “Politics, Health and Health Care.”

http://www.philly.com/philly/opinion/20150413_Medicare_fix_needs_fixing.html

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Comment:

By Don McCanne, MD

The Senate is back in session this week and is expected to rush through H.R.2 – the House approved “SGR fix.” SGR has got to go and CHIP needs to be funded, but the unproven and administratively burdensome replacement for SGR, along with the Medicare tweaks, are worse than the current fee-for-service method of financing health care. 

It is wrong to replace bad legislation with bad legislation. As an interim measure, we should get rid of the existing bad legislation by repealing SGR, since Congress has made it an emergency. Ted Marmor, in this important article, explains why this legislation then needs to be taken back to the drawing board so we can keep the good (funding CHIP) and get rid of the bad.

Ted Marmor is an icon in the academic world of the politics of Medicare. It is urgent that we take heed of his advice.

Where Government Excels

By Paul Krugman
The New York Times, April 10, 2015

Like all advanced nations, America mainly relies on private markets and private initiatives to provide its citizens with the things they want and need, and hardly anyone in our political discourse would propose changing that. The days when it sounded like a good idea to have the government directly run large parts of the economy are long past.

Yet we also know that some things more or less must be done by government. Every economics textbooks talks about “public goods” like national defense and air traffic control that can’t be made available to anyone without being made available to everyone, and which profit-seeking firms, therefore, have no incentive to provide. But are public goods the only area where the government outperforms the private sector? By no means.

One classic example of government doing it better is health insurance. Yes, conservatives constantly agitate for more privatization — in particular, they want to convert Medicare into nothing more than vouchers for the purchase of private insurance — but all the evidence says this would move us in precisely the wrong direction. Medicare and Medicaid are substantially cheaper and more efficient than private insurance; they even involve less bureaucracy. Internationally, the American health system is unique in the extent to which it relies on the private sector, and it’s also unique in its incredible inefficiency and high costs.

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Comment:

By Don McCanne, MD

Next week, when the Senate returns from its break, they will likely approve House-passed H.R.2 – the “SGR fix” – a bill that is being used as a vehicle to move Medicare closer to privatization by taking small incremental steps in increasing Medicare premiums and deductibles – features that are more characteristic of private individual plans than public social insurance programs.

Paul Krugman reminds us that governments are better at providing health insurance. So we should reject the current bipartisan efforts that are moving us further in the direction of converting Medicare from a public insurance program into a premium support model (defined contribution vouchers) of a market of private health plans.

This week’s taxpayer boost given by the Obama administration to the private Medicare Advantage plans – the fourth such devious boost in the past four years – enhances the private plans to set them up as a model for privatized Medicare. Is there no stopping this?