WASHINGTON — The health care provisions in the federal economic stimulus package continue to spark disagreement between Republicans and Democrats, as seen at a diabetes meeting sponsored by Avalere Health.
Wendell Primus, senior policy advisor to House Speaker Nancy Pelosi (D-Calif.), noted three provisions of interest in the Recovery Act (formally called the American Recovery and Reinvestment Act of 2009): $87 billion in Medicaid funding to states; a 65% subsidy to laid-off workers who are still receiving health coverage from their former employers through the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986; and $19 billion to be invested in health information technology (HIT).
Under the HIT component of the law, the government must develop certain technology standards, he explained.
One important standard is interoperability. “We have an example [of noninteroperability] right here in town,” Mr. Primus noted. “The George Washington [University] Hospital just recently bought an HIT system for its emergency department and one for its inpatient department, and unfortunately those two systems don't talk to one other. We're going to try to make sure that doesn't happen.”
Functionality is another critical standard. “If I have a doctor-patient relationship, I may know what I think your situation is, but I may not know the four doctors that have seen you since your last visit to me,” said Mr. Primus. “I want [the medical record] to quickly be able to tell the doctor that's currently visiting that patient what has happened, and what the other four doctors have prescribed. We also want the system to be able to do reminders and things like that.” The government also must develop standards for data security and for privacy.
The Recovery Act includes incentives of $40,000–$60,0000 for providers to use toward the purchase of an HIT system. Over time, “those incentives turn into penalties” in the form of reduced reimbursement from government health care programs if physicians do not adopt an HIT system, he said. “We're using the sticks of Medicare and Medicaid to make sure we get all doctors' offices wired within 8–10 years.”
From the Republican perspective, Dan Elling, minority staff director on the House Ways and Means subcommittee on health, said some of the HIT provisions were problematic.
“We were glad to see HIT move forward. Having hospitals and doctors be able to talk to one another and coordinate care … is going to improve our health care system,” he said. However, “the incentive payments don't start until 2011. If this is part of the stimulus bill and we're not spending the money for another 3 years, what are we doing?”
In addition, “each physician would be able to qualify for up to $64,000 in incentive payments, independent of the actual cost of the system,” said Mr. Elling, whose boss is Rep. Dave Camp (R-Mich.). “So if you're part of a 20-doctor practice that's able to use economies of scale … and purchase an HIT system that costs $20,000 per physician, that doctor is able to pocket the extra $44,000. That's taxpayer money. We'd [prefer] language that says, 'You only get what you pay [out]' “ in terms of reimbursement by the government.
Another big chunk of Recovery Act funds is the $1.1 billion for comparative effectiveness research. CER is designed to “make doctors and [other] providers smarter” by letting them know which treatments are the most clinically effective and the most cost effective, according to Mr. Primus. He said that CER is not “cookbook medicine,” but is aimed at producing “better public knowledge.”
Mr. Elling agreed that “done effectively, there's a lot of promise in CER. Getting more information to patients and physicians is outstanding and we should be doing that.” But he added that “this is the camel's nose under the tent on government control of your health care,” especially since the consumer effectiveness board that's called for in the bill comprises only government employees, with no practicing clinicians or patient advocates as members.
Mr. Elling offered a cautionary tale about CER. “We've seen how they apply [CER] in other countries,” he said.
For instance, the policy at the U.K. National Institute for Health and Clinical Excellence, the organization that determines which treatments the National Health Service will pay for, says that “if you want the expensive drug for macular degeneration, you have to go blind in one eye before they'll give it to you for the other eye. That's CER right there.”