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Entries from February 2009

US Behind in HIT Spending – Stimulus Insufficient

February 28, 2009 · Leave a Comment

Despite the fact that the US spends nearly twice as much on healthcare as any other country, the US is as much as 12 years behind other OECD countries in health information technology investment. See the Commonwealth Fund’s entry on Health Care Spending and Use of Information Technology in OECD Countries.

hit-efforts-in-six-countries

The American Recovery & Reinvestment Act of 2009–the Stimulus Package–apportions $19 billion for investment into the HIT infrastructure in the US. As much as $3 billion goes to the Office of the National Coordinator (which will now be codified) and other standards creating bodies. The remaining amount will be given to providers primarily through increased Medicare reimbursement. If divided evenly, each hospital would receive approximately $11 million. A substantial sum, but hardly close to the $200 million over 3 years required in a typical implementation at a 300+ bed hospital. Only 10% of hospitals currently have full electronic health records. Another 20-30% are in planning or implementation stages. The stimulus may encourage more providers to enter the planning stages and will help along those already in the process during difficult economic times. But $11 million for the remaining 60-70% is entirely insufficient.

Evidence shows that the only providers that stand to get a return on investment in HIT are large network providers with geographically distributed practices, such as Kaiser or the VA. This makes sense, as the administrative cost of sharing information is high. The early adopters (the 10%) consist of these large networks and a few providers with well-funded, forward-thinking CIOs. The 20-30% currently planning hope to break even at best and justify the investment by improved patient care (especially through CPOE). The rest are mostly too small to realize significant cost savings and will likely need much more than $11 million to break even.

Categories: health information technology · politics
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Congress approves $19 billion for health IT

February 13, 2009 · 1 Comment

Excerpt by Andrew Noyes, Congress Daily from NextGov.com

Deal Leaves Money, Language On Health IT Mostly Intact

The compromise stimulus deal leaves much of each chamber’s proposed funding for health information technology intact, according to an overview circulated by House Speaker Pelosi Wednesday and a preliminary summary of the compromise that was subject to change. The final package provides $19 billion to encourage nationwide adoption of electronic medical records, with $17 billion for Medicare and Medicaid incentives for federally qualified health centers, rural health clinics, children’s hospitals, and others. The Senate version, which won approval Tuesday after members stripped out $100 billion, included $16 billion for Medicare and Medicaid incentives, about $2 billion less than the House plan that passed last month. The Senate also imposed a $1.5 billion cap on incentive payments to “critical access hospitals,” while the House included no such language. Conferees reportedly accounted for those facilities, but it is unclear whether the cap remained.

The negotiated stimulus would provide temporary bonuses of as much as $64,000 for physicians and up to $11 million for hospitals that adopt e-health records, the summary document stated. Medicare penalties for noncompliance would also be phased in starting in 2014. The package would also codify the HHS Office of the National Coordinator for Health IT and establish a transparent process for developing standards for e-health records by 2010. An immediate $2 billion would be available to HHS for health IT infrastructure, training, telemedicine, and other grants. The Senate had previously asked for $3 billion, while the House wanted just over $2 billion.

The package would also expand federal privacy and security protections for health IT, such as requiring that an individual be notified if there is an unauthorized disclosure or use of their health information and requiring a patient’s permission to use their personal records for marketing purposes. Details had not emerged by presstime about whether complaints by the privacy community had been addressed. Some watchdogs pressed conferees to take specific steps to close what they argued were marketing loopholes left open in the House and Senate versions as well as make changes to breach notification language. Several sources said they believed a House provision mandating healthcare operations rules from HHS had been dropped entirely. Providers complained the regulations could have required either prior patient consent or the use of de-identified data before information could be exchanged.

Categories: current events · health information technology · politics
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MCPI Growth Factors

February 10, 2009 · Leave a Comment

According to the National Health Statistics Group (NHSG), the primary drivers of personal health care spending growth between 2008 and 2017 will be increasing medical prices and utilization followed by the changing age-sex mix and population growth. What surprised me is that the aging population is not the primary problem.

MCPI Growth Factors

The article unfortunately requires subscription or one-time fee, but it may be worthwhile. Here’s the abstract:

Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare

Sean Keehan, Andrea Sisko, Christopher Truffer, Sheila Smith,Cathy Cowan, John Poisal, M. Kent Clemens the National Health Expenditure Accounts Projections Team

The outlook for national health spending calls for continued steady growth. Spending growth is projected to be 6.7 percent in 2007, similar to its rate in 2006. Average annual growth over the projection period is expected to be 6.7 percent. Slower growth in private spending toward the end of the period is expected to be offset by stronger growth in public spending. The health share of gross domestic product (GDP) is expected to increase to 16.3 percent in 2007 and then rise throughout the projection period, reaching 19.5 percent of GDP by 2017.

Keehan S et al.  Health Spending Projections Through 2017: The Baby-Boom Generation Is Coming To Medicare. Health Aff., March 1, 2008; 27(2): w145 – w155.

Categories: public health
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Copenhagen Consensus 2008

February 6, 2009 · Leave a Comment

Over the last 2 years, many of the world’s top economists, including 5 Nobel Laureates, ranked 30 high-impact solutions to address the world’s greatest challenges. The panel estimates there is a $17 return for every dollar invested into these solutions, in terms of reduced medical expenses and significantly increased earnings.

At the top of the list is providing micronutrient supplements for children (esp. vitamin A and zinc), meaning that the panel of economist that formed the Copenhagen Consensus believe that providing vitamin supplements is the most cost-effective way that the world can improve the state of our planet. Complying with the Doha development agenda would be the second, and so on down to 30. Malnutrition tops the list, with 5 solutions in the top 10, with education and women next. Diseases of the developing world are of course high priorities, but perhaps more surprisingly, so is acute care for heart attacks. 7 entries for global warming and air pollution are also on the list.

These solutions provide a great template for planning cost-effective, high-impact, and globally relevant interventions. The development community would do well to focus on these.

Read more about each of these solutions at  Copenhagen Consensus 2008.

 
Solution
Challenge
1
Micronutrient supplements for children (vitamin A and zinc)
Malnutrition
2
The Doha development agenda
Trade
3
Micronutrient fortification (iron and salt iodization)
Malnutrition
4
Expanded immunization coverage for children
Diseases
5
Biofortification
Malnutrition
6
Deworming and other nutrition programs at school
Malnutrition & Education
7
Lowering the price of schooling
Education
8
Increase andimprove girls’ schooling
Women
9
Community-based nutrition promotion
Malnutrition
10
Provide support for women’s reproductive role
Women
11
Heart attack acute management
Diseases
12
Malaria prevention and treatment
Diseases
13
Tuberculosis case finding and treatment
Diseases
14
R&D in low-carbon energy technologies
Global Warming
15
Bio-sand filters for household water treatment
Water
16
Rural water supply
Water
17
Conditional cash transfers
Education
18
Peace-keepingin post‐conflict situations
Conflicts
19
HIV combination prevention
Diseases
20
Total sanitation campaign
Water
21
Improving surgical capacity at district hospital level
Diseases
22
Microfinance
Women
23
Improved stove intervention
Air Pollution
24
Large, multipurpose dam in Africa
Water
25
Inspection and maintenance of diesel vehicles
Air Pollution
26
Low sulfur diesel for urban road vehicles
Air Pollution
27
Diesel vehicle particulate control technology
Air Pollution
28
Tobacco tax
Diseases
29
R&D and mitigation
Global Warming
30
Mitigation only
Global Warming

Categories: public health · social enterprise
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President Bush Delivers Farewell Speech – Jan 15

February 3, 2009 · 1 Comment

President Bush delivered his farewell address Jan 15, 2009. Regardless of one’s party affiliation and political likes and dislikes, a Presidential farewell provides an interesting perspective into the legacy by which a President hopes to be remembered. And this is why I found President Bush’s address so shocking. He begins by acknowledging the truly astonishing nature of the transition:

Five days from now, the world will witness the vitality of American democracy. In a tradition dating back to our founding, the presidency will pass to a successor chosen by you, the American people. Standing on the steps of the Capitol will be a man whose history reflects the enduring promise of our land. This is a moment of hope and pride for our whole nation. And I join all Americans in offering best wishes to President-elect Obama, his wife Michelle, and their two beautiful girls.

Then, he narrows in to the single event that shaped both his speech and his entire presidency:

This evening, my thoughts return to the first night I addressed you from this house — September the 11th, 2001.

Some insight into the administration’s view of US intervention in Afghanistan and Iraq:

Afghanistan has gone from a nation where the Taliban harbored al-Qaida and stoned women in the streets to a young democracy that is fighting terror and encouraging girls to go to school. Iraq has gone from a brutal dictatorship and a sworn enemy of America to an Arab democracy at the heart of the Middle East and a friend of the United States.

Bush contributes 7 years with no terrorist attacks to the creation of the Department of Homeland Security, transformation of the military and intelligence community, and taking “the fight to terrorists and those who support them”:

There is legitimate debate about many of these decisions. But there can be little debate about the results. America has gone more than seven years without another terrorist attack on our soil.

Now, a return to the ideological struggle between good and evil:

The battles waged by our troops are part of a broader struggle between two dramatically different systems. Under one, a small band of fanatics demands total obedience to an oppressive ideology, condemns women to subservience and marks unbelievers for murder. The other system is based on the conviction that freedom is the universal gift of Almighty God, and that liberty and justice light the path to peace.

I’ve often spoken to you about good and evil, and this has made some uncomfortable. But good and evil are present in this world, and between the two of them there can be no compromise. Murdering the innocent to advance an ideology is wrong every time, everywhere. Freeing people from oppression and despair is eternally right. This nation must continue to speak out for justice and truth. We must always be willing to act in their defense — and to advance the cause of peace.

9/11 laid such a heavy burden on this administration that Bush only gives a single paragraph to the other major events of his administration: expansion of Medicare prescription drug benefits, No Child Left Behind (which he doesn’t mention by name), lower taxes, promotion of faith-based programs, and providing assistance to persons living with HIV/AIDS.

Let’s spend a minute on that last one. The President’s Emergency Plan for AIDS Relief (PEPFAR) is largely considered to be the most successful international aid program the US has enacted and recieves strong bipartisan support. PEPFAR provided $50 billion over 5 years to fund anti-retrovirals and contraceptive distribution networks, as well as educational programs (usually abstinence based, although this is changing). PEPFAR has had a slew of problems, but is still one of the largest sources of funding for AIDS relief. Yet, President Bush hardly even mentions it.

But more than anything, I am struck by the divisiveness of his language. President Bush entered office vowing to be a “uniter not a divider”, yet he left with extremely low approval ratings and negative perceptions of the US worldwide. Drawing sharp lines between black and white, good and evil, may be useful to him in his personal life, but divisions such as these can have harmful and polarizing effects in politics. Unity is not achieved by publicly labeling outsiders. If a group identifies themselves by their opposition to you, calling them evil strengthens their identity and opens you up to scrutiny (consider Bush and the torture at Guantanamo).

While discussing this issue with a friend of mine, he said something quite insightful: “Great men in history have created divisiveness and offense without exception.  They simply know that their ultimate goals are more important than public acceptance…Great men may create terrible controversy, but at least they have the appropriate methodology and results to back it up.” Therefore, division isn’t the problem, it creating division without support, without evidence, without proper methodology.

Politics is labeled the art of compromise for a reason. Political philosopher Jean Bethke Elshtain states: “But compromise is not a mediocre way to do politics; it is an adventure, the only way to do democratic politics.” Certainly, this argument is a simplification, but I look forward to the departure of divisive ideology from the White House.

(Read the full text of President Bush’s farewell address here: http://www.baltimoresun.com/news/nation/bal-bushtext0115,0,3697667.story)

(Read more of my friend’s blog at http://nateahern.blogspot.com/)

Categories: current events · politics
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President Barack Obama’s Inaugural Address

February 3, 2009 · Leave a Comment

Inaugural Address, by President Barack Hussein Obama

http://www.whitehouse.gov/blog/inaugural-address/ 

My fellow citizens:  I stand here today humbled by the task before us, grateful for the trust you’ve bestowed, mindful of the sacrifices borne by our ancestors. 

I thank President Bush for his service to our nation — (applause) — as well as the generosity and cooperation he has shown throughout this transition.

Forty-four Americans have now taken the presidential oath.  The words have been spoken during rising tides of prosperity and the still waters of peace.  Yet, every so often, the oath is taken amidst gathering clouds and raging storms.  At these moments, America has carried on not simply because of the skill or vision of those in high office, but because we, the people, have remained faithful to the ideals of our forebears and true to our founding documents. 

So it has been; so it must be with this generation of Americans.

That we are in the midst of crisis is now well understood.  Our nation is at war against a far-reaching network of violence and hatred.  Our economy is badly weakened, a consequence of greed and irresponsibility on the part of some, but also our collective failure to make hard choices and prepare the nation for a new age.  Homes have been lost, jobs shed, businesses shuttered.  Our health care is too costly, our schools fail too many — and each day brings further evidence that the ways we use energy strengthen our adversaries and threaten our planet.

These are the indicators of crisis, subject to data and statistics.  Less measurable, but no less profound, is a sapping of confidence across our land; a nagging fear that America’s decline is inevitable, that the next generation must lower its sights.

Today I say to you that the challenges we face are real.  They are serious and they are many.  They will not be met easily or in a short span of time.  But know this America:  They will be met.  (Applause.)

On this day, we gather because we have chosen hope over fear, unity of purpose over conflict and discord.  On this day, we come to proclaim an end to the petty grievances and false promises, the recriminations and worn-out dogmas that for far too long have strangled our politics.  We remain a young nation.  But in the words of Scripture, the time has come to set aside childish things.  The time has come to reaffirm our enduring spirit; to choose our better history; to carry forward that precious gift, that noble idea passed on from generation to generation:  the God-given promise that all are equal, all are free, and all deserve a chance to pursue their full measure of happiness.  (Applause.)

In reaffirming the greatness of our nation we understand that greatness is never a given.  It must be earned.  Our journey has never been one of short-cuts or settling for less.  It has not been the path for the faint-hearted, for those that prefer leisure over work, or seek only the pleasures of riches and fame.  Rather, it has been the risk-takers, the doers, the makers of things — some celebrated, but more often men and women obscure in their labor — who have carried us up the long rugged path towards prosperity and freedom. 

For us, they packed up their few worldly possessions and traveled across oceans in search of a new life.  For us, they toiled in sweatshops, and settled the West, endured the lash of the whip, and plowed the hard earth.  For us, they fought and died in places like Concord and Gettysburg, Normandy and Khe Sahn. 

Time and again these men and women struggled and sacrificed and worked till their hands were raw so that we might live a better life.  They saw America as bigger than the sum of our individual ambitions, greater than all the differences of birth or wealth or faction.

This is the journey we continue today.  We remain the most prosperous, powerful nation on Earth.  Our workers are no less productive than when this crisis began.  Our minds are no less inventive, our goods and services no less needed than they were last week, or last month, or last year.  Our capacity remains undiminished.  But our time of standing pat, of protecting narrow interests and putting off unpleasant decisions — that time has surely passed.  Starting today, we must pick ourselves up, dust ourselves off, and begin again the work of remaking America.  (Applause.)

For everywhere we look, there is work to be done.  The state of our economy calls for action, bold and swift.  And we will act, not only to create new jobs, but to lay a new foundation for growth.  We will build the roads and bridges, the electric grids and digital lines that feed our commerce and bind us together.  We’ll restore science to its rightful place, and wield technology’s wonders to raise health care’s quality and lower its cost.  We will harness the sun and the winds and the soil to fuel our cars and run our factories.  And we will transform our schools and colleges and universities to meet the demands of a new age.  All this we can do.  All this we will do.

Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans.  Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose, and necessity to courage.  What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long no longer apply. 

The question we ask today is not whether our government is too big or too small, but whether it works — whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified.  Where the answer is yes, we intend to move forward.  Where the answer is no, programs will end.  And those of us who manage the public’s dollars will be held to account, to spend wisely, reform bad habits, and do our business in the light of day, because only then can we restore the vital trust between a people and their government.

Nor is the question before us whether the market is a force for good or ill.  Its power to generate wealth and expand freedom is unmatched.  But this crisis has reminded us that without a watchful eye, the market can spin out of control.  The nation cannot prosper long when it favors only the prosperous.  The success of our economy has always depended not just on the size of our gross domestic product, but on the reach of our prosperity, on the ability to extend opportunity to every willing heart — not out of charity, but because it is the surest route to our common good.  (Applause.)

As for our common defense, we reject as false the choice between our safety and our ideals.  Our Founding Fathers — (applause) — our Founding Fathers, faced with perils that we can scarcely imagine, drafted a charter to assure the rule of law and the rights of man — a charter expanded by the blood of generations.  Those ideals still light the world, and we will not give them up for expedience sake.  (Applause.)

And so, to all the other peoples and governments who are watching today, from the grandest capitals to the small village where my father was born, know that America is a friend of each nation, and every man, woman and child who seeks a future of peace and dignity.  And we are ready to lead once more.  (Applause.)

Recall that earlier generations faced down fascism and communism not just with missiles and tanks, but with the sturdy alliances and enduring convictions.  They understood that our power alone cannot protect us, nor does it entitle us to do as we please.  Instead they knew that our power grows through its prudent use; our security emanates from the justness of our cause, the force of our example, the tempering qualities of humility and restraint.

We are the keepers of this legacy.  Guided by these principles once more we can meet those new threats that demand even greater effort, even greater cooperation and understanding between nations.  We will begin to responsibly leave Iraq to its people and forge a hard-earned peace in Afghanistan.  With old friends and former foes, we’ll work tirelessly to lessen the nuclear threat, and roll back the specter of a warming planet.

We will not apologize for our way of life, nor will we waver in its defense.  And for those who seek to advance their aims by inducing terror and slaughtering innocents, we say to you now that our spirit is stronger and cannot be broken — you cannot outlast us, and we will defeat you.  (Applause.)

For we know that our patchwork heritage is a strength, not a weakness.  We are a nation of Christians and Muslims, Jews and Hindus, and non-believers.  We are shaped by every language and culture, drawn from every end of this Earth; and because we have tasted the bitter swill of civil war and segregation, and emerged from that dark chapter stronger and more united, we cannot help but believe that the old hatreds shall someday pass; that the lines of tribe shall soon dissolve; that as the world grows smaller, our common humanity shall reveal itself; and that America must play its role in ushering in a new era of peace.

To the Muslim world, we seek a new way forward, based on mutual interest and mutual respect.  To those leaders around the globe who seek to sow conflict, or blame their society’s ills on the West, know that your people will judge you on what you can build, not what you destroy.  (Applause.)  

To those who cling to power through corruption and deceit and the silencing of dissent, know that you are on the wrong side of history, but that we will extend a hand if you are willing to unclench your fist.  (Applause.)

To the people of poor nations, we pledge to work alongside you to make your farms flourish and let clean waters flow; to nourish starved bodies and feed hungry minds.  And to those nations like ours that enjoy relative plenty, we say we can no longer afford indifference to the suffering outside our borders, nor can we consume the world’s resources without regard to effect.  For the world has changed, and we must change with it.

As we consider the role that unfolds before us, we remember with humble gratitude those brave Americans who at this very hour patrol far-off deserts and distant mountains.  They have something to tell us, just as the fallen heroes who lie in Arlington whisper through the ages. 

We honor them not only because they are the guardians of our liberty, but because they embody the spirit of service — a willingness to find meaning in something greater than themselves. 

And yet at this moment, a moment that will define a generation, it is precisely this spirit that must inhabit us all.  For as much as government can do, and must do, it is ultimately the faith and determination of the American people upon which this nation relies.  It is the kindness to take in a stranger when the levees break, the selflessness of workers who would rather cut their hours than see a friend lose their job which sees us through our darkest hours.  It is the firefighter’s courage to storm a stairway filled with smoke, but also a parent’s willingness to nurture a child that finally decides our fate.

Our challenges may be new.  The instruments with which we meet them may be new.  But those values upon which our success depends — honesty and hard work, courage and fair play, tolerance and curiosity, loyalty and patriotism — these things are old.  These things are true.  They have been the quiet force of progress throughout our history. 

What is demanded, then, is a return to these truths.  What is required of us now is a new era of responsibility — a recognition on the part of every American that we have duties to ourselves, our nation and the world; duties that we do not grudgingly accept, but rather seize gladly, firm in the knowledge that there is nothing so satisfying to the spirit, so defining of our character than giving our all to a difficult task.

This is the price and the promise of citizenship.  This is the source of our confidence — the knowledge that God calls on us to shape an uncertain destiny.  This is the meaning of our liberty and our creed, why men and women and children of every race and every faith can join in celebration across this magnificent mall; and why a man whose father less than 60 years ago might not have been served in a local restaurant can now stand before you to take a most sacred oath.  (Applause.)

So let us mark this day with remembrance of who we are and how far we have traveled.  In the year of America’s birth, in the coldest of months, a small band of patriots huddled by dying campfires on the shores of an icy river.  The capital was abandoned.  The enemy was advancing.  The snow was stained with blood.  At the moment when the outcome of our revolution was most in doubt, the father of our nation ordered these words to be read to the people: 

“Let it be told to the future world…that in the depth of winter, when nothing but hope and virtue could survive… that the city and the country, alarmed at one common danger, came forth to meet [it].”

America:  In the face of our common dangers, in this winter of our hardship, let us remember these timeless words.  With hope and virtue, let us brave once more the icy currents, and endure what storms may come.  Let it be said by our children’s children that when we were tested we refused to let this journey end, that we did not turn back nor did we falter; and with eyes fixed on the horizon and God’s grace upon us, we carried forth that great gift of freedom and delivered it safely to future generations.

Thank you.  God bless you.  And God bless the United States of America.

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