• Dr. Ted (he’s not me) | The Economist – Comment from a user of The Economist.com that refers to the Kaiser Permanente study showing a 21.5 % decrease in office visits in Hawaii. (see http://content.healthaffairs.org/cgi/content/abstract/28/2/323 ). I agree that the majority of care to Americans is provided in small practices, as well as the idea that physicians who want to perform virtual care find it difficult with today's reimbursement approach. (50% of the reason I’m posting this is to clarify that I’m not this Dr. Ted. I post comments on others’ blogs as “Ted Eytan.”

• DWT LLP | Practice Areas: Health Law Group Bulletin – Carrots and Sticks: The Stimulus Package Promotes Health Information Technology – a nice overview of the details of health information technology stimulus.

Baker LC, Atlas SW, Afendulis CC. Expanded Use Of Imaging Technology And The Challenge Of Measuring Value [Internet]. Health Aff. 2008 Nov 1;27(6):1467-1478.[cited 2008 Nov 27 ]

The quote in the title of this post is the paraphrase of a conversation I have had more than a few times with someone who has asked me, “Ted, what’s the return on investment for web services for patients?” The answer I have usually gotten when I ask the question back is usually no answer.

Two papers just published in HealthAffairs provide a little more background for that conversation. The first is about the growth of the use of imaging technology in the United States. As you might expect, it is growing, and more with every new scanner put in operation.

To put things in better perspective, I created this graph from the data, showing the increase in the number of scans/beneficiary. In 2005, there were 547 CT scans per 1,000 Medicare beneficiary, or about 1 scan per 2 beneficiaries. What the article doesn’t mention is that the radiation load from a CT scan is high, anywhere to 15 – 100 times the dose of radiation from a chest X-ray. Medicare reimburses, on average $308 for a CT scan, $713 for an MRI.

A basic return on investment analysis is performed for abdominal aortic aneurysm (AAA) screening, which shows that as more people are screened using CT, less are screened using catheter angiography (which is more invasive). This is good, except, the reduction is less than 1:1, so there is overall expansion of screening to more people, and more procedures to fix AAA associated with this. The problem is that there isn’t data on whether this is overall a good thing or not from a cost/benefit perspective.

Because CT and MRI are a physician preference item, reimbursement and use is typically physician directed, which can create conflict (see Jaime Robinson’s paper in the same Health Affairs issue for more about this).

It’s interesting that the adoption curve of CT/MRI looks a lot like the adoption curve of personal health records in organizations that prioritize them, like Kaiser Permanente and Group Health Cooperative.

Currently, Medicare pays $0.00 per certified empowered/activated patient (potentially defined by more than 2 accesses to a comprehensive personal health record in 6 months).

So we know from this is example that it’s possible for health care to adopt technology. How can we recreate the magic of the CT/MRI adoption curve for something that’s patient directed? I have some ideas but want to see your comments first.

• Insurers Embrace Online Physician Visits, But Doctor Participation Slow To Catch On – iHealthBeat – “Aetna is agressively marketing the tool to its contracted providers” – some information about the support for patient-physician messaging in the fee for service sector. Also some information from Kaiser Permanente’s work. California Medical Association provides a distinctive perspective on change. See what you think. Why isn’t this catching on in the fee for service healthcare community? (Audiocast)

• ConsumerReports.org – Self-test kits: Ratings, How to choose – The Good and Not So Good about this report – GOOD: Consumer Reports publishes an article looking at the accuracy of blood pressure monitors, testing them against medical technicians using a mercury sphygmomanometer. Also, nice quote from an MD representing the American Heart Association about the empowering effect of self-monitoring. NOT SO GOOD: A vague recommendation that "patients home monitor" – they did not cite the AHA recommendations about frequency and duration (just twice a day, for 7 days at a time, don’t bring the monitor to work, don’t do it more than twice per day), which may lead to excess or inaccurate monitoring of the condition. I think this is reflective of the fact that the medical profession still has not bought into the value of self-monitoring, and the industry hasn’t bought into reimbursing for it. In the future, reimbursement would be in the form of clinician time to assess and manage conditions, rather than patient time to come into the office, where the readings will be less predictive of a patient’s condition anyway. It could be as simple as a slight change to a pre-existing CPT code for Ambulatory BP Monitoring, which almost no one uses, because 24-hour around the clock blood pressure monitoring is a procedure that has not been state of the art for a long time.

• Getting What We Pay For: Innovations Lacking in Provider Payment Reform for Chronic Disease Care – From the Center for Studying Health System Change. Asking the obvious question (in a useful way) about how payment per service is helpful to patients with chronic illness

• Medicare Coverage of Ambulatory Blood Pressure Monitoring – CMS's coverage criteria for ambulatory blood pressure monitoring. Could home blood pressure monitoring be covered similarly?

I learned about this at the CCR workshop. The CCR accomodates elements of this, but CMS has not endorsed it yet as a standard.

AMCP.org – Comments on Standard SIG – The NCPDP was working on the standard for Med Sigs – a little background

• Ning – Create your own Social Networks! – As it says, a way to create a social network. What if a physician created one for her patients (who opted in)?
• The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) – ALLHAT treatment information
• Prevent and Control High Blood Pressure: Mission Possible – Information from the NHLBI about hypertension control – unfortunately, it looks like the site has been abandoned. Another argument for a Web 2.0, more interactive approach.
• Sixty minutes of health reform education: Frontline is required watching – Overview of international health systems – incentives seem more aligned, and of interest, when reforms are society/community focused, the professions understand their utility.
• NEJM — Characteristics of Patients with Uncontrolled Hypertension in the United States – "Undiagnosed hypertension and treated but uncontrolled hypertension occur largely under the watchful eye of the health care system;"

May 6th through May 7th:

• The Happy Hospitalist: This Deserves The Middle Finger – I guess it is controversial (the RUC report on Medical Home Reimbursement)
• AMA (RBRVS) RUC Medicare Medical Home Demonstration project recommendations – RUC and Medical Home. Might this be controversial?
• reportonbusiness.com: Asking ‘why’ again and again is harder than you think, but it works – Good description of the 5 Why's Exercise
• What is Hypertension? – WrongDiagnosis.com – Factoids about Hypertension, useful in planning a community intervension
• Cigna clients seek answers after expiration –
• Cigna ends pact with hospitals, leaves thousands in the lurch – This local story has not made the national news. I wonder why?