Electronic Medical Records:Marginal Quality of Care & Length of Stay Benefits

Today's New York Times contains an article about Boston area hospitals entitled “Little benefit seen so far in electronic patient records.” At present, less than 2% of hospitals and less than 13% of offices have electronic medical resords (EMR) systems. Few of these are comprehensive systems with scheduling, patient intake information, consult notes, nursing notes, labs/diagnostics and billing, etc. The federal government has designated $19 billion in TARP money to help physicians and hospitals make the conversion claiming cost savings and improved patient care.

It seems finally we have the empiric evidence to support what medical professionals have long suspected – that EMRs do NOT translate to better hospital care or shorter lengths of stay. So why should a doctor's office spend $40-60 thousand plus $20 thousand annually in licensing fees for such a system? Why should a hospital system spend tens of millions and up to $100 million to implement such a system? Where is the return on investment?

There are four main issues in implementing electronic medical records.
1.These systems cost a lot of money.
2.The purchasers of EMRs are not the ones to reap the benefits of the system; benefits accrue to the patients, employers, insurers and government.
3.There is no readily exchangable format, as there is no off-the-shelf Microsoft Office version of EMRs that works well for the various specialties and levels of hospital care.
4.There is no means of readily assembling the patient's complete medical record from all sources from which they have sought care when they are sitting on the examining table in front of you.

The benefits of EMRs often touted are elimination of waste, fraud and abuse of the healthcare system. Yes, EMRs could decrease the costs of defensive medicine, estimated at 5-9% of total medical expenditures. They could decrease the need for repeated testing , lower perscription expenditures, facilitate authorization for procedures, verify services provided, shorten payment time, etc. But this does not necessarily occur just because an office or hospital has an EMR in place. There must be a way to access and assemble a complete record when needed. We don't need necessarily EMRs, what we really need is an electronic medical filing cabinet. Similar to the way the credit bureaus assemble financial records, we need a way for verified credentialed providers of healthcare to access the system when a patient is biometrically identified in their office. While the intricate details are too much for a blog, suffice it to say it could be done for the price of a print scanner and biometric scanner at a penny or so per transaction. [See Chapter 5 of Healthcare Solved, if you are curious for more details.]

Senate Bill 1776: The Fix?

Yesterday, the press finally reported the whole story on the Baucus Bill, which you read here on October 13. Senate Bill 1776, which was supposed to fix the faulty Medicare physician reimbursement formula (Medicare SGR as continued under the Baucus Bill), failed to pass Wednesday. Congress somehow thought the American people would not figure out that paying doctors would be considered part of their supposed comprehensive healthcare “reform” if they put it in another bill. Instead, S. 1776 was an attempt to add $249 billion straight to the national debt. Let’s crunch the numbers: the $81 billion dollar savings of the Baucus bill minus the $249 billion appropriation to “fix” the physician payment formula equals +$168 billion to the national debt – not exactly budget neutral.

Senator Nelson of Florida was interviewed by Greta van Susteren last night saying he hoped this did not derail the Senate’s reform bill. He claimed perhaps we if we had a 5-year fix or even a 3-year fix, we should still push through “reform.” How does postponing the day of reckoning make it better? Certainly, physicians will be right back in the same position they are now, with further cuts threatening because the formula used is faulty; except by then healthcare reform fatigue will have set in with the American public and no one will want to hear about it.

Worse yet, with the current printing and spending spree in Washington, the present economic downturn is going to persist for a considerable period of time. Central banks around the world are warning us that our fiscal and monetary policies are “imprudent.” Given the current policies being pursued on an array of issues, there will be fewer small business starting up and more businesses laying off people. As a result, tax revenues will continue to go down, adding further to the annual deficit and ultimately the federal debt. If this continues, the country may not be able to fix the problem in 3 years. Americans voted for change. Our legislators must be responsible and get it right. If not the only change Americans may have is the change in their pockets.

The Baucus Bill & Physician Reimbursement

The Baucas Bill [America's Healthy Future Act of 2009] does not eliminate the flawed physician reimbursement formula [Medicare SGR (sustainable growth rate)]. It allows for the .5% increase Congress appropriated for 2010; however, it does not eliminate the scheduled 25% cut in 2011. It is assumed that reimbursement rates will remain at current low levels (as specified by the SGR) for the subsequent years through 2019.

Historically, Congress has made adjustments annually to this "flawed" reimbursement formula which rises significantly slower than the rate of medical inflation. By cutting reimbursement rates in 2011 by 25% and keeping them there, there will be far fewer providers willing to provide services to Medicare patients. On the other hand, if Congress continues the annual adjustment process, the projected Congressional Budget Office "savings" in the bill begin to evaporate.

The bill does little to address the current high costs of providing actual care, which someone must pay. Physicians will not be able to sustain a 25% pay cut to provide care for Medicare patients. Those that do, will not be able to continue such services in subsequent years without any inflation adjustments. Apparently, a significant portion of the expense of providing care for the elderly in the future is expected to be born by physicians.

The projected "savings" of this bill are dubious at best; it is really cost-shifting. It seems a bit premature for the Senate Finance Committee to be patting itself on the back, given that this is not actually a viable solution.