January 8, 2010

Government Control of Health Care: The Health Insurance Mandate and Electronic Health Records

Editor's Note: The real goal of the healthcare bill is to mandate that every American have health insurance (those who resist will be charged a penalty collected by the IRS) and to create an electronic health record for each person, which will allow the government to implement RFID and GPS technology as a means to control and track society.

Q&A: Electronic Health Records and You

By Declan McCullagh, CBS News
May 19, 2009

Chuck Morton's family suffered three disruptive data breaches when its bank, its credit union, and a credit card processor were penetrated by hackers on separate occasions. The laborious process of closing and reopening accounts took them weeks.

So it's little surprise that Morton, who lives in Greensboro, N.C., and is in his late 40s, was not exactly delighted when he realized that his medical records would be computerized too.
"I don't know who has access to that information, who's selling it, who's doing what with it," Morton said. "Can you imagine someone showing up and saying, 'I'm going to extort some money out of you?'"
After discussions with his physician, Morton said he's managed to keep his medical record largely offline.

If a recent federal law is as successful at promoting computerized medical records as its backers hope, Morton may become part of a shrinking minority of Americans. The stated goal of the stimulus bill that President Obama signed in February is sweeping and optimistic: "utilization of an electronic health record for each person in the United States by 2014."

To answer some common questions about electronic medical records and how they might affect you, CNET News has prepared the following list of frequently asked questions:

What do people mean by electronic medical records?

Instead of having your medical history saved in paper files, it would be computerized and stored electronically. That promises some obvious automation benefits and could reduce mistakes such as improper medications prescribed, but it raises new questions about privacy and security. For instance, a burglar breaking into a doctor's office would be able to access hundreds of physical files, but a hacker breaking into a database could abscond with millions.

Some of the advantages of electronic medical records come only if older paper records are scanned or incorporated into the new system, a laborious and expensive process.

What are the promised benefits of electronic medical records?

Supporters say electronic medical records will boost the quality of medical care, reduce duplication of services, and limit errors, all of which could save money and lives. The National Academy of Sciences' Institute of Medicine estimates that between 44,000 and 98,000 people in the United States die each year because of errors such as being prescribed medicine to which they are allergic.

Google Health, for instance, is designed to check your prescriptions for potential interactions between your drugs, allergies, and conditions. In addition, a physician making a referral could, depending on the system, forward a patient's complete medical records with a single keystroke.

Not everyone agrees with those optimistic notions. An analysis published this year in the Health Affairs journal analyzed four years of Medicare patient data and found that electronic medical records have only a "small, positive effect on patient safety." It recommends that more evaluations be performed.

How many physicians are currently using electronic medical records?

An in-depth survey published last year in The New England Journal of Medicine found that about 4 percent of physicians have a fully functional electronic-records system and 13 percent have a basic system. Another 34 percent had ordered one but had not installed it or planned to purchase one in the next two years. Details of these systems vary, so the fact that a physician uses an electronic system for medical records does not necessarily mean that the data can be shared with colleagues.

What form is an electronic medical record likely to take?

For physicians who are early adopters, the common practice has been to store data as an extension of their existing records on patients, sometimes called an "integrated personal health record."

The competing model, targeted at consumers, is to create a standalone personal health record, an idea that companies such as Google, Microsoft, and WebMD are supporting.

Standalone records may incorporate data from existing health care providers, and the companies behind them are hoping to convince pharmacies, lab operators, and physicians to encrypt and share data. Sometimes the existing records can be imprecise, as cancer survivor Dave deBronkart learned recently, when his Google Health record said cancer had spread to his brain or spine, thanks to not-quite-accurate billing records using codes required by insurers.

Microsoft, Google, WebMD, the American Medical Association, Aetna, Blue Cross Blue Shield Association, and others have jointly endorsed a set of guidelines for personal health records. An opinion article published in The New England Journal of Medicine in March recommends that future development focus on open standards, citing the Apple iPhone as an example of a device with a published interface for which independent software developers can create applications.

One benefit of standalone records is that they're under the patient's control.

Which of these approaches is the federal government likely to back?

It's too early to tell. David Blumenthal, a former Harvard Medical School professor who has written about electronic medical records, was appointed to the post of national coordinator for health information technology in March.

Kenneth Mandl of the Children's Hospital Boston told The New York Times that it would be a bad idea to lock in the current office-based systems.

"If the government's money goes to cement the current technology in place," Mandl said, "we will have a very hard time innovating in health care reform."
Instead, as Mandl and a co-author suggested in their New England Journal of Medicine column in March, the federal government should encourage "interoperability and substitutability" similar to what Apple's online store provides to iPhone and iPod Touch customers. The key, Mandl says, is to be able to swap modules.

Why did the stimulus package that Congress enacted earlier this year push for electronic medical records?

Democrats who inserted the language in the bill defended it as a long-term investment designed to curb the rate of increase in health care costs. Sen. Patrick Leahy of Vermont predicted that:
"Long-term cost-cutting measures, such as the use of electronic medical records, can help stimulate the health care economy and create much-needed jobs."
Peter Orszag, the White House's budget director, warned last week that Medicare and Medicaid costs will spiral out of control in the next few decades, and said electronic medical records are one way to control costs.

Perhaps just as importantly, it was President Obama's chance to fulfill a campaign pledge. As a candidate, Obama incorporated electronic medical records into his campaign platform, arguing that they would save $120 billion a year, or $2,500 per family. In a town hall meeting last year, Obama said his plan would, within four years, "lower premiums by up to $2,500 for a typical family per year" by taking steps including "investing in a paperless health care system to reduce administrative costs."

Not everyone buys Obama's numbers: The nonpartisan Annenberg Public Policy Center of the University of Pennsylvania, which runs Factcheck.org, called this claim false.
"We find his statements to be overly optimistic, misleading and, to some extent, contradicted by one of his own advisers," Factcheck said in a June 2008 article, in part because it's based on a study estimating cost savings that won't happen until 2019.
What might be the downsides of the electronic medical records ushered in by the stimulus package?

There are four big ones: cost, complexity, privacy, and security.

A few years ago, after spending $34 million on a computerized system, the prestigious Cedars-Sinai Medical Center ditched it after three months. It proved to be slow, unwieldy, and complicated, requiring some technicians to spend 30 minutes checking boxes about a patient's condition rather than three minutes scribbling notes.

Privacy and security are what worry Twila Brase, a former nurse and current president of the Citizens' Council on Health Care in St. Paul, Minn., a state think tank that focuses on genetic privacy and medical-record privacy rights.

"They're creating a national template or national standard that everyone has to follow," she said. "The idea is for it to be interoperable. That means it's available and accessible and linkable and searchable, and all of those things. So everyone has, as the bill says, one medical record...We're going to lose the frank conversations that a patient really needs to have with his doctor and a doctor needs to have with his patient."
Other groups, including Consumer Watchdog and the World Privacy Forum, have raised similar concerns.

What, exactly, does the stimulus package say?

The legislation (PDF, on page 244) envisions the "utilization of an electronic health record for each person in the United States by 2014." Selecting official standards will be left to the Department of Health and Human Services, and many details are still unclear.

The databases will, "at a minimum," include information on every American's race and ethnicity. They will be used for "biosurveillance and public health," and "medical and clinical research," both of which raise privacy questions. They will become part of a "nationwide system for the electronic use and exchange of health information."

To accelerate this transition, the federal government will use its vast purchasing power — think Medicare and Medicaid — to compel adoption of e-records that meet government "standards and implementation specifications."

There are two pro-privacy components. The first says electronic-record holders "shall have a right to obtain" a copy of their data in an electronic format. The second includes a notification requirement in the case of a data breach, if the information is not encrypted; though, according to the definitions used, no notification is necessary if the unintentional disclosure was made "in good faith."

How will the stimulus package encourage physicians and hospitals to adopt electronic medical records?

Through using the threat of smaller (or the promise of larger) Medicare and Medicaid reimbursements. Physicians who are "meaningful users" of a government-certified e-record database get bonus payments, as long as the database meets still-to-be-determined regulations about information exchanges.

Physicians who don't participate in such a data-exchanging system, on the other hand, will see their Medicare and Medicaid reimbursements begin to decline by a few percentage points in 2015. The U.S. Department of Health and Human Services is required to improve the adoption of e-records "over time by requiring more stringent measures of meaningful use."

Will Americans be able to opt out?

Although a single paragraph promises that data sharing will "be voluntary," critics argue that there's no unambiguous way to opt out.

That's what worries Sue Blevins, a former nurse and head of the Institute for Health Freedom, a nonprofit, nonpartisan group founded in 1996 that advocates for free-market principles in health care.
"The stimulus package calls for the government to plan for everyone to use an electronic health record," she said. "My concern is, it doesn't say whether the electronic health record will be voluntary or mandatory."

"You need to make sure that if you don't want to use an e-health care record, you don't have to," Blevins said. "You need to have consent in there. If you think about it, with old paper records, when you had to give consent, do you know hard it would be to share those? Now data can be shared with the click of a mouse."
How secure will the data be?

We've recently seen some high-profile electronic intrusions, including a report saying a hacker broke into Virginia's "Prescription Monitoring Program," deleted records on 8 million patients, and demanded a $10 million ransom. Another report says overseas hackers gained access to the confidential medical information of students at the University of California at Berkeley, including 97,000 Social Security numbers, by electronically bypassing security mechanisms used by the campus health center.

The best answer might be that no data stored on a computer connected to the Internet can be completely safe. Rather, it makes sense to talk about multiple layers of defenses, solid audit logs, and making individual decisions about weighing the risk of placing the data online against the rewards it may provide.

Doesn't the Health Insurance Portability and Accountability Act (HIPAA) protect my privacy?

Only to some extent, and the Bush administration rewrote and reinterpreted some of the HIPAA regulations. A 2006 article in The Washington Post noted that the administration had received 19,420 complaints about wrongful disclosure but imposed only one fine.

An article in a journal published by The Hastings Center, a nonpartisan bioethics group, says:

"When sharing health information during health care operations, HIPAA could permit an insurer to give data to a bank it owns, which might then deny someone a loan on the basis of those data...While some laws protect against the disclosure of special kinds of information, such as HIV status, the lack of a HIPAA audit trail on routine disclosures means that HIPAA tends to undercut these restrictions."
Will the stimulus funds be sufficient to convince health care providers to switch to electronic health records?

That remains unclear. A consultancy in Washington, D.C., called Avalere Health estimates that a solo or small-group physician practice will spend an estimated $124,000 from 2011 to 2015 to adopt electronic medical records but will receive only $44,000 from the federal government toward doing so. That means that the out-of-pocket cost would still be $80,000.

Even after reductions in Medicare and Medicaid penalties kick in, starting in 2015 for doctors who aren't using electronic records, Avalere estimates that the reductions in reimbursements would amount to no more than $5,100 a year, or less than the cost of the switch. And because plenty of physicians already don't accept Medicare, the incentives may be weaker than federal officials would prefer. Economics, not privacy concerns, might prove to be the greatest hurdle for backers of electronic medical records to overcome.

Online Medical Records Offer Convenience, May Limit Privacy

By Janet Kornblum, USA TODAY
Originally Published on June 11, 2008

When Mary Adams had a mammogram in October, she didn't have to wait for a call from her doctor — or even a note in the mail — to get her results.

Instead, she got a message from her Cleveland Clinic doctor that her online health record had been updated. She logged onto MyChart, one of the nation's first online sites for personal health records, and voilà, there were the results: Everything was normal.

"It made me feel great," says Adams, 45, of LaGrange, Ohio. "I knew at a glance what my test results were."

Adams may be riding the wave of the future as one of the first to try out a new breed of websites that allow patients to store and access their own medical records. She has since added the newly launched Google Health to her online health arsenal.

A variety of companies — from private health-care providers and insurance companies to big technology firms such as Microsoft and Google — are developing and launching sites, most of them free, that allow patients to keep personal health records. They can include everything from medical histories to test results, doctors' notes and prescriptions.

Patients can input their records themselves or have them added by the few doctors' offices and other medical facilities that keep compatible electronic records online.

Because the field is so new, standards and legislation still are under development. And privacy advocates worry about sensitive records falling into the wrong hands.

But nearly everyone applauds the idea behind the records: They aim to bring the notoriously slow-to-computerize health records out of the era of manila folders and scribbled notes and into the future of electronic information that can be transported with the click of a button.

Most of the sites also are trying to become health leaders by running online health-care malls, where people can do everything from storing their own records to doing medical research online.
Google Health and Microsoft's HealthVault, for instance, are forming partnerships with companies that provide services such as pill reminders and glucose monitoring.

Adams, who is an information-technology professional, says she's happy with both MyChart and Google Health.

"I love it," she says. "I can log in from any computer, anywhere, and I can see the information that's available in my chart. … I can see test reminders — like you need to have your cholesterol checked in October 2009. I can see when I had my last tetanus shot. Before I had access to MyChart online, I had no clue when I had my last tetanus shot. Even if I had a piece of paper at home, I didn't have access to it where I was."
Everything in one place

Advocates of personal health records say they will result in better-informed patients, the elimination of redundant tests and better-prepared doctors who can get a more complete picture by having their patients' entire medical history in front of them.
With paper records, patients "are either forced to be their own medical historian or their own medical librarian. It's a real challenge for the typical patient to get everything right," says C. Martin Harris of the Cleveland Clinic.

"We're trying to make it easy for individuals to gather all their health information in one place, and they'll be able to use that information to make health care decisions," says Colin Evans, chief of Dossia, an electronic-records provider.
Errors will be reduced by quickly giving physicians access to crucial information, such as allergies, advocates say.
"People ought to be much more fearing about 200,000 (people) every year who are killed from medical errors," says David St. Clair, founder and chief executive of MEDecision, which works with health-insurance companies.
Ultimately, systems could allow emergency room physicians, for instance, to have instant access to incoming patients' records.

But others warn there's a big downside to personal health records, especially the chance that private and personal records could be bought and sold by, for instance, pharmaceutical companies.
"The idea is to give power to the end users by providing a set of tools to manage their own health information," says Greg Sterling, an analyst at Sterling Market Intelligence in San Francisco. "It makes a lot of sense in the abstract." But "like anything, there's this other side of it, which is people can get access to this information and misuse it."
All companies with private personal health records say privacy is of paramount importance and outline strict privacy measures in their terms of service agreements.

But promises are not enough, says Deborah Peel, a physician and founder of Patient Privacy Rights, a non-profit organization that is leading a bipartisan privacy-rights coalition that includes organizations as varied as the American Civil Liberties Union and the Gun Owners of America.
"We can't take anyone's word for it because the information is so incredibly valuable," she says.
Data-mining a concern

Privacy advocates worry that companies could legally sell medical records, valuable to drug and insurance companies.
"The concept is wonderful, but because we have absolutely no control over personal health information in electronic form, they're very dangerous," Peel says. "There's essentially no laws to stop (companies) from data-mining that information and using it in a way that you would never want."
Just the fear that records could be unsafe could lead patients to withhold important information from their physicians, worried that sensitive information, such as news of a sexually transmitted disease or cancer, might become known, says Tim Sparapani, senior legislative council for the ACLU.
"Whenever you digitize information and then make it, of course, searchable because that's how databases work, you facilitate snooping," Sparapani says.
Both houses of Congress are in the early stages of considering several pieces of legislation that deal with electronic records.

Peel's organization is beginning to certify personal health records. And the non-profit Certification Commission for Healthcare Information Technology announced Tuesday that in addition to certifying electronic health records systems, it will start certifying the personal-record sites.

Security risks should be put in perspective, says Peter Neupert, corporate vice president at Microsoft's health solutions group.
"The risky talk has to be counterbalanced against the benefits of being able to have better health outcomes, better health communications, better services and tools to lead healthy lives."
Patients ultimately have control over who sees their data, adds Harris of the Cleveland Clinic. They choose who can access their records. And unlike paper records, if there's an unauthorized viewing of a record, a patient will be informed.

Adams says she understands the risks and is willing to live with them.
"For me personally, there are risks with any type of online transaction, whether it's logging onto my bank or using my credit card online," she says. "It's just a matter of perspective."
William Straw, 59, a Los Altos, Calif., family physician, recently signed up to Google Health to see what the service was like.
"Nothing is 100% private," says Straw, who is in a practice that uses electronic records. "Electronic medical records are probably more secure than the paper record we used to have, which could be sitting around. …With our records we can trace who had access."

"It's fairly clear that the electronic medical record will become much more widespread," says Robert Steinbrook, a doctor and national correspondent for the New England Journal of Medicine.

"Since we haven't had a situation where patients have been in control of their data, much less having that data online, this is really a grand experiment, and it will take some time to see whether concerns about privacy and data security are real."

Health Bills Could Expand IRS Role

By Phil Galewitz and Christopher Weaver, Kaiser Health News
January 5, 2010

Under the current versions of the health care bills, the IRS would oversee:
  • Subsidies for low-income people purchasing health insurance through newly created state exchanges.

  • Small-business tax credits to provide insurance to employees.

  • Enforcement of mandate that all U.S. citizens and legal residents have insurance.

  • Penalties on employers for not providing affordable coverage if any of their employees get subsidies under the new insurance exchanges.

  • A tax on insurers that provide high-cost "Cadillac" insurance benefits.

  • Penalties for improper distributions from Health Savings Accounts, which would increase under the legislation.

  • Contributions to Flexible Savings Accounts, which would be limited.

  • New requirements for non-profit hospitals to prove their charitable missions, such as doing a "community needs assessment" once every three years.

  • Taxes on pharmaceutical companies, medical device companies and health insurance providers.
Internal Revenue Service agents already try to catch tax cheats and moonshiners. Under the proposed health care legislation, they would get another assignment: checking to see whether Americans have health insurance.

The legislation would require most Americans to have health insurance and to prove it on their federal tax returns. Those who don't would pay a penalty to the IRS.

That's one of several key duties the IRS would assume under the bills that have been approved by the House of Representatives and Senate and will be merged by negotiators from both chambers.

The agency also would distribute as much as $140 billion a year in new government subsidies to help small employers and as many as 19 million lower-income people buy coverage.

In addition, the IRS would collect hundreds of billions of dollars in new fees on employers, drug companies and device makers, according to the non-partisan Congressional Budget Office (CBO).

Some critics of the health bill question whether the IRS, which has struggled in recent years with budget problems, staffing shortages and outdated computer systems, will be up to the job of enforcing the mandate and efficiently handling the subsidies.

"It's hard to see how the IRS could take on the huge responsibility it would be given under pending health care legislation without some real glitches, or worse," said Sen. Chuck Grassley of Iowa, the top Republican on the Senate Finance Committee.
He voted against the bill, as did every other Republican senator.

The CBO estimated the IRS would need $5 billion to $10 billion in the first decade to cover the costs of its expanded role. The IRS' annual budget is currently $11.5 billion.

Neither the House nor Senate bill includes funding for the IRS, but money could be added by House and Senate negotiators.

The IRS already has trouble meeting its primary duty: collecting taxes. By the IRS's own estimates, it failed to collect about $290 billion in taxes in 2005, the latest year for which data are available.

Pete Sepp, spokesman for the National Taxpayers Union, an IRS watchdog group, says the IRS might be the "logical" agency to enforce the mandate, "but that doesn't mean things will go smoothly."

'Social engineering'

Howard Gleckman of the Urban Institute, an economics and social policy think tank, sees the IRS' proposed new role as a part of a historical pattern.
"We are always asking the IRS to do all kinds of social engineering," he said, such as tax credits for new homeowners and renewable-energy companies.
In one of the biggest examples of using the tax code to achieve a social goal, Congress shifted much of its effort to help the poor in the 1990s from direct spending to the Earned Income Tax Credit, an IRS-run program that pays rebates to low-income working people to offset taxes.

In 2005, more than 22 million people claimed the credit, resulting in more than $40 billion in payments, a Treasury Department inspector general found last year. The audit found $11.4 billion in improper payments in 2005 — about 28 cents of every dollar paid out.

Grassley has called the program "rife with fraud and abuse." John Dalrymple, a former IRS deputy commissioner, said the tax-credit program — despite its flaws — demonstrates that the IRS has the experience to handle the new subsidy program.

Under the health care legislation, the IRS would determine who qualifies for the insurance subsidies. Those subsidies would apply to people with incomes up to four times the federal poverty level, which is $43,320 for an individual and $88,200 for a family of four. The government would pay insurance companies to help individuals buy policies on the new exchanges. The exchanges, a central feature in both bills, would be a sort of marketplace where small businesses and individuals who don't get employer-sponsored coverage could shop for health plans.

To meet the mandate, Americans would have to provide proof of insurance coverage with their annual tax returns. The mandate would begin in 2013 under the House bill; 2014 in the Senate bill.

The penalty in the Senate bill for not having coverage would start in 2014 at $95 or 0.5% of an individual's income, whichever is greater. It would rise to $750 or 2% of annual income in 2016, up to the cost of the cheapest health plans. The House bill penalty would be up to 2.5% of an individual's income up to the cost of the average health plan.

Massachusetts as a model

In 2007, Massachusetts became the first state to enact a health insurance mandate and lowered the percentage of uninsured residents from 7% to 4%.

State residents are required to report their health insurance status on a special form they attach to state income tax returns. Insurers provide statements to policyholders confirming coverage and report that data to the state Department of Revenue.

The state tax agency did not get extra staff or money for enforcement and has not had serious difficulties gathering the information, spokesman Robert Bliss said. In 2008, more than 96% of tax filers provided proof of coverage. Only 1.3% of filers, or about 45,000 residents, were assessed a no-coverage penalty of up to $1,068.

The "vast majority" of Massachusetts residents who pay the penalty are self-reported, Bliss said.

Bliss said the fact that the department had 18 months to get ready for the state's insurance mandate was "enormously important" in making sure it was ready to handle the assignment. That bodes well for the IRS, which would have three to four years to get ready under the bills.

Despite concerns over whether IRS will be up to the job in the health bills, Gerard Anderson, health policy professor at Johns Hopkins University, said:
"The IRS seems like the only logical enforcement mechanism."
Galewitz and Weaver report for Kaiser Health News, an editorially independent news service and a program of the Kaiser Family Foundation, a non-partisan health care policy research organization. Neither KFF nor KHN is affiliated with Kaiser Permanente.

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The Move to Digital Medical Records Begins in Tampa
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Pharm Industry Loves Obamacare
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The Politics of Obammunism
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Obama faces a fight over the health-care overhaul from states that sued today because the legislation’s expansion of Medicaid imposes a fiscal strain on their cash-strapped budgets.
Rasmussen: 55% Favor Repeal of Health Care Bill
Rasmussen Reports 52% say they’d vote for a candidate who favors repeal over one who does not.
U.S. healthcare reform is boon for India outsourcing companies
Obama Just Got His Private Army
Obama’s private army is buried in the Senate revisions to the health care bill.
Don’t Be Fooled: Republicans Love Government Enforced Healthcare
Both Republicans and Democrats are enforcers for the global elite and transnational corporations.
The Shadow Government’s Healthcare Bill Rules
How can we obey laws if we don’t even know what they are?
Help! I’ve Been Taxed and I Can’t Get Up
Regardless of how you feel about the bill, the fact is that taxes are going up, and not necessarily just on the “wealthy.”
Obama Signs Final Health Care Changes, Defends Overhaul, March 30, 2010
Health Reform Law to Spawn More Tax Men?
16,500 new IRS auditors and investigators — or 17 percent of the agency’s current work force — could be needed to administer and enforce new health insurance rules under the law.
Judge lets states' healthcare suit go forward

Updated 10/15/10 (Newest Additions at End of List)

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