Free beer tomorrow...

...said the sign in the restaurant. Sound familiar when you think about health reform and the changes since it passed in 2010? Transparency cried the masses! We need transparency through access to data to determine what is really going on! Yet, call a Medicare Administrative Contractor ("MAC") and ask for de-identified utilization data. Click... buzz is what you will hear. Call Medicare directly and ask the same. After several hoops you can get a 5 percent file. That is one in 20 claims; hardly representative and impossible to determine who is referring what to whom with statistical certainty. HIPAA rules aren't making it any easier. The problem is, in order to get to real automated clinical decision support, we need access to the linear patient records, including outcomes. Another way to think about "pre-encounter" clinical decision support is predictive healthcare. Using the scads of data already available in the hundreds of millions of patient records to analyze treatment and outcome patterns would clearly reveal what works and what does not.


Solving the riddle

Self-referral (of diagnostic testing services) is a complex issue and is driven by several factors. Some legitimate, like proximity to the testing services; other self-referral excuses perhaps not so legitimate. Self-referral, the growing use of diagnostic testing services in general and the increasing cost to payers, including Medicare, are the primary engines behind the cry for appropriate use. Then, in no small part due to the efforts of some clever statisticians who quantified broad gaps in patient outcomes compared to costs in several markets across the country, the light came on flashing "Pay for Performance" ("P4P") not just for doing the work. Quality in other words. Perhaps you see now how wise the statement was in our first paragraph: "Medicine is not the problem, it the business of Medicine". Any business with a poor quality product (Inappropriate use, poor outcomes, high cost) will not last long. Not everyone is on board with pay for performance as a recent study by the JAMA published by Diagnostic Imaging found 70 percent of 2556 respondents not in support of eliminating fee-for-service. However, that same study revealed 89 percent believe they need to take a more prominent role in limiting the use of unnecessary tests.

Healthcare Act