Datapalooza Report on Data Economics and a Call for Reciprocity
Uwe Reinhardt said it perfectly in a Tuesday plenary but I can only paraphrase his point: “health information is a public good that brings more wealth the more people use it.” Or, as Doc Searls puts it: personal data is worth more the more it is used. Datapalooza is certainly the largest meeting of the year focused on health data, and our Health and Human Services data liberation army was in full regalia. My assessment is: so far, so good but, as always, each data liberation maneuver also reveals the next fortified position just ahead. This post will highlight reciprocity as a new challenge to the data economy.
The economic value of health data is immense. Without our data it’s simply impossible to independently measure quality, get independent second opinions or control family health expenses. The US is wasting $ 750 Billion per year on health care which boils down to $ 3,000 per year that each man, woman and child is flushing down the drain.
Data liberation is a battle in the cloud and on the ground. In the cloud, we have waves of data releases from massive federal data arsenals. These are the essential roadmap or graph to guide our health policy decisions. I will say no more about this because I expect Fred Trotter (who is doing an amazing job of leading in this space) will cover the anonymous and statistical aspects of the data economy. Data in the cloud provides the basis for clinical decision support.
On the ground, where $ 2.7 Trillion of clinical decisions are made one patient and doctor at a time, the data liberation weapon of choice is Blue Button and Blue Button+. Blue Button is the patient’s ability to download and to transmit a useful health record to Anywhere. The economic impact of Blue Button follows from the power of Anywhere to liberate data for independent analysis and even competition. Meaningful Use Stage 2 mandates this foundation for data liberation but stops well short of actually making it timely, complete or scalable to the extent required for it to have economically meaningful impact on our $ 3,000 per year.
Blue Button + adds automation and scalability on top of the MU2 mandate and shows us, for the first time, a path to patient-directed health reform. Blue Button + enables the cost-effective delivery of second opinions. This technolgy will allow every patient to access independent information about risks and costs. Think Consumer Reports for your costliest and most life-changing decisions.
Unfortunately for us and for the federal regulators, Blue Button + is not part of Meaninful Use Stage 2. Adoption of BB+ to the extent needed to have a real impact on health reform therefore has to be driven by public relations extravaganzas like Datapalooza, by the power of the purse in federal EHR and state health information exchange procurement and, most important, by the leadership of corporations that stand to gain from data liberation. This private-sector leadership leads to the issue of reciprocity.
Reciprocity is the commitment by every data holder that benefits from Blue Button data liberation to implement Blue Button +. Reciprocity is essential for a network effect that enables the explosion in the economic value of our personal data.
Datapalooza brings together all of the hopeful beneficiaries of data liberation: Personal health records in the cloud, personal health records on your smartphone, health records in your state health information exchange, in the state all payer claims database, in a research project or clinical trial and in all of the other private and public-sector systems that are not your health care provider or insurance company.
Data liberation reciprocity is simply the call for everyone that has data about me to give me convenient and standardized access to my data via Blue Button +. The beneficiaries of data liberation are not subject to Meaningful Use and some are not even subject to HIPAA. Their voluntary adoption of Blue Button + is absolutely essential to the network and economic effect. This is the reason for reciprocity.
Data liberation should not have to wait for even more federal regulation. The voluntary adoption of Blue Button + reciprocity by corporations that are not covered by HIPAA and HITECH will bring public pressure to bear on hospitals and state dataholders that we are forced to use to adopt Blue Button +. I expect Blue Button + in my hospital and anyone else that has my personal health data before next year’s Datapalooza.
Adrian Gropper, MD is Chief Technical Officer of Patient Privacy Rights and participates in Blue Button+, Direct secure messaging governance efforts and the evolution of patient-directed health information exchange.
Medicare Trustees Report 2013
Full 2013 Medicare Trustees Report (PDF)
Social Security and Medicare Boards of Trustees
A MESSAGE TO THE PUBLIC:
Each year the Trustees of the Social Security and Medicare trust funds report on the current and projected financial status of the two programs. This message summarizes the 2013 Annual Reports.
Neither Medicare nor Social Security can sustain projected long-run programs in full under currently scheduled financing, and legislative changes are necessary to avoid disruptive consequences for beneficiaries and taxpayers. If lawmakers take action sooner rather than later, more options and more time will be available to phase in changes so that the public has adequate time to prepare. Earlier action will also help elected officials minimize adverse impacts on vulnerable populations, including lower-income workers and people already dependent on program benefits.
Social Security and Medicare together accounted for 38 percent of federal expenditures in fiscal year 2012. Both programs will experience cost growth substantially in excess of GDP growth through the mid-2030s due to rapid population aging caused by the large baby-boom generation entering retirement and lower-birth-rate generations entering employment and, in the case of Medicare, to growth in expenditures per beneficiary exceeding growth in per capita GDP. In later years, projected costs expressed as a share of GDP trend up slowly for Medicare and are relatively flat for Social Security, reflecting very gradual population aging caused by increasing longevity and slower growth in per-beneficiary health care costs.
Social Security
Social Security’s Disability Insurance (DI) program satisfies neither the Trustees’ long-range test of close actuarial balance nor their short-range test of financial adequacy and faces the most immediate financing shortfall of any of the separate trust funds. DI Trust Fund reserves expressed as a percent of annual cost (the trust fund ratio) declined to 85 percent at the beginning of 2013, and the Trustees project trust fund depletion in 2016, the same year projected in the last Trustees Report. DI cost has exceeded non-interest income since 2005, and the trust fund ratio has declined since peaking in 2003. While legislation is needed to address all of Social Security’s financial imbalances, the need has become most urgent with respect to the program’s DI component. Lawmakers need to act soon to avoid reduced payments to DI beneficiaries three years from now.
Social Security’s total expenditures have exceeded non-interest income of its combined trust funds since 2010, and the Trustees estimate that Social Security cost will exceed non-interest income throughout the 75-year projection period. The deficit of non-interest income relative to cost was about $ 49 billion in 2010, $ 45 billion in 2011, and $ 55 billion in 2012. The Trustees project that this cash-flow deficit will average about $ 75 billion between 2013 and 2018 before rising steeply as income growth slows to the sustainable trend rate after the economic recovery is complete and the number of beneficiaries continues to grow at a substantially faster rate than the number of covered workers. Redemption of trust fund asset reserves by the General Fund of the Treasury will provide the resources needed to offset Social Security’s annual aggregate cash-flow deficits. Since the cash-flow deficit will be less than interest earnings through 2020, reserves of the combined trust funds measured in current dollars will continue to grow, but not by enough to prevent the ratio of reserves to one year’s projected cost (the combined trust fund ratio) from declining. (This ratio peaked in 2008, declined through 2012, and is expected to decline steadily in future years.) After 2020, Treasury will redeem trust fund asset reserves to the extent that program cost exceeds tax revenue and interest earnings until depletion of total trust fund reserves in 2033, the same year projected in last year’s Trustees Report. Thereafter, tax income would be sufficient to pay about three-quarters of scheduled benefits through 2087.
A temporary reduction in the Social Security payroll tax rate in 2011 and 2012 reduced payroll tax revenues by an estimated $ 222 billion in total. The legislation establishing the payroll tax reduction also provided for transfers from the General Fund to the trust funds in order to “replicate to the extent possible” payments that would have occurred if the payroll tax reduction had not been enacted. Those General Fund reimbursements amounted to about 15 percent of the program’s non-interest income in 2011 and 2012. The temporary payroll tax reduction expired at the end of 2012.
Under current projections, the annual cost of Social Security benefits expressed as a share of workers’ taxable earnings will grow rapidly from 11.3 percent in 2007, the last pre-recession year, to roughly 17.0 percent in 2037, and will then decline slightly before slowly increasing after 2050. Cost displays a slightly different pattern when expressed as a share of GDP. Program cost equaled 4.2 percent of GDP in 2007, the last pre-recession year, and the Trustees project that cost will increase to 6.2 percent of GDP for 2036, then decline to about 6.0 percent of GDP by 2050, and thereafter rise slowly reaching 6.2 percent by 2087.
The projected 75-year actuarial deficit for the combined Old-Age and Survivors Insurance and Disability Insurance (OASDI) Trust Funds is 2.72 percent of taxable payroll, up from 2.67 percent projected in last year’s report. This deficit amounts to 21 percent of program non-interest income or 17 percent of program cost. A 0.06 percentage point increase in the OASDI actuarial deficit would have been expected if nothing had changed other than the one-year extension of the valuation period to 2087. The effects of recently enacted legislation, updated demographic data, updated economic data and assumptions further worsened the actuarial deficit, but these effects were completely offset by the favorable effects of updated programmatic data and improved methodologies.
While the combined OASDI program fails the long-range test of close actuarial balance, it does satisfy the test for short-range (ten-year) financial adequacy. The Trustees project that the combined trust fund asset reserves at the beginning of each year will exceed that year’s projected cost through 2027.
Medicare
The Trustees project that the Medicare Hospital Insurance (HI) Trust Fund will be the next to face depletion after the DI Trust Fund. The projected date of HI Trust Fund depletion is 2026, two years later than projected in last year’s report, at which time dedicated revenues would be sufficient to pay 87 percent of HI cost. The Trustees project that the share of HI cost that can be financed with HI dedicated revenues will decline slowly to 71 percent in 2047, and then rise slowly until it reaches 73 percent in 2087. As it has since 2008, the HI Trust Fund will pay out more in hospital benefits and other expenditures than it receives in income in all years until reserve depletion.
The projected HI Trust Fund’s long-term actuarial imbalance is smaller than that of the combined Social Security trust funds under the assumptions employed in this report.
The estimated 75-year actuarial deficit in the HI Trust Fund is 1.11 percent of taxable payroll, down from 1.35 percent projected in last year’s report. The HI fund again fails the test of short-range financial adequacy, as its trust fund ratio is already below 100 percent and is expected to decline continuously until reserve depletion in 2026. The fund also continues to fail the long-range test of close actuarial balance. The HI 75-year actuarial imbalance amounts to 29 percent of tax receipts or 23 percent of program cost.
The modest improvement in the outlook for HI long-term finances is principally due to: (i) lower projected spending for most HI service categories�especially for skilled nursing facilities�to reflect lower-than-expected spending in 2012 and other recent data; (ii) lower projected Medicare Advantage program costs that reflect recent data suggesting that certain provisions of the Affordable Care Act will reduce growth in these costs by more than was previously projected; and (iii) a refinement in projection methods that reduces assumed per beneficiary cost growth during the transition period between the short-range projections and the long-range projections. Partially offsetting these favorable changes to the projections are somewhat lower projected levels of tax income that reflect lower-than-expected tax income in 2012.
The Trustees project that Part B of Supplementary Medical Insurance (SMI), which pays doctors’ bills and other outpatient expenses, and Part D of SMI, which provides access to prescription drug coverage, will remain adequately financed into the indefinite future because current law automatically provides financing each year to meet the next year’s expected costs. However, the aging population and rising health care costs cause SMI projected costs to grow steadily from 2.0 percent of GDP in 2012 to approximately 3.3 percent of GDP in 2035, and then more slowly to 4.0 percent of GDP by 2087. General revenues will finance roughly three quarters of these costs, and premiums paid by beneficiaries almost all of the remaining quarter. SMI also receives a small amount of financing from special payments by States and from fees on manufacturers and importers of brand-name prescription drugs. Projected costs for Part B assume an almost 25-percent reduction in Medicare payment rates for physician services will be implemented in 2014 as required by current law, which is highly unlikely.
The Trustees project that total Medicare cost (including both HI and SMI expenditures) will grow from approximately 3.6 percent of GDP in 2012 to 5.6 percent of GDP by 2035, and will increase gradually thereafter to about 6.5 percent of GDP by 2087.
The drawdown of Social Security and HI Trust Fund reserves and the general revenue transfers into SMI will result in mounting pressure on the Federal budget. In fact, pressure is already evident. For the seventh consecutive year, the Social Security Act requires that the Trustees issue a “Medicare funding warning” because projected non-dedicated sources of revenues�primarily general revenues�are expected to continue to account for more than 45 percent of Medicare’s outlays in 2013, a threshold breached for the first time in fiscal year 2010.
Conclusion
Lawmakers should address the financial challenges facing Social Security and Medicare as soon as possible. Taking action sooner rather than later will leave more options and more time available to phase in changes so that the public has adequate time to prepare.
By the Trustees:
Jacob J. Lew,
Secretary of the Treasury,
and Managing Trustee
of the Trust Funds.
Kathleen Sebelius,
Secretary of Health
and Human Services,
and Trustee.
Charles P. Blahous III,
Trustee.
Secretary of the Treasury,
and Managing Trustee
of the Trust Funds.
Kathleen Sebelius,
Secretary of Health
and Human Services,
and Trustee.
Charles P. Blahous III,
Trustee.
Seth D. Harris,
Acting Secretary of Labor,
and Trustee.
Carolyn W. Colvin,
Acting Commissioner of
Social Security,
and Trustee.
Robert D. Reischauer,
Trustee.
Acting Secretary of Labor,
and Trustee.
Carolyn W. Colvin,
Acting Commissioner of
Social Security,
and Trustee.
Robert D. Reischauer,
Trustee.
A SUMMARY OF THE 2013 ANNUAL SOCIAL SECURITY
AND MEDICARE TRUST FUND REPORTS
Projected long-range costs for both Medicare and Social Security are not sustainable with currently scheduled financing and will require legislative action to avoid disruptive consequences for beneficiaries and taxpayers. If lawmakers act sooner rather than later, they can consider more options and more time will be available to phase in the changes, giving the public adequate time to prepare. Earlier action would also provide more opportunity to ameliorate any adverse impacts on vulnerable populations, including lower-income workers and people already dependent on program benefits.
What Are the Trust Funds? Congress established trust funds managed by the Secretary of the Treasury to account for Social Security and Medicare income and disbursements. The Treasury credits Social Security and Medicare taxes, premiums, and other income to the funds. There are four separate trust funds. For Social Security, the Old-Age and Survivors Insurance (OASI) Trust Fund pays retirement and survivors benefits and the Disability Insurance (DI) Trust Fund pays disability benefits. (OASDI is the designation for the two trust funds when they are considered on a combined basis.) For Medicare, the Hospital Insurance (HI) Trust Fund pays for inpatient hospital and related care. The Supplementary Medical Insurance (SMI) Trust Fund comprises two separate accounts: Part B, which pays for physician and outpatient services, and Part D, which covers the prescription drug benefit. In 2012, 45.9 million people received OASI benefits, 10.9 million received DI benefits, and 50.7 million were covered under Medicare.
The only disbursements permitted from the funds are benefit payments and administrative costs. Federal law requires that all excess funds be invested in interest-bearing securities backed by the full faith and credit of the United States. The Department of the Treasury currently invests all program revenues in special non-marketable securities of the U.S. Government which earn a market rate of interest. The balances in the trust funds represent the accumulated value, including interest, of all prior program annual surpluses and deficits, and provide automatic authority to pay benefits.
What Were the Trust Fund Results in 2012? Trust fund operations, in billions of dollars, are shown in the following table. (Totals may not add due to rounding.) The OASI Trust Fund showed a net increase in asset reserves in 2012; reserves in the DI, HI, and SMI Trust Funds declined.
| OASI | DI | HI | SMI | |
|---|---|---|---|---|
| reserves (end of 2011) | $ 2,524.1 | $ 153.9 | $ 244.2 | $ 80.7 |
| Income during 2012 | 731.1 | 109.1 | 243.0 | 293.9 |
| Cost during 2012 | 645.5 | 140.3 | 266.8 | 307.4 |
| Net change in Reserves | 85.6 | -31.2 | -23.8 | -13.5 |
| Reserves (end of 2012) | 2,609.7 | 122.7 | 220.4 | 67.2 |
The following table shows payments, by category, from each trust fund in 2012. (Totals may not add due to rounding.)
| Category (in billions) | OASI | DI | HI | SMI |
|---|---|---|---|---|
| Benefit payments | $ 637.9 | $ 136.9 | $ 262.9 | $ 303.0 |
| Railroad Retirement financial interchange | 4.1 | 0.5 | — | — |
| Administrative expenses | 3.4 | 2.9 | 3.9 | 4.4 |
| Total | 645.4 | 140.3 | 266.8 | 307.4 |
Trust fund income, by source, in 2012 is shown below. (Totals may not add due to rounding.)
| Source (in billions) | OASI | DI | HI | SMI |
|---|---|---|---|---|
| Payroll taxes | $ 503.9 | $ 85.6 | $ 205.7 | — |
| Taxes on OASDI benefits | 26.7 | 0.6 | 18.6 | — |
| Beneficiary premiums | — | — | 3.7 | $ 66.6 |
| Transfers from States | — | — | — | 8.4 |
| General Fund reimbursements | 97.7 | 16.5 | 0.5 | — |
| General revenues | — | — | — | $ 214.8 |
| Interest earnings | 102.8 | 6.4 | 10.6 | 2.8 |
| Other | a | — | 3.9 | 2.2 |
| Total | 731.1 | 1099.1 | 243.0 | 293.9 |
a Less than $ 50 million.
In 2012, Social Security’s cost continued to exceed the program’s tax income and also continued to exceed its non-interest income, a trend that the Trustees project to continue throughout the short-range period (2013-22) and beyond. The 2012 deficit of tax income relative to cost was $ 169 billion. The temporary 2-percentage point reduction in the 2012 OASDI employee payroll tax rate, for which the trust funds were fully reimbursed by the General Fund, accounts for $ 114 billion of the 2012 deficit.
In 2012, the HI fund used interest income ($ 11 billion) and asset reserves ($ 24 billion) to help finance expenditures beyond those that could have been made solely on the basis of tax and premium income. For SMI, transfers from the General Fund of the Treasury represent the largest source of income. Because Part B account asset reserves were above the level considered to be adequate at the end of 2011, Part B financing for 2012 was set intentionally to draw down some of the excess reserves, resulting in a decrease of about $ 13 billion.
What is the Outlook for Future Social Security and Medicare Costs in Relation to GDP? One instructive way to view the projected costs of Social Security and Medicare is to compare the costs of scheduled benefits for the two programs with the gross domestic product (GDP), the most frequently used measure of the total output of the U.S. economy (Chart A). Under the intermediate assumptions employed in the reports and throughout this Summary, costs for both programs increase substantially through 2035 when measured this way because: (1) the number of beneficiaries rises rapidly as the baby-boom generation retires; and (2) the lower birth rates that have persisted since the baby boom cause slower growth of the labor force and GDP. Social Security’s projected annual cost increases to about 6.2 percent of GDP by 2035, declines to 6.0 percent by 2050, and remains between 6.0 and 6.2 percent of GDP through 2087. Under current law, projected Medicare cost rises to 5.6 percent of GDP by 2035, largely due to the rapid growth in the number of beneficiaries, and then to 6.5 percent in 2087, with growth in health care cost per beneficiary becoming the larger factor later in the valuation period.
 |
In 2012, the combined cost of the Social Security and Medicare programs equaled 8.7 percent of GDP. The Trustees project an increase to 11.8 percent of GDP in 2035 and 12.7 percent of GDP in 2087. Although Medicare cost (3.6 percent of GDP) is smaller than Social Security cost (5.0 percent of GDP) in 2012, the gap closes gradually until 2056, when Medicare is projected to be the more costly program. During the final decade of the long-range projection period, Medicare cost is modestly larger than Social Security cost.
The projected costs for OASDI and HI depicted in Chart A and elsewhere in this document reflect the full cost of scheduled current-law benefits without regard to whether the trust funds will have sufficient resources to meet these obligations. Current law precludes payment of any benefits beyond the amount that can be financed by the trust funds, that is, from annual income and trust fund reserves. In years after trust fund depletion, the amount of benefits that would be payable is lower than shown, as described later in this summary, because benefit cost exceeds annual income. In addition, the projected costs assume realization of the full estimated savings of the Affordable Care Act as well as adherence to Medicare’s sustainable growth rate limits. Lawmakers are likely to prevent an almost 25-percent reduction in payment rates for physician services that would take effect in 2014 under current law. Also, as described in the Medicare Trustees Report, the projections for HI and SMI Part B depend significantly on the sustained effectiveness of various current-law cost-saving measures—in particular, the lower increases in Medicare payment rates to most categories of health care providers.
What is the Outlook for Future Social Security and Medicare HI Costs and Income in Relation to Taxable Earnings?Since the primary source of income for OASDI and HI is the payroll tax, it is informative to express the programs’ incomes and costs as percentages of taxable payroll—that is, of the base of worker earnings taxed to support each program (Chart B). Both the OASDI and HI annual cost rates rise over the long run from their 2012 levels (13.79 and 3.67 percent). Projected Social Security cost grows to 16.98 percent of taxable payroll by 2035, declines to 16.78 percent in 2050, and then rises gradually to 18.01 percent in 2087. The projected Medicare HI cost rate rises to 5.44 percent of taxable payroll in 2050, and thereafter gradually increases to 5.87 percent in 2087. HI taxable payroll is almost 25 percent larger than that of OASDI because the HI payroll tax is imposed on all earnings while OASDI taxes apply only to earnings up to an annual maximum ($ 113,700 in 2013).
The OASDI income rate—which includes payroll taxes, taxes on benefits, and any other transfers of revenues to the trust funds excepting interest payments—was 12.83 percent in 2012 and increases slowly over time, reaching 13.25 percent in 2087. The scheduled payroll tax rate remains unchanged from the current 12.4 percent level. Annual income from the other tax source, the taxation of OASDI benefits, will increase gradually relative to taxable payroll as a greater proportion of Social Security benefits is subject to taxation in future years, but will continue to be a relatively small component of program income.
 |
The HI income rate—which includes payroll taxes and taxes on OASDI benefits, but excludes interest payments—rises gradually from 3.18 percent in 2012 to 4.30 percent in 2087 due to the Affordable Care Act’s increase in payroll tax rates for high earners beginning in 2013. Individual tax return filers with earnings above $ 200,000, and joint return filers with earnings above $ 250,000, will pay an additional 0.9 percent tax on earnings above these earnings thresholds. An increasing fraction of all earnings will be subject to the higher tax rate over time because the thresholds are not indexed.
How Will Cost Growth in the Different Parts of Medicare Change the Sources of Program Financing? As Medicare cost grows over time, general revenue and beneficiary premiums will play an increasing role in financing the program. Chart C shows scheduled cost and non-interest revenue sources under current law for HI and SMI combined as a percentage of GDP. The total cost line is the same as displayed in Chart A and shows Medicare cost rising to 6.5 percent of GDP by 2087.
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Projected revenue from payroll taxes and taxes on OASDI benefits credited to the HI Trust Fund increases from 1.4 percent of GDP in 2013 to 1.8 percent in 2087 under current law, while projected general revenue transfers to the SMI Trust Fund increase from 1.5 percent of GDP in 2013 to 2.9 percent in 2087, and beneficiary premiums increase from 0.5 to 1.0 percent of GDP. The share of total non-interest Medicare income from taxes falls substantially (from 41 percent to 30 percent) while general revenue transfers rises (from 43 to 50 percent), as does the share of premiums (from 14 percent to 17 percent). The distribution of financing changes in part because in Parts B and D—the Medicare components that are financed largely from general revenues—costs increase at a faster rate than Part A cost under the Trustees’ projections. By 2087, the Medicare SMI program will require general revenue transfers equal to 2.9 percent of GDP. Moreover, the HI deficit represents a further 0.7 percent of GDP in 2087. There is no provision under current law to finance this deficit through general revenue transfers or any other revenue source.
The Medicare Modernization Act (2003) requires that the Board of Trustees determine each year whether the annual difference between program cost and dedicated revenues (the bottom four layers of Chart C) exceeds 45 percent of total Medicare cost in any of the first seven fiscal years of the 75-year projection period. In that case, the annual Trustees Report must include a determination of “excess general revenue Medicare funding.” Two consecutive reports with such a determination triggers a “Medicare funding warning.” The warning directs the President to submit proposed legislation within 15 days of the next budget submission to respond to the warning and requires Congress to consider the proposal on an expedited basis. To date, elected officials have not enacted legislation responding to these funding warnings which have been included in the six previous reports.
This year’s report shows the difference between cost and dedicated financing revenues to exceed 45 percent of total Medicare cost during fiscal year 2013, prompting a determination of “excess general revenue Medicare funding,” triggering another “Medicare funding warning” for the seventh consecutive year.
What are the Budgetary Implications of Rising Social Security and Medicare Costs? Concern about the long-range financial outlook for Medicare and Social Security often focuses on the depletion dates for the HI and OASDI trust funds—the times when the projected trust fund balances under current law will be insufficient to pay the full amounts of scheduled benefits. A more immediate issue is the effect the programs have on the unified Federal budget prior to depletion of the trust funds.
Chart D shows the excess of scheduled costs over dedicated tax and premium income for the OASDI, HI, and SMI trust funds expressed as percentages of GDP. Each of these trust funds’ operations will contribute increasing amounts to Federal unified budget deficits in future years. General revenues pay for roughly 75 percent of all SMI costs. From now through 2026, interest earnings and asset redemptions, financed from general revenues, will cover the shortfall of HI tax and premium revenues relative to expenditures. In addition, general revenues must cover similar payments as a result of growing OASDI deficits through 2033.1
In 2013, the projected difference between Social Security’s expenditures and dedicated tax income is $ 79 billion. For HI, the projected difference between expenditures and dedicated tax and premium income is $ 26 billion. The projected general revenue demands of SMI are $ 239 billion. Thus, the total General Fund requirements for Social Security and Medicare in 2013 are $ 344 billion, or 2.1 percent of GDP. Redemption of trust fund bonds, interest paid on those bonds, and transfers from the General Fund provide no new net income to the Treasury, which must finance these payments through some combination of increased taxation, reductions in other government spending, or additional borrowing from the public.
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Chart D shows that the difference between cost and revenue (expressed as a percentage of GDP) from dedicated payroll taxes, income taxation of benefits, and premiums will grow rapidly through the 2030s as the babyboom generation reaches retirement age. This imbalance would result in vastly increased pressure on the Federal budget if the law were changed to maintain scheduled benefits in the absence of an increase in dedicated tax revenues, with such financing requirements equaling 4.5 percent of GDP by 2040.
What Is the Outlook for Short-Term Trust Fund Adequacy? The reports measure the short-range adequacy of the OASI, DI, and HI Trust Funds by comparing fund asset reserves to projected costs for the ensuing year (the “trust fund ratio”). A trust fund ratio of 100 percent or more—that is, asset reserves at least equal to projected cost for the next year—is a good indicator of a fund’s short-range adequacy. That level of projected reserves for any year suggests that even if cost exceeds income, the trust fund reserves, combined with annual tax revenues, would be sufficient to pay full benefits for several years.
By this measure, the OASI Trust Fund is financially adequate throughout the 2013-22 period, but the DI Trust Fund fails the short-range test because its trust fund ratio was 85 percent at the beginning of 2013, with projected depletion of all reserves in 2016.
The HI Trust Fund also does not meet the short-range test of financial adequacy; its trust fund ratio was 81 percent at the beginning of 2013 based on the year’s anticipated expenditures, and the projected ratio does not rise to 100 percent within five years. Projected HI Trust Fund asset reserves become fully depleted in 2026. Chart E shows the trust fund ratios through 2040 under the intermediate assumptions.
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The Trustees apply a less stringent annual “contingency reserve” test to SMI Part B asset reserves because the overwhelming portion of the financing for that account consists of beneficiary premiums and general revenue contributions that are set each year to meet expected costs. Part D premiums paid by enrollees and the amounts apportioned from the General Fund of the Treasury are determined each year. Moreover, flexible appropriation authority established by lawmakers for Part D allows additional General Fund financing if costs are higher than anticipated, thereby eliminating the need for a contingency reserve in that account. Note, however, that estimated Part B costs are improbably low for 2014 and beyond because the projections assume that current law, which substantially reduces physician payments per service under the sustainable growth rate system, will not change. The estimated physician fee reduction for 2014 is 24.7 percent. A reduction in fees of this magnitude is highly unlikely; lawmakers have acted to prevent similar reductions in every year since 2003. Underestimated payments to physicians would affect projected costs for Part B, total SMI, and total Medicare.
What Are Key Dates in OASI, DI, and HI Financing? The 2013 reports project that the DI, OASI, and HI Trust Funds will all be depleted within the next 25 years. The following table shows key dates for the respective trust funds.
| OASI | DI | OASDI | HI | |
|---|---|---|---|---|
| Year of peak trust fund ratioa | 2011 | 2003 | 2008 | 2003 |
| First year outgo exceeds income excluding interestb | 2010 | 2005 | 2010 | 2018 |
| First year outgo exceeds income including interestb | 2022 | 2009 | 2021 | 2021 |
| Year trust funds are depleted | 2035 | 2016 | 2033 | 2026 |
a Dates pertain to the post-2000 period.
b Dates indicate the first year that a condition is projected to occur and to persist annually thereafter through 2087.
b Dates indicate the first year that a condition is projected to occur and to persist annually thereafter through 2087.
DI Trust Fund asset reserves, which have been declining since 2008, are projected to be fully depleted in 2016, as reported last year. Payment of full DI benefits beyond 2016, when tax income would cover only 80 percent of scheduled benefits, will require legislation to address the financial imbalance, possibly including a reallocation of the OASDI payroll tax rate between OASI and DI.
The OASI Trust Fund, when considered separately, has a projected reserves depletion date of 2035, unchanged from last year’s report.
The combined OASDI trust funds have a projected depletion date of 2033, also unchanged from last year’s report. After the depletion of reserves, continuing tax income would be sufficient to pay 77 percent of scheduled benefits in 2033 and 72 percent in 2087.
The OASDI reserves currently continue to grow because projected interest earnings ($ 103 billion in 2013) still substantially exceed the non-interest income deficit. This year’s report indicates that annual OASDI income, including payments of interest to the trust funds from the General Fund, will exceed annual cost every year until 2021, increasing the nominal value of combined OASDI trust fund asset reserves. The trust fund ratio (the ratio of projected reserves to annual cost) will continue to decline gradually, as it has since 2008, despite this nominal balance increase. Beginning in 2021, net redemptions of trust fund asset reserves with General Fund payments will be required until projected depletion of these reserves in 2033.
The projected HI Trust Fund depletion date is 2026, two years later than reported last year. Under current law, scheduled HI tax and premium income would be sufficient to pay 87 percent of estimated HI cost in 2026 and 73 percent by 2087.
This report anticipates that in 2013 the HI Trust Fund’s non-interest income deficit ($ 31 billion) will exceed projected interest earnings ($ 9 billion), requiring the use of $ 22 billion in asset reserves. Non-interest income is projected to exceed cost for 2015 through 2020 as the economic recovery continues, followed by increasing annual shortfalls of non-interest income through the remainder of the long-range projection period.
What is the Long-Range Actuarial Balance of the OASI, DI, and HI Trust Funds? Another way to view the outlook for payroll tax-financed trust funds is to consider their actuarial balances for the 75-year valuation period. The actuarial balance measure includes the trust fund asset reserves at the beginning of the period and all costs and income during the valuation period, all expressed as a percentage of taxable payroll for the 75-year projection period. Premium increases and general revenue transfers necessary to bring SMI into annual balance occur as a requirement of Federal law so actuarial balance is not an informative concept for that program.
The actuarial deficit represents the average amount of change in income or cost that is needed throughout the valuation period in order to achieve actuarial balance. The actuarial balance equals zero if cost for the period can be met for the period as a whole and trust fund asset reserves at the end of the period are equal to the following year’s cost. The OASI, DI, and HI Trust Funds all have long-range actuarial deficits under the intermediate assumptions, as shown in the following table.
| OASI | DI | OASDI | HI | |
|---|---|---|---|---|
| Actuarial deficit | 2.40 | 0.32 | 2.72 | 1.11 |
The Trustees project that Social Security’s annual deficits, expressed as the difference between the cost rate and income rate for a particular year, will decline from 1.26 percent of taxable payroll in 2013 to 0.98 percent in 2018 before increasing steadily to 3.87 percent in 2037. Annual deficits then decline slightly through 2050 before resuming an upward trajectory and reaching 4.77 percent in 2087 (Chart B). Increasing annual deficits during the final three decades of the projection indicate that a single tax rate increase for all years starting in 2013 sufficient to achieve actuarial balance would result in large annual surpluses early in the period followed by increasing deficits in later years. The relatively large deficits at the end of the 75-year projection period—equal to 4.77 percent of taxable payroll in 2087 (see Chart B discussion)—indicate that sustained solvency would require payroll tax rate increases or benefit reductions (or a combination thereof) by the end of the period that are substantially larger than those needed on average for this report’s long-range period (2013-87).
Projected HI tax-income deficits (0.35 percent of taxable payroll in 2013) gradually decline to become a slight surplus in 2017 before deficits re-emerge to grow each year, reaching 1.58 percent of taxable payroll in 2048, after which the deficits remain in the 1.50 to 1.70 percent range through 2087.
The financial outlooks for both OASDI and HI depend on a number of demographic and economic assumptions. Nevertheless, the actuarial deficit in each of these programs is large enough that averting trust fund depletion under current-law financing is extremely unlikely. An analysis that allows plausible random variations around the intermediate assumptions employed in the report indicates that OASDI trust fund depletion is highly probable by mid-century.
How Has the Financial Outlook for Social Security and Medicare Changed Since Last Year? Under the intermediate assumptions, the combined OASDI trust funds have a projected 75-year actuarial deficit equal to 2.72 percent of taxable payroll, 0.05 percentage point larger than last year’s estimate. The anticipated asset reserves depletion date remains 2033. The actuarial deficit increased by about 0.06 percent of payroll solely due to advancing the valuation date by one year and including the year 2087. The effects of recently enacted legislation, updated demographic data and assumptions, and updated economic data and assumptions worsened the actuarial deficit, but these effects were offset by updated programmatic data and improved methodologies, causing little additional change in the actuarial deficit.
Medicare’s HI Trust Fund has a long-range actuarial deficit equal to 1.11 percent of taxable payroll under the intermediate assumptions, 0.24 percentage point smaller than reported last year. The lower Medicare cost projections are primarily due to favorable changes in provider assumptions based on recent data (for example, lower skilled nursing facility utilization and case mix increases for the next several years, and lower Medicare Advantage plan bid assumptions) and reduced HI expenditures experienced in the projection base year (2012). The projected date of depletion of the HI Trust Fund is now 2026, two years later than reported last year.
Who Are the Trustees? There are six Trustees, four of whom serve by virtue of their positions in the Federal Government: the Secretary of the Treasury, the Secretary of Labor, the Secretary of Health and Human Services, and the Commissioner of Social Security. The other two Trustees are public representatives appointed by the President and confirmed by the Senate: Charles P. Blahous III, Research Fellow at the Hoover Institution and Senior Research Fellow at the Mercatus Center, and Robert D. Reischauer, President Emeritus and Distinguished Fellow of the Urban Institute.
How Are Social Security and Medicare Financed? For OASDI and HI, the major source of financing is payroll taxes on earnings paid by employees and their employers. Self-employed workers pay the equivalent of the combined employer and employee tax rates. During 2012, an estimated 161 million people had earnings covered by Social Security and paid payroll taxes; for Medicare the corresponding figure was 165 million. Current law establishes payroll tax rates for OASDI, which apply to earnings up to an annual maximum ($ 113,700 in 2013) that ordinarily increases with the growth in the nationwide average wage. In contrast to OASDI, covered workers pay HI taxes on total earnings. The scheduled payroll tax rates (in percent) for 2013 are:
| OASI | DI | OASDI | HI | Total | |
|---|---|---|---|---|---|
| Employees | 5.30 | 0.90 | 6.20 | 1.45 | 7.65 |
| Employers | 5.30 | 0.90 | 6.20 | 1.45 | 7.65 |
| Combined total | 10.60 | 1.80 | 12.40 | 2.90 | 15.30 |
Note that starting in 2013, the Affordable Care Act applies an additional HI tax equal to 0.9 percent of earnings over $ 200,000 for individual tax return filers, and on earnings over $ 250,000 for joint return filers.
Payments from the General Fund currently finance about 75 percent of SMI Part B and Part D costs, with most of the remaining costs covered by monthly premiums charged to enrollees or in the case of low-income beneficiaries, paid on their behalf by Medicaid for Part B and Medicare for Part D. Part B and Part D premium amounts are determined by methods defined in law and increase as the estimated costs of those programs rise.
In 2013, the Part B standard monthly premium is $ 104.90. There are also income-related premium surcharges for Part B beneficiaries whose modified adjusted gross income exceeds a specified threshold. In 2013 through 2019, the threshold is $ 85,000 for individual tax return filers and $ 170,000 for joint return filers. Income-related premiums range from $ 146.90 to $ 335.70 per month in 2013.
In 2013, the Part D “base monthly premium” is $ 31.17. Actual premium amounts charged to Part D beneficiaries depend on the specific plan they have selected and average around $ 30 for standard coverage. Part D enrollees with incomes exceeding the thresholds established for Part B must pay income-related monthly adjustment amounts in addition to their normal plan premium. For 2013, the adjustments range from $ 11.60 to $ 66.60 per month. Part D also receives payments from States that partially compensate for the Federal assumption of Medicaid responsibilities for prescription drug costs for individuals eligible for both Medicare and Medicaid. In 2013, State payments will cover about 12 percent of Part D costs.
1 As noted earlier in this summary, if trust fund depletion actually occurred as projected for HI in 2026 and for OASDI in 2033, each program could pay benefits thereafter only up to the amount of continuing dedicated revenues. Chart D, by contrast, compares dedicated sources of tax and premium income with the full cost of paying scheduled benefits under each program. In practice, lawmakers have never allowed the asset reserves of the Social Security or Medicare HI trust funds to become depleted.
A MESSAGE FROM THE PUBLIC TRUSTEES
These are the third annual reports in which we have participated as Public Trustees. As with our experiences preparing the prior years’ reports, we were once again impressed by the quality and professionalism of the work performed by the actuaries’ offices in the Social Security Administration and the Centers for Medicare and Medicaid Services, and by all of the staff dedicated by the departments of the ex officio Trustees. We believe the public continues to be well served by the statutory process for developing the financial projections for Social Security and Medicare. Though only the passage of time will reveal the degree of accuracy in our projections, we are pleased to vouch for the objectivity and integrity of the Trustees’ estimation process.
Both the Social Security and Medicare programs face substantial financing shortfalls that require legislative corrections, but the implications are different for each one. Of the two programs, Social Security faces the larger actuarial imbalance as well as the most immediate threat of trust fund depletion, again projected in 2016 for its Disability Insurance (DI) Trust Fund. Accordingly, more far-reaching legislative measures are required to maintain the solvency of Social Security relative to Medicare. On the other hand, Medicare is projected to experience relatively greater cost growth over the long-range valuation period, posing greater strains for the federal budget as a whole due to the extent to which its financing depends on general revenues. The legislative measures required to maintain Medicare solvency are not as pronounced as they are for Social Security, but Medicare still requires substantial further reforms if it is not to eventually subject the general budget to severe levels of strain.
Chart A in our report summary illustrates how, relative to GDP, both Social Security and Medicare costs increased sharply in recent years, largely as a consequence of the Great Recession. The economic recovery will cause costs for both programs relative to GDP to level off during the middle of this decade. But as Chart A also shows, both programs are poised to resume a rapid pace of annual cost growth by the end of this decade.
Social Security’s long-term income shortfall is now larger than it has been at any point since before the landmark program reforms of 1983. The dates of projected depletion of each of its trust funds are unchanged from last year’s report. It is important to grasp that the amount of time remaining to enact a financing solution that is both reasonably balanced and politically plausible is far less than the amount of time projected before final depletion of Social Security’s combined trust funds. Toward that end, this year’s report contains new illustrations of the magnitudes of benefit changes required if lawmakers wish to preserve solvency without affecting current beneficiaries. Importantly, even if a Social Security solution were enacted today and effective immediately, it would require financing corrections that are substantially more severe than those enacted in the 1983 program amendments. Each passing year of legislative inaction reduces the likelihood that a solution can be found that is acceptable to lawmakers on both sides of the political aisle.
As Table IV.B7 of the Social Security Trustees Report shows, those now entering the Social Security system as workers will contribute more in taxes (in present value) than they receive in benefits under current schedules. The entirety of Social Security’s financing shortfall thus consists of an excess of scheduled benefits over taxes contributed for current and past program participants. This information highlights the importance, from an equity perspective, of enacting a solution promptly enough so that more generations contribute to correcting the program’s financing shortfall. Substantial further delay risks further concentrating the burdens of correcting the shortfall on the younger workers who already stand to be treated less favorably, thereby undermining Social Security’s efficacy in serving future generations.
As lawmakers contemplate solutions to Social Security’s shortfall, we commend the information published by the Social Security Chief Actuary’s office at: www.ssa.gov/OACT/solvency/index.html , andwww.ssa.gov/OACT/solvency/provisions/index.html . These links provide access to the SSA Chief Actuary’s analyses of individual provisions as well as comprehensive proposals for addressing program financing.
Because the primary focus is on the revenues and benefit costs associated with current law, this year’s Medicare Trustees Report contains fewer references to the alternative scenarios in which certain cost-saving provisions of the 2010 Affordable Care Act are assumed to be overridden. Readers who want additional information about the illustrative alternative fiscal scenario can find it at: www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/2013TRAlternativeScenario.pdf .
As with Social Security, we recommend that legislative measures be enacted to close the Medicare Hospital Insurance (HI) financing shortfall, and to reduce projected cost growth in its SMI components of Parts B and D. But to a greater extent than Social Security, the Medicare projections also depend on the course of new technology and whether various revenue and cost-reduction measures scheduled to be phased in over the next several years are successfully implemented. It is important for Medicare finances that these measures not be scaled back or repealed without replacing them with others that produce an equal or greater amount of cost savings.
The durability of the Social Security and Medicare programs through the decades rests in large part on public perceptions that their methods of financing, while not perfect, are generally fair. While considerations of equity and adequacy will inevitably accompany any legislative effort to restore these programs to long-term financial balance, a broadly accepted solution becomes less likely the longer that financing corrections are postponed. In the interests of those who depend on these programs as beneficiaries, as well as those who contribute to them as taxpayers, we urge lawmakers to correct the financial imbalances of Social Security and Medicare soon.
Charles P. Blahous III,
Trustee.
Trustee.
Robert D. Reischauer,
Trustee.
Trustee.
see socialsecurity.gov
Healthcare, Technology & Government 2.0
Open Research For Open Cures: A Report From Sage Congress
Over four years of Congresses, Sage Bionetworks has drawn together leading thinkers and doers throughout the fields of genetic research and drug development. For two days each year, the conference floor is colonized by clumps of eagerly networking PhDs from academic, pharma, government, non-profits, biotech firms, and patient advocacy groups–people who often glide from one domain to another within this tight-knit cohort.
A cohort, certainly, we can characterize this group of attendees, sharing as they do a mysterious language drawn from years of research most of us will never understand. But is it a community? That will be tested over the following year as Sage Bionetworks lets go of the Congress. Founder Stephen Friend says it is up to others to create the next Congress, and its success or failure will be a measurement of the sweat and passion that Friend and Sage have put into attempts to build a community.
Why should a reader look further at this struggle among a tiny elite, rather than clicking on the next article? Well, first, if you’re one of the 48% of Americans who took a prescription drug this month, you should be concerned about where new breakthrough drugs will emerge. If you visit this web site because you want a more responsive health care system that can match patients to treatments more quickly and cheaply, recognize that new methods are important nowhere as much as at the foundation of the system where new treatments are discovered. And if you are just curious about the potential for global cross-institutional teams and loose networks connecting experts with ordinary members of the public to find creative solutions to old problems, this article will provide insights.
Don’t get too close, you don’t know what I have
The premise on which Friend founded Sage is that research and drug development have stagnated and cannot progress without more collaboration and data sharing. Therefore, with all due regard for the presentations at the recent Sage Congress on cancer research projects and other individual experiments, the real theme of the conference is in the keynotes about open source, the use of social media, and crowdsourcing. The challenge of this community–if we find that it has indeed become a community–is to analyze and deal with the particular challenges that genetic research and drug development inject into trends toward open collaboration.
It’s hard to determine who has a higher aversion to sharing data: pharma or academia. The starter in the pharma compound is their fear that someone else will discover and patent the billion-dollar drug they’ve been sleuthing after, into which they mix in the worry that publicizing negative trials will lead to their drug’s rejection.
Academics mirror these disincentives, panicking that they’ll lose the race to discovery or that their methods of massaging their data will wither under the harsh light of review. Furthermore, academics are acutely aware of the accomplishments that garner promotion, tenure, and the funding of grants. The mundane tasks of preparing and cleaning data earn them nothing in those areas.
What can detoxify these tendencies to remain isolated? Moral persuasion has limited effect, so the main vector of attack is a growing understanding that tried-and-true research methods are petering out and need some radical rethinking. As I reported from last year’s Congress, the costs of drug development are rapidly increasing, and fewer truly novel drugs are being submitted to regulators for approval over the years.
Stung by evidence that many drugs approved for use are not as safe or efficacious as promised, the FDA has tightened its requirements for Phase 3 testing, which taxes the resources drug companies put into development and further lengthens the time between the patenting of a compound and its actual sale. The “patent cliff” that the drug companies are facing, as lucrative compounds enter the public domain and fewer new ones replace them as sources of revenue, has been widely reported.
Researchers in both pharma and academia have started to cast longing glances at the repositories of data and computer code maintained by other researchers. Just as public health can be judged much better from a nationwide database than from an individual hospital’s case load, genetic research can benefit from larger collections of samples. Still, data is finicky. We’ll look further at some of the complications of data sharing and collaboration.
Pharma companies will continue to hold their cards close to the chest when testing compounds (drug products), but will probably share more data about activities that go on outside their core research, such as tests that validate the efficacy and safety of drugs. Public pressure may convince them to release the data from negative trials, which may save researchers a lot of time when looking for other compounds.
Changing the equations for rewarding research
What incentives can the field offer academic researchers whose careers revolve around publishing papers? One tactic can be borrowed from NIH, which now requires all grant recipients to put their data in public repositories. One manager at the National Cancer Institute lamented that although government agencies require grantees to submit a plan for data sharing, the agencies don’t actually follow up to see that the plan was carried out. So journals can do even better than the federal government in this area.
Further incentives for sharing research data include citations for data sets, which are supported in science by the notion of a Digital Object Identifier (DOI). The field can now track the reuse of data just as it tracks citations in journals.
WikiPathways allows researchers to share information they have about relationships between genes and diseases. As a wiki, the site lets the public edit information about these pathways. But visitors can also search for overlaps and other key relationships.
A platform like Synapse can let writers post drafts of papers that are associated with data stores. Publishers can follow these along and benefit from the free peer review provided by comments. Not only do they make papers better, they help the publisher decide what’s worth publishing. Could these ongoing comments–sometimes called pipelined peer review–substitute for formal peer review? One publisher assured us they would not, but the possibility remains that someday they will, cutting publishers totally out of the distribution of research results.
Room for the patient
Arcane and complex as genetic research is, Sage and its collaborators are committed to bringing patients into the planning process. A number of separate efforts aim at maximizing patient control.
The most familiar kind of patient involvement is the militant advocacy seen in the movement of AIDS victims, chronicled in a talk by HIV researcher Joep Lange. Luckily, both the AIDS professionals and other medical researcher have developed more collaborative relationships with patients as well.
Why should patients determine research goals? Surprisingly, perhaps, genetics researchers in their zeal to uncover causes and treatments often miss what the patients feel is most important to them. Take Fanconi Anemia, a terrible condition involving the blood that gives its victims an average life expectancy of 30 years. One of Fanconi Anemia’s most feared impacts is a higher risk of developing cancer that can drastically shorten the patient’s life. So patients would like researchers to focus on ways to predict cancer and catch it early, not a direction that the research community would discover on its own.
Fanconi Anemia is one of the first areas on which Sage is focusing in its Bridge project. Just in its preliminary stages, Bridge aims to tie patients, doctors, and researchers together. Patients will be abloe donate genetic data and information on their conditions, propose and fund trials, and suggest directions for research. If drafts of papers are posted online during development, Bridge members will be abloe comment on them. The hope is that all this will lead to better research and faster cures.
Bridge will provide a platform for sharing and patient participation that is more open than services such as 23andMe and PatientsLikeMe. In his opening remarks, John Wilbanks laid out three models for medical research. The first is a collection of dynamic but independent companies withholding data for competitive reasons. The second model encompasses relatively recent innovations like 23andMe and PatientsLikeMe. The third is the commons that Sage would like to build. This commons is based on a recognition that progress is not just a series of discrete steps that can be monetized or turned into grant opportunities, but an ongoing exploration involving loosely organized groups of people from many backgrounds.
Consent forms are another area of research under Sage’s microscope. Current forms leave much to be desired. Still in recovery from an era many decades ago when patients were mistreated and kept from a full understanding of what researchers were doing, current consent processes are very heavy-weight and hard for patients to understand. Furthermore, they throw up walls against the kind of data-sharing that Sage promotes.
Meanwhile, popular social networks for patients rely on advertising and other services that aggregate patient data for revenue. These raise privacy concerns for some patients, and make them wonder about the motives of the sites’ owners.
Sage has developed a portable legal consent process that steps the patient through the benefits and risks of sharing (including the risk of re-identification) and lets the patient choose the degree of sharing permitted. Many patients are scared off by the process, quite properly, but those who make it through and decide to sign the consent open up their data to a great many more researchers. Portable legal consent was discussed in depth at last year’s Congress.
When ordinary people get involved in experiments, they can measure personal information (phenotypic data) in their homes and vastly increase the quantities of data available to researchers. Quantified Self enters the lab. But such an innovation, of course, raises questions of how trust data submitted by the patient.
The commitment of Sage to patient control was evident in the range of patient advocates and others who spoke of its importance at the conference. Greg Biggers of Genomera was just one of the experts testifying to the possibilities and potential of bringing patients into the process. The paper describing the results of Sage’s successful breast cancer prognosis challenge offered to develop means for patients to “work alongside Challenge participants” in the future.
The power of positive thinking
It’s easy to provide a forum for public comment and input, but usually unproductive to do so. Whether on the White House’s We the People petition site or Wikipedia, the trick is to find a strategy that encourage participants to contribute positively, not just to carp and tear each other apart.
Let’s review the article and see some of the ways to make participation bear fruit in medical research:
- Helping people form communities with shared goals, such as Bridge.
- Giving patients more of a say in what research is conducted and how it is conducted.
- Safeguarding patient privacy. This is particularly important for populations whose conditions are stigmatizing, such as veterans suffering from neurological damage.
- Providing clean, reusable data and code to researchers, which involved incentives for them to prepare the data and code and describe its provenance. This involves the adoption of standards.
- Requiring data and code to be shared as a condition for funding or publication.
- Running challenges such as the Sage/DREAM breast cancer challenge
What will the coming year see?
The Sage vision for sharing and collaboration is completely in harmony with famous projects outside medicine, including open source software, Wikipedia, Mechanical Turk, and open government initiatives. The means are often also familiar: code repositories in the style of GitHub, challenges, etc.
But many participants at Sage Congress each year need reassurance that these strategies can work. This seemed to be the goal behind lining up such keynoters as Wadah Khanfar, cofounder of Al Jazeera, who talked about openings and transformations in the middle each, Bob Young, founder of Red Hat, and Jennifer Pahlka, founder of Code for America.
Audience members raised typical worries about being open while raising money to get a project done. John Wilbanks, who came from the Creative Commons foundation to lead Sage’s work on portable legal consent, pointed out that making more code and data into free public resources will drastically reduce costs. Still, the attendees are right to be concerned, because research in genetics runs at several million dollars a pop.
Fluctuating buy-in and resistance raises the question whether Sage’s strategy will break through into the mainstream. The conference ended with announcement that surprised even one of Sage’s advisory board: Sage will no longer organize the Congress it has held for the past four years.
Friend’s stated reason for giving up control over the Congress was that Sage is now a player with its own agenda and that the Congress needs to reflect the needs and input of more stakeholders. I suspect the announcement was also meant to put pressure on organizations that have failed to move as fast as Sage. Sage’s work on Synapse, portable legal consent, challenges, and other areas have outstripped the abilities of potential users. It’s time for them to make similar efforts.
But I think Friend has measured his own prospects carefully, and that the announcement was preceded by behind-the-scenes negotiations with key funders and players in genetics and pharma. I expect to see a Congress next year, and to see progress in community-building for which Sage has laid a foundation.
Parts of Sage Congress were videotaped and posted online.
Andy Oram is an editor at O’Reilly Media, a highly respected book publisher and technology information provider. His work for O’Reilly includes the influential 2001 title Peer-to-Peer, the 2005 ground-breaking book Running Linux, and the 2007 best-seller Beautiful Code.
HealthEd Academy Report: Speaking Multiculturally in Health Care
An often repeated saying in health care goes that patients lose about 80% of the information they heard during a doctor’s appointment by the time they reach the parking lot. It emphasizes that patients aren’t able to put followup care instructions into practice when they either forget or don’t comprehend what was said during a visit. Whatever the actual percentage might be, a guaranteed way to ensure that patients take home 0% of that information is to talk to them in a language they don’t understand.
Twenty percent of the United States population reported that they speak a language other than English at home, according to the U.S. Census Bureau. Many health care workers see limited English proficient patients every day, and within Accountable Care Organizations (ACOs) and Patient-Centered Medical Homes (PCMHs) it will be up to these workers to make sure that patients have the best health outcomes, no matter how high the language barriers are.
Today HealthEd Academy released the results of a survey that looked at the way non-MD health care professionals interact with their patients from multicultural backgrounds. The report examined responses from a survey of 192 health care extenders, which included nurses, social workers, pharmacists, patient educators, and more. One in five of those surveyed were part of an ACO or PCMH.
The respondents reported working with a huge array of languages. They were asked to name the most common languages spoken by their patient populations, and four out of 10 checked “other,” despite being able to choose from 10 languages identified by the Census Bureau as the most commonly spoken. Among the languages respondents wrote in were Arabic, Yiddish, several Indian/Pakistani languages, and sign language.
“An alarming finding is there is such a large potential for miscommunication between health care extenders and patients, and that can have all sorts of health and safety ramifications,” said Katherine Margolis, PhD, one of the lead analysts of the survey and director of health behavior strategy and research at HealthEd Academy. And health care workers certainly don’t have all of the patient education materials they need in each of the languages they need them in. Margolis said that materials are typically developed in English first, then in Spanish, but it usually ends there.
Another interesting but not entirely surprising finding from the report was a statistic about the respondents themselves. More than 80% are Caucasian. HealthEd Academy said this reflects the current racial profile of health care extenders in the U.S., citing other national surveys like ones that found that 83% of registered nurses are white, and so are 82% of registered dietitians.
Half of HealthEd’s survey respondents reported that they are making an effort to recruit staff that better reflect the populations they serve. “I think it will be interesting to see how the demographics shift in time because I think it’s only a matter of time before they do. The U.S. Census has reported that over 50% of people under the age of one are from a minority group,” Margolis said.
Some of HealthEd Academy’s other findings from this report include that:
- Health care extenders usually forgo technology and primarily deliver education materials in print or in person
- Health care extenders involve minority community members less often than they involve health care providers when designing patient education materials
- Patient education is provided at many community locations, but it’s rarely provided at pharmacies
The report is full of examples of what health care professionals are doing to better care for their patients from minority populations. For example, in addition to using interpreters, many said that they are currently working on translating patient education materials into other languages. HealthEd Academy pointed to existing resource Healthy Roads Media for help with this. Healthy Roads is a grant-supported organization, which creates materials in all different languages in written, audio and mobile formats. The report highlights other tools health care extenders can use to serve all of their subpopulations and concludes that providing this kind of tailored care is complex, but it’s critical.
A Significant Additional Observation on the PA Patient Safety Authority Report “The Role of the Electronic Health Record in Patient Safety Events” — Risk
At a Dec. 13, 2012 post “Pennsylvania Patient Safety Authority: The Role of the Electronic Health Record in Patient Safety Events” I alluded to risk in a comment in red italics:
… Reported events were categorized by their reporter-selected harm score (see Table 1). Of the 3,099 EHR-related events, 2,763 (89%) were reported as “event, no harm” (e.g., an error did occur but there was no adverse outcome for the patient) [a risk best avoided to start with, because luck runs out eventually - ed.], and 320 (10%) were reported as “unsafe conditions,” which did not result in a harmful event.
The focus of the report is on how the “events” did not cause harm. Thus the relatively mild caveat:
“Although the vast majority of EHR-related reports did not document actual harm to the patient, analysts believe that further study of EHR-related near misses and close calls is warranted as a proactive measure.”
It occurs that if the title of the paper had been “The Role of the Electronic Health Record in Patient Safety Risk“, the results might have been interpreted far differently:
In essence, from from June 2, 2004, through May 18, 2012 (the timeframe of the Pennsylvania Patient Safety Reporting System or PA-PSRS database), from a dataset highly limited in its comprehensiveness as written in the earlier post, there were approximately 3,000 “events” where an error did occur that potentially put patients at risk.
That view – risk – was not the focus of the study. Should it have been?
These “events” really should be called “risk events.”
It is likely the tally of risk events, if the database were more comprehensive (due to better recognition of HIT-related problems, better reporting, etc.) would be much higher. So would the reports of “harm and death” events as well.
That patient harm did not occur from the majority of “risk events” was through human intervention, which is to say, luck, in large part
Luck runs out, eventually.
I have personally saved a relative several times from computer-related “risk events” that could have caused harm if I were not there personally, and with my own medical knowledge, to have intervened. My presence was happenstance in several instances; in fact a traffic jam or phone call could have caused me to have not been present.
What’s worse, the report notes:
Analysts noted that EHR-related reports are increasing over time, which was to be expected as adoption of EHRs is growing in the United States overall.
In other words, with the current national frenzy to implement healthcare information technology, these “risk events” – and “harm and death events” – counts will increase. My concern is that they will increase significantly.
I note that health IT is likely the only mission-critical technology that receives special accommodation regarding risk events. “If the events didn’t cause harm, then they’re not that important an issue” seems to be the national attitude overall.
Imagine aircraft whose avionics and controls periodically malfunction, freeze, provide wrong results, etc., but most are caught by hyper-vigilant pilots so planes don’t go careening out of control and crash. Imagine nuclear plants where the same occurs, but due to hypervigilance the operators prevent a nuclear meltdown.
Then, imagine reports of these “risk events” – based on fragmentary reporting of pilots and nuclear plant operators reluctant to do so for fear of job retaliation – where the fact of their occurrence takes a back seat to the issue that the planes did not crash, or Three Mile Island or Chernobyl did not reoccur.
That, in fact, seems to be the culture of health IT.
I submit that the major focus that needs addressing in health IT is risk - not just confirmed body counts.
– SS
What If the Institute of Medicine Wrote a Report and Nobody Followed it? – the Case of the Standards for Developing Trustworthy Guidelines
For over 20 years, clinical practice guidelines (CPGs) have been touted to improve health care quality and control costs. Enormous numbers of guidelines have been developed, but with seemingly little impact on health outcomes. While some of those leading health care organizations have predictably blamed individual practitioners for obstinately ignoring or challenging guidelines, there is increasing evidence that maybe the guidelines themselves are part of the problem.
An Example of a Guideline that Apparently was Not Trusted
One example Dr Wally Smith and I have taught in our recurring mini-course on why physicians fail to follow guidelines (and otherwise appear not to practice in accord with others’ wishes) is that of the guidelines on management of depression in primary care. Most existing guidelines urge physicians to screen patients for (presumably mild-to-moderate) depression and treat them aggressively, with emphasis on the use of the newer anti-depressants. These guidelines, in turn, were based on numerous published randomized clinical trials that showed that these drugs were safe and efficacious. Yet multiple studies showed that physicians failed to follow these guidelines, and various attempts to improve their adherence did little. So for years the assumption was that physicians at best experienced practical and system barriers to follow these guidelines, and at worst were ill-informed or irrational.
However, information that came out gradually during the early part of the 21st century suggested that perhaps the problem was within the guidelines, not the health care professionals. First, documents produced during New York Attorney General Eliot Spitzer’s lawsuit against GlaxoSmithKline about the marketing of one of these drugs (Paxil, paroxetine) suggested that the company had suppressed clinical trial data that reflected poorly on the drug (See Kondro W. Drug company experts advised staff to withold data about SSRI use in children. Can Med Assoc J 2004; 170: 783. Link here.) These suspicions were later fleshed out by consideration of documents further disclosed in litigation (e.g., see this post and its links). Then several studies, most particularly that by Erick Turner and colleagues, showed that numerous trials of new anti-depressants had been suppressed, that is, never published (Turner et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med 2008; 358:252-260. Link here). When the results of these trials were added to those that were published, the efficacy of anti-depressants was no longer so clear. So maybe the guidelines that physicians did not follow were not trustworthy, and should not have been followed in the first place.
Would IOM Standards to Improve Guideline Trustworthiness Help?
So in 2011, the prestigious Institute of Medicine released a report on the development of better standards to produce more trustworthy guidelines (Clinical Practice Guidelines We Can Trust. Link here.) We posted about that report here, but noted that it was receiving little other attention, an example of the anechoic effect.
A few weeks ago, an article appeared documenting a study meant to assess the the trustworthiness of clinical practice guidelines published soon after the IOM report. Its title telegraphs the results. ( Kung J, Miller RR, Mackowiak PA. Failure of clinical practice guidelines to meet Institute of Medicine standards: two more decades of little, if any progress. Arch Intern Med 2012. Link here.)
Methods and Results
The investigators selected a random sample of 114 individual guidelines available during June, 2011 stratified by 26 clinical topics. The versions of the guidelines used were those archived in the National Guideline Clearinghouse (NGC) maintained by the Agency for Healthcare Research and Quality (AHRQ).
The goal of the study was to “examine adherence to the IOM standards” by guidelines published after the standards were published. Actually, the study only assessed adherence to 18 of the 25 standards espoused by the IOM (because the remaining seven were “too vague and subjective to be analyzed.”)
Furthermore, the criteria used to determine if a specific guideline met each of the three items above were rather lax:
In evaluating each guideline summary, care was taken to be as liberal as possible in considering that a standard was met when the individual guideline summary provided any information pertaining to that particular standard.
Nevertheless, using these lax standards to only evaluate adherence to 18/25 guidelines, the authors found that “the overall median number of IOM standards satisfied (out of 18) was 8 (44.4%) …. Fewer than half of the guidelines surveyed met more than 50% of the IOM standards.”
An examination of the details of the study’s methods reveals things are even worse than that.
Analyzing the Study’s Methods to Find that Things Are Worse Than They Seem
Review of the study’s methods show that they provided a very optimistic view of adherence to the IOM standards. As noted above, the study did not look for adherence to all of the IOM standards. Moreover, those they did consider were simplified and made less rigorous. For example, Standard 2 from the IOM on management of conflict of interest (COI) was:
STANDARD 2
Management of conflict of interest (COI)2.1
Prior to selection of the Guideline Development Group (GDG), individuals being considered for membership should declare all interests and activities potentially resulting in COI with development group activity, by written disclosure to those convening the GDG.
- Disclosure should reflect all current and planned commercial (including services from which a clinician derives a substantial proportion of income), non-commercial, intellectual, institutional, and patient/public activities pertinent to the potential scope of the CPG.2.2
Disclosure of COIs within GDG
- All COI of each GDG member should be reported and discussed by the prospective development group prior to the onset of their work.
- Each panel member should explain how their • COI could influence the CPG development process or specific recommendations.2.3
Divestment
- Members of the GDG should divest themselves of financial investments they or their family members have in, and not participate in marketing activities or advisory boards of, entities whose interests could be affected by CPG recommendations.2.4
Exclusions
- Whenever possible GDG members should not have COI.
- In some circumstances, a GDG may not be able to perform its work without members who have COIs, such as relevant clinical specialists who receive a substantial portion of their incomes from services pertinent to the CPG.
- Members with COIs should represent not more than a minority of the GDG.
- The chair or co-chairs should not be a person(s) with COI.
- Funders should have no role in CPG development.
However, the study boiled all this down to three items:
- COIs stated
- Chair has COI
- Co-chairperson has COI
Thus the study did not address standards requiring full and complete disclosure (not just some disclosure) of all COIs; consideration of how the COIs might influence the particular guideline; divestment of specific types of conflicts of interest, that is, financial investments, and cessation of participation in marketing activities or advisor boards; minimization of conflicts of all members of the committee; and barring of participation of funders in guideline development.
Even so, the guidelines assessed did a very poor job upholding even these few liberalized standards regarding conflicts of interest. Of the guidelines assessed, less than half, 46.8% provided ANY disclosure of conflicts of interest. Those written by sub-specialty societies were particularly opaque in this regard. Less than one-third, 29.3%, provided any disclosure. Thus the majority of guidelines assessed were not at all transparent about conflicts of interest affecting the guideline development process.
Furthermore, of the 46.8% of all the guidelines which made any disclosures of conflicts of interest, 71.4% admitted their chair people HAD a conflict of interest. Thus, only (0.468 * [1 - .714]) = 13.3% provided assurance that they fulfilled the single requirement (from standard 2.4 above) that the chair person did not have a COI. For the guidelines written by sub-specialty societies, by a similar calculation, only 12.2% provided an assurance that the chair had no COI. (The proportions providing assurance that the co-chair people had no COI were even lower.) Thus the vast majority of guidelines did not clearly follow two straight-forward standards for minimizing the effects of conflict of interest, that the guideline committee chair and co-chair should not have any relevant conflicts.
Given the miserable results concerning even minimal adherence to some of the IOM report’s conflict of interest standards, it is likely that almost no published guidelines from 2011 came close to fulfilling the full set of IOM standards. Despite the best efforts of the IOM, it appears that guideline developers have not progressed at all towards providing trustworthy guidelines.
Summary
An editorial (Shaneyfelt T. In guidelines we cannot trust. Arch Intern Med 2012) accompanying the article by Kung and colleagues summarized its results thus:
The same problems that have plagued guideline development continue to plague guideline development; namely, their variable and opaque development methods, their often conflicted and limited panel composition, and their lack of significant external review by stakeholders throughout the development process. As a result, the trustworthiness of guidelines is limited.
While guidelines may have seemed to be a promising method to improve health care in the early 1990s, they have failed to live up to that promise. Shaneyfelt was not optimistic they would improve in the future:
I am not optimistic that much will improve. No one seems interested in curtailing the out-of-control guideline industry.
On the other hand, in my humble opinion, it is not that on one is interested in better guidelines. It would clearly be in the best interests of patients and the public, and of health care professionals who care about the quality of their practice and the outcomes of their patients to curtail that industry. The issue is why patients’, the public’s, and professional’s interests were ignored.
Neither Shaneyfelt nor Kung et al discussed why there has been so little attention to patients’ and the public’s health, and to health care professionalism in all this. For a quick answer, we do not have to look far on Health Care Renewal.
In fact, the IOM report on guideline development from 2011 was a serious challenge to the powers that be in health care. In particular, it challenged the cozy relationships that had grown up among the organizations that undertook guideline development and the health care professionals on guideline panels on one hand and organizations that stand to gain were specific guidelines to favor their products, services, and agendas on the other. The standards mandated transparency and honesty about conflicts of interest affecting guideline committees and the organizations which assembled them, and if upheld would have greatly reduced these relationships.
Now it turns out that the guideline standards have been honored mainly in the breach. Of course, these standards, while increasing trustworthiness, would have cost a lot of medical societies considerable commercial funding, and would have cost a lot of health care professionals on guideline panels considerable personal wealth. These standards would probably also have cost a lot of companies whose products and services were addressed by guidelines to lose revenue. So it is not surprising that the IOM standards were ignored. Their implementation would have cost too many people who are financially benefiting from the status quo too much money. And these people, that is, leaders of professional societies dependent on commercial outside funding, health care professionals and academic used to financial support from commercial interests, and health care corporations are good at making sure their interests are not ignored, even if their interests conflict with those of patients, the public, and well-intentioned health care professionals.
So, the flouting of the well reasoned IOM guideline standards adds one more reason for patients and the general public to distrust modern health care and all those who “deliver” it, even to distrust well-intentioned health care professionals who have not been able to distinguish themselves from their colleagues who are too happy to help commercial interests while taking commercial money. If health care professionals want to regain the public’s trust, they could do worse than publicly declaring their intention to show that their practice in the future will be guided by trustworthy guidelines based on clinical research evidence and knowledge of biomedical science, drawn up by health care professionals independent of commercial interests.
Jobs Report Shows Improvement; Unhelpful To People Without Jobs
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For a while in 2008, Bono maintained her former employer's health insurance policy at full cost through the government's COBRA program. She got laid off too early to be eligible for the 2009 stimulus bill's COBRA subsidy and eventually gave up on the …
Read more on Huffington Post
Commissioners approve purchase of Stun Cuffs
In other action Monday, commissioners increased the monthly premium for COBRA coverage through the county's employee health insurance plan to $ 600 per month from the current $ 415. The actual cost of the coverage, according to County Treasurer Ida …
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Why Do Academic Medical Centers Do Poorly on Quality Report Cards?
In September 2012, the Joint Commission recognized 620 hospitals (about 18% of the total number of accredited American hospitals) as “top performers,” but many were surprised when some of the biggest names in academic medical centers failed to make the cut. Johns Hopkins, Massachusetts General Hospital, and the Cleveland Clinic (perennial winners in the US News & World Report best hospital competition) did not qualify when the Joint Commission based their ranking not on reputation but on specific actions that “add up to millions of opportunities ‘to provide the right care to the patients at American hospitals.’”
The gap between the perceived reputation of America’s “best” hospitals and medical schools and their performance on an evidence-based medicine report card provides an interesting lens through which to understand the role and performance of America’s academic medical centers in the 21stcentury.
The most pressing challenge for American medicine has been summarized in the triple aim: how to cut the per-capita cost of healthcare, how to increase the quality and experience of the care for the patient, and how to improve the health and wellness of specific populations.
Can we expect academic medical centers to lead the country in meeting the challenge? If history is any guide, the answer may be no. In a 2001 article titled “Improving the Quality of Health Care: Who Will Lead?” the authors write:
“We see few signs that academic medical leaders are prepared to expend much effect on health care issues outside the realms of biomedical research and medical education. They exerted little leadership in what may arguably be characterized as the most important health policy debates of the past thirty years: tobacco control, health care cost containment, and universal access.”
Having been a professor at several medical schools (UCSF, University of Iowa, Allegheny University of the Health Sciences, and Michigan State), I learned early on that the key to academic advancement was NIH funded basic science research. While lip service was paid to the ideal triple threat professor (great clinician, superb teacher, and peer reviewed published investigator), the results of the tenure process clearly resulted in a culture where funded research counted far more than teaching and clinical care delivery.
This gap between what the country needs and what medical schools traditionally emphasize was demonstrated when researchers studied more than 60,000 medical school graduates from 1999 to 2001. As Pauline W. Chen, MD wrote in the New York Times:
“Putting the issues of primary care shortage, underserved communities and workforce diversity under the banner of ‘social mission,’ the researchers found that many of the schools that were traditionally ranked highly were also among those least focused and least successful in addressing the most pressing issues facing the country right now.”
A recent report from the Lucien Institute at the National Patient Safety Foundation describes the kind of culture required to achieve the goals of the triple aim.
“Achieving safety in the work environment requires much more than implementing new rules and procedures. It requires developing and sustaining cultures of safety that engender trust and embrace reporting, transparency, and disciplined practices. It also requires an atmosphere of respect among the health care disciplines and a fundamental ability of all practitioners to work together in teams.”
The Association of American Medical Colleges survey on medical school culture reveals a culture that does little to encourage trust and transparency. From 2004 to 2008, 12.7% to 16.7% of students reported being publicly belittled or humiliated. The best program for implementing a culture of safety I have seen did not originate in an academic medical center; it was developed and implemented at the Sentara Healthcare System in Virginia.
Academic medical center hospitals often save the lives of patients with complicated conditions who benefit from cutting edge treatments supported by basic science research. However, it is revealing that the community Holy Cross Hospital in Silver Spring, Maryland made the Joint Commission’s list of “top performers” and the famed Johns Hopkins did not do as well on the quality scoring report card.
The 2009 Report on Accident and Health Insurance and Medical Service Plans: World Market Segmentation by City Reviews
The 2009 Report on Accident and Health Insurance and Medical Service Plans: World Market Segmentation by City
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Comments by Dr. Reed Gelzer on RAND Health IT Report and Op-Ed in Pittsburgh Post Gazette
A new Op-Ed by Kellerman and Jones entitled “IT in health care is MIA“ appeared on Mar. 3, 2013 in the Pittsburgh Post-Gazette.
They wrote:
Of course, the U.K. recently suffered a rather severe blow, on the order of 13 billion Pounds’ worth, to its National Programme for Health IT in the NHS (NPfIT). Australia is not exactly an “Emerald City” in terms of health IT, either, as can be seen from numerous links at the blog of Sydneysider Dr. David More, Australian Health Information Technology.
The RAND authors throw in some boilerplate grandiose predictions of certainty about health IT, which seems to have become a common phenomenon in newspapers and even scientific publications of late:
Read the whole Op-Ed at the Gazette.
(My mother, an unwitting expert with significant experience on health IT adverse effects, is unavailable for comment, as she is dead due to a HIT-related accident.)
However, another expert is available:
Reed D. Gelzer, MD, MPH is an EHR/HIT systems and policy analyst for private and Federal agency clients, primarily in program integrity and clinical quality support. In clinical practice for 11 years before transitioning into health IT, he also co-chairs the HL7 Records Management and Evidentiary Support (RMES) Workgroup. He served US Navy Medicine’s Data Quality Office, various private insurers, as well as three years on CCHIT workgroups. He was the Prevention Workgroup Chair for the 2007 ONC study on mitigation of EHR mediated waste fraud and abuse.
I find his opinions posted at the Gazette comment board of interest. Some of the themes are very familiar. His comments are reproduced here with just a few comments of mine interjected:
These are good thoughts.
I repeat my warnings that until sanity and caution is restored to the health IT sector (or started, as it may never have existed) it is not likely that “we may soon wonder how health care could have been delivered any other way.”
– SS
Health Care Renewal