Google Health--online personal health records

In my opinion, this will soon be the status quo. Regardless, it's an interesting idea.

Google makes health service publicly available
By RACHEL METZ, The Associated Press

Google's online filing cabinet for medical records opened to the public Monday, giving users instant electronic access to their health histories while reigniting privacy concerns.

Called Google (nasdaq: GOOG - news - people ) Health, the service lets users link information from a handful of pharmacies and care providers, including Quest Diagnostics (nyse: DGX - news - people ) labs. Google plans to add more.

Similar offerings include Microsoft Corp. (nasdaq: MSFT - news - people )'s HealthVault and Revolution Health, which is backed by AOL co-founder Steve Case.

Google Health differentiates itself from the pack through its user interface and things like the public availability of its application program interface, or API, said Marissa Mayer, the Google executive overseeing the service.

Mary Adams, 45, a Cleveland Clinic patient who participated in the Google Health pilot, said that she was initially concerned about the privacy of her medical information.

Still, she felt safe enough to enroll and has been using the service for about six months, linking it with an online health management tool from the Cleveland Clinic and adding information on prescriptions and doctors to her online profile.

"I hate pieces of paper lying around my house, so I love the fact that i can log on with my normal Google login info and see everything at a glance," she said, adding that with its public availability she'll try to get her sister to use it.

The service, still a non-final "beta" version, does not include ads. But Mayer said Google doesn't plan to start placing them to support the site. A search box on Google Health pages leads to standard Google search results pages, where there are advertisements.

Besides importing records from providers, users can enhance their password-protected profiles with details such as allergies and medications, they can search for doctors and they can locate Web-based health-related tools.

Mountain View-based Google Inc. views its expansion into health records management as logical because its search engine already processes millions of requests from people trying to find information about injuries, illnesses and recommended treatments.

Before this public launch, Google stored medical records for a few thousand patient volunteers at the nonprofit Cleveland Clinic.

The health venture provides fodder for privacy watchdogs who believe Google already has too much about the interests and habits of its users in its logs of search requests and its vaults of e-mail archives.

Pam Dixon, executive director of the World Privacy Forum, said services like Google Health are troublesome because they aren't covered by the Health Insurance Portability and Accountability Act, or HIPAA.

Dixon's group issued a cautionary report on the topic in February on such third-party services.

Passed in 1996, HIPAA set strict standards for the security of medical records. Among other things, the law requires anyone seeking a patient's records by subpoena to notify the patient and give the patient an opportunity to fight the request.

By transferring records to an external service, patients could unwittingly make it easier for the government, a legal adversary or a marketing concern to obtain private information, Dixon said.

"We are in uncharted territory here. A privacy policy, I don't think, is enough to protect what needs to be protected in a doctor-patient record," Dixon said.

Mayer said, however, that users medical records "are generally speaking as safe with Google as they would be with a HIPAA-regulated entity."

During a webcast Monday, she said users' health information is stored at Google's "highest level of security" on computers that are more secure than those used for the company's search functions.

Mayer said in an interview with The Associated Press that Google will not aggregate users' health information across services so activity on the health service will not show up in search results.

Health Policy Made Ridiculously Simple

AMSA has a great set of primers on health policy, under their "Health Policy Made Ridiculously Simple" section. Find it here: http://www.amsa.org/hp/hpsimple.cfm

Tax Financing in Health Care

Even in America, where we do not have a national health care system, over half of our health-care spending is financed through tax dollars. Some background on Medicare financing, and taxes in general, is below.

http://www.kff.org/medicare/7305.cfm

http://en.wikipedia.org/wiki/Progressive_tax
http://en.wikipedia.org/wiki/Regressive_tax
http://en.wikipedia.org/wiki/Hypothecation

Employment-based Health Insurance

In the last decade we have seen a rise in problems with America's traditional employment-based health insurance, including rising cost of business (Ford pays more for health care per car than for steel), trouble for small businesses, loss of job mobility, and a perverse incentive for employers to choose health plans not best suited to the needs of their employees. Some of the articles below touch on the debate over these issues, but they only represent a small proportion of the wealth of information available on this topic.

http://content.healthaffairs.org/cgi/reprint/hlthaff.w3.237v1.pdf

http://www.jstor.org/sici?sici=0033-5533(199402)109%3A1%3C27%3
AEHIAJM%3E2.0.CO%3B2-F&cookieSet=1

http://books.google.com/books?hl=en&lr=&id=tIXSFDEzDf8C&oi=fnd&pg=PA1&dq=
employment+based+health+insurance&ots=VWTyA-DuHt&sig=PG_5gBng71hWgulrhe-
Zhr6uoRk#PPP9,M1

Medical Savings Accounts

There really are no reputable papers supporting medical savings accounts, so if the opinions represented here appear biased it is because there is consensus in the policy community that MSAs are a bad idea. However, that doesn't stop many American politicians from using MSAs as a cornerstone for their policy reform packages, so it is important to understand their arguments and why they don't hold true in theory or in practice.

http://books.google.com/books?hl=en&lr=&id=EHGelqyhVKQC&oi=fnd&pg=PA133&dq=
medical+savings+account&ots=3_--PndlUi&sig=IyxF8rnZCpTXlQyHSB0ORQetAA8#PPA133,M1

http://www.cmaj.ca/cgi/reprint/167/2/143

RAND Health Insurance Study

The definitive study on the impact of cost-sharing on health behavior was done by the RAND group in the 1970s. There are links to the RAND website and a few discussions of the study below. I've tried to get a few different perspectives in the mix, remember to think about the
biases of each source as you read through them.

http://rand.org/pubs/reports/R3055/

http://www.kff.org/insurance/upload/7566.pdf

http://cdhc.ncpa.org/policy-issues/rand-retrospective-study-finds-cost-sharing-affects-medical-usage

April 8 HPAP

The topic for Health Policy and a Pint this month is fundraising. There are several ways to collect money to pay for health care, including:

1. Taxes
2. Insurance Premiums
a. Employer
b. Individual
3. Out of pocket
a. Co-payments
b. Co-insurance
4. Health Savings Accounts (combination out-of-pocket and tax incentives)

Below is a link to the online version of a book with everything you might ever want to know about health care financing. I'll put up separate posts with background info on these topics as I find it. We will also have brief presentations before our discussion. I hope to see everyone at the Kitty Cat Club tomorrow at 5!

http://mcgraw-hill.co.uk/openup/chapters/0335209246.pdf

Health Policy and a Pint Goes National!

Health Policy and a Pint is going to become a national AMSA franchise! We need your help to make it as good as it can be - let us know what works and what doesn't, and any suggestions you may have for the future of HPAP.

Health Policy and a Pint

This Tuesday, February 8th AMSA is hosting the first meeting of Health Policy and a Pint. Join us at the Kitty Kat Club in Dinkytown at 5 pm to discuss the health care plans of the '08 Presidential hopefuls. We will be focusing on the plans of the winners of the Iowa Caucus, Senator Obama (D) and Governor Huckabee (R).

For more information on all candidates, visit the AMSA website or the League of Women Voters website.

For Barack Obama, see http://www.barackobama.com/issues/healthcare/

For Mike Huckabee, see http://www.mikehuckabee.com/?FuseAction=Issues.View&Issue_id=8

Financing Health Care - The Basics

Very Basic Health Care Financing for the Interested Medical Student¹

The basics of financing any health care system boil down to three components, which are not all that different from how money works in your house and mine. They are:

1. Getting the money. This is analogous to your income. Just as you may receive income from many sources – a paycheck from work, $30 cash from babysitting your nephew, that quarter you found yesterday on the sidewalk – so can a health care system raise funds from several places. Examples include premiums, deductibles, co-payments, and taxes.
2. Pooling the money. This is analogous to your savings – putting your money in a bank, wrapping it in tin-foil and keeping it in the freezer, or burying it in a mayonnaise jar in the back yard like I do. In America the money is largely pooled by private health insurance funds. In England there is one big pool for the whole public health care system.
3. Spending the money. This is analogous to when you go out and splurge on those fancy new shoes. The merchant selling you the shoes is similar to the health care provider. You might buy shoes at a big department store, in which case the person who sells you the shoes (the doctor, in this metaphor) probably doesn’t have a lot of say in the way the company is run. A small boutique owner (administrator) who is also the salesman (doctor) may have more flexibility to stock the styles and prices of shoes that are appropriate for the population of customers living around the shoe store. The three most commonly used methods of transferring money from a central funding source to a provider are fee-for-service, capitation, and budgeting. Outcome-based payment – both to providers and individual practitioners – is being used with increasing frequency both here and abroad.

I’ll now say a few words about the benefits and drawbacks of the provider reimbursement schemes.

Fee-for-service, a very popular model in the United States, is good because when doctors work harder, they get more money. We like doctors to work hard. But not too hard. Personally, I would like my doctor to do as little work as necessary to get me well. I think most patients would agree. Doing less work – as long as the results are the same – takes less of the patient’s time and costs less money. However, the fee-for-service scheme establishes a disincentive for providers to find more efficient ways to perform the same medical care. This is what I call the, “Why do a physical exam when an MRI will do?” mentality. Medicare uses something called yardstick competition² in an attempt to insert efficiency back into a fee-for-service framework.

Capitation is a method of reimbursing providers where the money follows the patient, rather than the service. Every year a health care provider receives a lump sum for each patient enrolled with it’s service. If a service is really terrible and people leave, the provider loses money. If a service is really great, it can attract more patients and more money. This creates an incentive for providers to offer the kind of care their patients want – whatever that care may be. There is also an incentive to be efficient, since any savings created by lowering practice costs can be transferred to the doctors, or be invested back in the clinic.

This incentive to be efficient can be taken too far, however – it doesn’t take a Masters of Health Administration to figure out that sick patients cost more than healthy ones, and the clinic that enrolled the healthy and excluded the sick might find itself happily in the black at the end of the year. This processes is called cream-skimming. Cream skimming may be overt or subversive. Overt cream skimming – where providers refuse to enroll patients based on health status – can be neutralized by requiring that providers accept all patients. The problem of subversive cream skimming –where providers attempt to make themselves less attractive to sick patients through inconvenient location or hours or through providing fewer services – requires a slightly more finessed policy solution. In this case the capitation formula is usually adjusted to offset the financial burden of taking on a sick patient. It can even be over adjusted in order to create an incentive for providers to offer more services to suit the needs of the sick. For example, a health care system could pay double for a diabetic patient what they pay for a non-diabetic patient, giving providers an incentive to create special diabetic clinics and patient management programs to attract more diabetic patients and the financial windfall that accompanies them.

Global budgeting is being used less and less in health care systems across the world. The idea of a budget is that a provider is given a lump sum at the beginning of the year to treat all their patients. The budget may be determined based on many variables, but often historical operating costs are the major determining factor. This provides a disincentive for efficiency, as the hospital that spends less, gets less, and existing operating inefficiencies are not addressed. Giving hospitals less money than they spent the previous years may give an incentive to increase overall efficiency, but budgeting remains a crude mechanism of cost control when compared with other financing methods.

Outcome-based reimbursement schemes, otherwise known as "Pay for Performance", are a newer way to pay providers that focus on increasing quality of care. The idea is that doctors should get paid for results. The problem is that medical outcomes often reflect many factors, including not only the input of the provider and practitioner but also medical uncertainty and patient variables such as co-morbidity or compliance. More recent models reward the steps that have been proven to lead to good outcomes – such as counseling smoking cessation or performing a foot exam in a diabetic – rather than the outcomes themselves. For more information on how the UK pays for performance in general practice, please see the post on Creativity in Health Policy. A great article on pay for performance (P4P) in America is available through the American Association of Family Practitioners (AAFP) Journal Family Practice Management. Find it at http://www.aafp.org/fpm/20060700/69what.html

(FOOTNOTE 1) I would encourage any person in the healthcare field to become well versed in economic theory (I’m not yet there myself, but I continue to try). I find that evolutionary biology and ecology – more familiar subjects for medical types – are a great place to start. Animals behave with an economics very similar to ours, just with a different currency.

(FOOTNOTE 2). The basics of yardstick competition is to base fee-for-service payments on the average cost of providing a service among hospitals in an area. If four hospitals in and around Duluth provide MRIs for $1,000, $1,200, $2,200 and $2,300, the yardstick payment would be $1,675. If the hospitals can do MRIs for less, they save money. Say the next year the average cost among the four hospitals comes down to $1,100, due to investments in efficiency in the most expensive hospitals. The new yardstick payment is $1,100, creating a drive for hospitals to be more efficient still. This process continues until hospitals cannot provide the service any cheaper, and this is approximated as the true cost of the service. For more on yardstick competition and diagnosis-related groups (DRGs), I would recommend consulting The Economics of Health and Healthcare, eds. Folland, Goodman and Stano.

Welcome to the UofM AMSA Health Policy Blog

This blog was created as a place for University of Minnesota medical students, faculty, and other community members to discuss the social aspects of health and health care. Topics of interest may vary widely, from health policy to practice management to the place of art in medicine. We encourage you to submit a post on an issue you feel passionate about. Vent your frustrations, educate your peers, and share your insights into the intricacies of providing health care in an ever-shrinking, increasingly technological, profoundly complicated world. The only requirement is that statements of opinion- in posts or comments - be backed by verifiable evidence. We hope this forum provides an outlet for constructive, informative, and enthusiastic discussion of the sundry issues that impact our lives in health care.

Please e-mail postings to:
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