I am a wife, a mother of two awesome kids, a daughter, a sister and a nurse.

I am also a survivor.

At the age of 43 a routine screening mammogram picked up an abnormality in my left breast that turned out to be invasive lobular carcinoma. I had no family history or major risk factors, but there it was: breast cancer. I had breast-sparing surgery to remove the tumor and then six weeks of radiation therapy. I started oral treatment with tamoxifen to reduce the incidence of a recurrence. My life was saved. The system worked.

Thus, on Nov. 16, 2009, I was horrified, stunned, angry and scared for myself and all American women when I read that the U.S. Preventive Services Task Force (USPSTF) was recommending against routine screening mammography in women between the ages of 40 and 49. Their assessment in recommending this mind-blowing change is "moderate certainty that the net benefit is small."

What is the USPSTF, anyway? A few clicks on Google told me: The USPSTF is an independent group of "experts" appointed by the federal Department of Health and established by congressional mandate. It is charged with reviewing the scientific evidence related to the effectiveness, appropriateness and cost-effectiveness of clinical preventive services for the purpose of developing recommendations for the health care community.

And net benefit to whom? Certainly not women.

How will this translate to the lives of American women if this policy becomes the standard of care? That, it seems, is really the heart of the matter. My American sisters, it means that our right to choose the preventive health care that is right for us is on the line. The false-positive mammograms in our age group (ages 39-49) cost the insurance companies money. Those false positives often result in retesting, which costs more money.

The ugly and painful truth is that the USPSTF does not think the cost is worth it to save one woman. As one woman whose life was spared by a screening mammogram, I can tell you: American women are not statistics. Each and every woman is of immense worth and value, and we will not have our lives marginalized by a "decision analysis." If the USPSTF guidelines were to become the standard of care, I am frightened for the lives of all American women, thousands of whom would likely die due to lack of access to preventive mammography services.

Did the USPSTF consider the "net" cost to society of the deaths of the women aged 40-49 years who will not be alive to raise their children? To be wives to their spouses? To care for their aging parents? To contribute to the workforce, to PTAs, to carpools, to community service projects, to houses of worship? 

The answer is a glaring no, they did not. Make no mistake: The controversy over screening mammography is about women's rights -- our right to choose the preventive health care that is right for us. The decision to have a screening mammogram should be between a woman and her health care provider. It is essential that insurance companies and third-party payers fund annual mammography if a woman and her health care provider opt for this approach.

Health care reform legislation is currently being considered in the Senate. If the USPSTF recommendations are widely adopted, insurers could deny payment for screening mammograms. I am standing for myself, and for women everywhere in supporting screening mammography every year for women aged 40 and over.

Let your voice be heard.

Ms. Chapman, a pediatric nurse for 25 years, is a three-year breast cancer survivor. She lives in Medford, N.J. with her husband and two children.

With the passage of the American Recovery and Reinvestment Act (ARRA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act, the focus of debate has fallen squarely on the challenge of defining "meaningful use" of an electronic health record (EHR). Maybe it's time to turn our attention to actually achieving meaningful use. It's clear that the concept is intended to ensure that any transformation within the health care system is focused on improved health care professionals' ability to deliver better care, better patient experience leading to better outcomes, but the question still remains: What should health care providers be doing right now to ensure their operations fulfill the requirements of meaningful use to receive maximum reimbursement? If you wait until the proposed set of standard are delivered at the end of 2009 and wait till after the 60-day comment period...it will be too late.

Understanding "meaningful use"
Of course, the major incentive to become a meaningful user is that ARRA authorizes the Centers for Medicare & Medicaid Services (CMS) to provide reimbursements to physician and hospital organizations who meet the meaningful-use requirements of an EHR. So it becomes a matter of practical and financial importance that we have a clear understanding of how to achieve meaningful use, and what we should be putting in place toward that end.

The HIT Policy Committee of the Department of Health & Human Services identifies seven national priorities that were used to create the framework for meaningful use, including: patient engagement, reduction of racial disparities, improved safety, increased efficiency, coordination of care, improved population health, privacy and security. But ultimately, meaningful use is linked to achieving measurable outcomes in only three of these priorities: patient engagement, care coordination and population health within specific timeframes. The HIT Policy Committee "Meaningful Use" Workgroup drafted recommendations that call for health care providers to:

• implement data-sharing and capture by 2011;
• incorporate data into establishing Advanced Clinical Processes by 2013; and
• improve outcomes through information-sharing by 2015.

In August 2009, the HIT Policy Committee also submitted to the National Coordinator recommendations for defining meaningful use. This matrix outlines specific objectives and measures that must be recorded, accessed and reported in order to achieve meaningful use.

The HIT Policy Committee matrix goes on to provide further detail of such objectives and measures for 2011, 2013 and 2015 in direct response to the Meaningful Use Workgroup's recommendations. The matrix -- which can be used by health care organizations as a readiness guideline  -- also outlines differences between objectives and measures for hospitals as compared to those required of other eligible providers.

Various levels of readiness
Every organization has a unique culture and context, which needs to be taken into consideration in drawing up plans for achieving meaningful use. But there are a few important steps that all organizations should take in the early phases of preparing to become a meaningful user of EHRs. These steps include:

• assessing where the organization is now, where the organization needs to be and what the organization needs to do, in order to achieve meaningful use;
• identifying and addressing workflow, technology and culture barriers to clinician adoption;
• ensuring that opinion leaders within the organization adopt early;
• driving adoption of meaningful use throughout the organization (perhaps through formal exposure and training sessions, or providing internal user recognition and incentives);
• encouraging adopters to draw along others who have a tendency to adopt later, through peer-to-peer interactions and training opportunities;
• consulting the Meaningful Use matrix and assessing progress; and
• drawing on the expertise of qualified teams, experienced in realizing maximum value from critical, large-scale initiatives.

Today, there's a broad spectrum of readiness toward achieving meaningful use across health care organizations. Some providers already may have been working toward achieving the parameters of meaningful use of an EHR and are therefore well on their way. Others may have some basic capabilities in place, but are still waiting for definitions and measures to be completely finalized. Still other providers may be taking the stance that they'll do only what's necessary to prevent penalties.

ARRA and HITECH operate on the understanding that becoming a meaningful user benefits the individual health care provider or health care organization, and by extension, our nation's health care system. By this logic, regardless of readiness ranking, all health care organizations should be pursuing meaningful use actively and working to get every member of the organization ready.

Clinical adoption as a "meaningful use" achievement
The multifaceted nature of meaningful use suggests that achieving this status will require great attention to detail. In order to ensure optimum compliance with meaningful use, health care providers need to ensure that their teams are not only equipped and ready to engage clinical transformation, but that they have detailed action plans in place to achieve clinical adoption of these technologies. For this is what is truly at the core of the meaningful use debate.

As with other major organizational changes, the achievement of meaningful use requires active planning, preparation and the building of an organization-specific strategy for widespread adoption of EHR technology. With millions of dollars at stake, aggressive timelines and the collective attention of health care leaders across the country, it's time to move past the meaningful-use debate and prioritize our focus on its execution to gain clinical adoption.

Mr. Evans can be reached at evansc@greencastleconsulting.com.

The Protecting America's Workers Act of 2009, if passed by Congress, would dramatically alter the regulatory regime.

Guest commentary from Eric J. Conn and Robert C. Gombar, partners in the law firm of McDermott Will & Emery, LLP, based in Washington, D.C.

Just weeks before his death, the late Senator Ted Kennedy (D-MA), with the help of Senate Majority Leader Harry Reid (D-NV), introduced legislation to amend the Occupational Safety and Health Act of 1970 (OSH Act), which has not been significantly altered since its inception. The proposed legislation, S. 1580, is known as the Protecting America's Workers Act of 2009 (PAWA). A companion bill, H.R. 2067, has been introduced in the House of Representatives by Representative Lynn Woolsey (D-CA).

Similar legislation had been introduced in both the House and the Senate in recent sessions of Congress. PAWA is sponsored by 18 members of the Senate (it was 19 until the death of Senator Kennedy) and has been referred to the Senate Committee on Health, Education, Labor, and Pensions. Previous versions of PAWA, introduced in 2004, 2007 and 2008, gained increasing support, including co-sponsorship by then-Senators Barack Obama and Joe Biden. What makes this legislation different is that it actually may make it out of committee and, with the blessing of the current administration, be passed by Congress in some form.

PAWA would make a number of major changes to enforcement of the OSH Act. This commentary, however, focuses on the very significant changes to criminal and civil penalties under the OSH Act proposed in this legislation.

More "meaningful" OSHA penalties
Penalty amounts under the current OSH Act regime have been criticized as too small to effectively promote worker safety. Congressman George Miller (D-CA), chairman of the House Committee on Education and Labor, recently wrote on The Hill's Congress blog: "Penalties are the key enforcement mechanism under the OSH Act. They must be real. They must be meaningful. They must function to deter violations. They must get people's attention. And, these enforcement mechanisms must not be a mere cost of doing business." PAWA increases the size and application of penalties in several important ways. The penalty increases contained in this bill, in conjunction with OSHA's new "per-employee" penalty rule issued in December 2008 (the final rule subjects employers to "per-employee" penalties for violating a large number of existing standards and permits OSHA to propose a separate penalty with respect to each employee not trained or not equipped with personal protective equipment), would dramatically increase the penalty amounts that may be assessed against employers. Under the OSH Act, OSHA has the authority only to propose penalties. Penalties are assessed by the Occupational Safety and Health Review Commission, an independent agency that is not part of OSHA. See 29 U.S.C. § 666(j).

Criminal penalties
PAWA would greatly expand the availability of criminal penalties against employers. The bill proposes to change the criminal charge for willful violations that result in an employee death from a misdemeanor to a felony. This change would make the prosecution of such charges much more attractive to local U.S. attorneys and give them an incentive, at OSHA's urging, to bring more criminal charges. Furthermore, for the purposes of felony OSHA prosecutions only, the legislation expands the definition of "employer" to include "any responsible corporate officer."

The maximum prison sentence for a willful violation that results in the death of an employee would increase under the bill from six months to 10 years for the first offense, and from one year to 20 years for repeat convictions. The maximum prison term for knowingly making a false statement, representation or certification to OSHA also would be increased by the legislation from six months to two years.

PAWA would also expand potential criminal liability for willful violations to include circumstances that do not involve the death of an employee. Under PAWA, employers or responsible corporate officers who commit a willful violation that results in the serious bodily injury of an employee would be subject to a felony criminal prosecution, with imprisonment up to five years for a first offense and up to 10 years for subsequent convictions.

Civil penalties
Civil penalties for willful and repeated violations would be increased under PAWA from a current maximum of $70,000 to a new maximum of $120,000 per violation. The bill would also increase the minimum penalty for a willful violation from $5,000 to $8,000 per violation. If a willful or repeated violation results in the death of an employee, PAWA would increase the penalties even higher, to a minimum of $50,000 and a maximum of $250,000 per violation. In conjunction with OSHA's new "per-employee" penalty rule, these increases could result in enormous proposed penalties.

Under the bill, the maximum civil penalty for serious and other-than-serious violations, and the maximum daily penalty for a failure to abate, would increase from $7,000 to $12,000 per violation. Should an employee death result from such a violation, the minimum penalty under the legislation would be $20,000 and the maximum would be $50,000 per violation.

Finally, regarding penalty amounts generally, PAWA would require OSHA to adjust these civil penalty minimums and maximums at least once every four years to account for increases or decreases in the Consumer Price Index.

Sweeping reform
The comprehensive reform envisioned under PAWA, which is far more sweeping than just the criminal and civil penalty changes discussed here, would dramatically change the regulatory regime faced by employers. These changes would require careful consideration of current practices and policies to ensure compliance, and will almost certainly increase litigation of OSHA enforcement actions.

Mr. Conn is a member of McDermott Will & Emery's OSHA, MSHA & Catastrophe Response Practice Group and Trial Department. He focuses his practice on occupational safety and health law and complex commercial litigation. He can be reached at (202) 756-8248 or econn@mwe.com.

Mr. Gombar is head of McDermott Will & Emery's OSHA, MSHA & Catastrophe Response Group. He is a former member of the firm's management, compensation and strategic planning committees. He can be reached at (202) 756-8242 or rgombar@mwe.com.

Evidence-based medicine will improve the quality of care and impact of each health care dollar spent.

Guest commentary from Marc Perlman, global vice president, Healthcare and Life Sciences Industry, Oracle

The U.S. health care industry is challenged like never before to improve outcomes while reducing costs. Our current rate of spending is unsustainable, and more important, the results we achieve do not always reflect the resources expended on care delivery.

As our national leaders debate the future of health care, it appears certain that evidence-based medicine (EBM) -- which integrates individual clinical expertise with the best available external clinical evidence from systematic research -- will play an expanded role in helping the health care community to improve quality of care as well as the value and impact of each health care dollar spent. Health information technology (HIT) will be essential to realizing this mission.

While many providers champion the use of electronic health information to improve outcomes and reduce costs, the health care industry has faced many hurdles in realizing this vision, including resistance to change, privacy considerations and funding issues. The American Recovery and Reinvestment Act, with its provisions for HIT funding, is revealing a path forward in terms of providing incentive and funding for investment.

The balance of the journey, however, is not without obstacles. For example, the wide variety of electronic health records (EHRs) in use and the presence of many disparate systems in the health care enterprise remain hurdles to the deployment of fully functional EHRs across the clinical enterprise -- crossing practice and provider boundaries. A lack of consistent standards across health records in a number of pertinent areas (e.g., content, terminology, clinical relevancy, interoperability, code sets and clinical practice) also impedes adoption.

How can the industry move beyond these challenges to pave a path forward for more informed and effective care? We offer four strategies to optimize the impact of HIT -- which is essential to successful EBM initiatives -- in the pursuit of more effective and cost-efficient health care.

Modernizing the health care infrastructure
One of most important first steps to widespread HIT adoption and optimization is the standardization of data-sets across care delivery organization (CDO) networks (encompassing hospitals, clinics, public health organizations and more), between CDOs and public and private payers -- and even to medical instrumentation, pharmaceutical manufacturers and regulatory bodies. This process creates the foundation for a grid for sharing information and automating process execution.

We are making progress on this front. Organizations, including the Office of the National Coordinator of Health Information Technology (ONCHIT) and Clinical Data Systems Interoperability (CDSI) are striving to make standards available and building standards-based reference architectures and reference implementations. In addition, standards such as HL7 for medical information in message packet format have been established along with schemas for transformation of legacy records from a vast array of systems and formats into a common XML-based schema and record. The end goal is to enable comprehensive records assembled from disparate information to be consumed and viewed by commercial solutions.

Ensuring security first and always
In order for HIT to be enthusiastically embraced across the health care industry, systems can and must ensure the security and privacy of patient information. Clinical data must be available only to those with the appropriate permissions based on role and need-to-know. The Health Insurance Portability and Accountability Act (HIPAA) provides strict regulations regarding access to medical information, and full compliance with HIPAA requirements is a key component of any health care information system.

Enabling intelligence
As EHR systems are integrated and new ones built to replace legacy environments, information will become more extensive and widely available. Data proliferation, however, can create the same types of challenges as too little information unless the health care community and providers can turn that data into actionable intelligence. Decision support and business intelligence systems are essential to transforming health and associated demographic and financial data into knowledge that drives more informed decisions and effective and efficient care.

The resources required to securely store and manage this vast amount of data is also an important consideration. With trillions of laboratory tests, diagnostic images and prescriptions filled, and millions of pages of patient visit logs written each year in the United States, health care data storage requirements are daunting. This represents just the start of the data necessary to build better decision-making. In addition, metadata on financial transactions; provider and payer details; and temporal, demographic, even spatial information must also be incorporated into an EHR to support EBM, making it a multi-modal dataset which, for a large hospital network or regional health information organization (RHIO), could generate EHR data warehouses in the high petabyte ranges. With the right analytics and health care intelligence tools attached to the EHR data warehouse, health care organizations can reveal new insight unavailable today.

Expanding collaboration
The fourth step required to optimize the use of HIT in health care to improve care and reduce costs is to create avenues for practitioners and patients to collaboratively leverage the grid and their past decisions and experience. This approach would augment the decision- making process by providing a far larger, near-real-time, intelligent evidence base to support a clinician's practice of medicine.

Consumers increasingly turn to the Internet for health care information. However, physician-only social networks, including Sermo, iMedExchange and Osmosis, are just launching. The biggest issue with these social networking sites is that they are not connected to the EHRs and to business intelligence tools that could be used to build hypotheses worth socializing. Furthermore, they do not have any guidelines, training or mandate for use, nor are they embedded in the diagnosis process in a way that a doctor would think to leverage the community as part of standard operating procedure. For EHRs and decision-making tools to be fully applied while at the same time safeguarding patient information, social networking tools must be modified and built on top of RHIOs and other networks that will serve as the basis of EBM platforms.

As our nation enters a new era for health care, HIT will play an essential role in our transformation -- with the potential to guide us toward improved care and cost efficiency. While challenges remain, they are by no means insurmountable as we have the tools required to capture data and crystallize our decisions in support of EBM initiatives and, the ultimate goal, improving health care outcomes and efficiency.

A research team at Harvard Medical School estimates that 2,266 U.S. military veterans under the age of 65 died last year because they lacked health insurance and thus had reduced access to care. That figure is more than 14 times the number of deaths (155) suffered by U.S. troops in Afghanistan in 2008, and more than twice as many as have died (911 as of Oct. 31) since the war began in 2001.

The researchers, who released their analysis Nov. 10, said the health reform legislation pending in the House and Senate will not significantly affect this grim picture.

The Harvard group analyzed data from the U.S. Census Bureau's March 2009 Current Population Survey, which surveyed Americans about their insurance coverage and veteran status, and found that 1,461,615 veterans between the ages of 18 and 64 were uninsured in 2008. Veterans were only classified as uninsured if they neither had health insurance nor received ongoing care at Veterans Health Administration (VA) hospitals or clinics.

Using their recently published findings in the American Journal of Public Health that show being uninsured raises an individual's odds of dying by 40 percent (causing 44,798 deaths in the United States annually among those aged 17 to 64), the researchers arrived at their estimate of 2,266 preventable deaths of non-elderly veterans in 2008.

"Like other uninsured Americans, most uninsured vets are working people -- too poor to afford private coverage but not poor enough to qualify for Medicaid or means-tested VA care," said Steffie Woolhandler, MD, MPH, a professor at Harvard Medical School who testified before Congress about uninsured veterans in 2007 and carried out the analysis released Nov. 10. "As a result, veterans go without the care they need every day in the U.S., and thousands die each year. It's a disgrace."

David Himmelstein, MD, the co-author of the analysis and associate professor of medicine at Harvard, commented, "On Veterans Day we should not only honor the nearly 500 soldiers who have died this year in Iraq and Afghanistan, but also the more than 2,200 veterans who were killed by our broken health insurance system. That's six preventable deaths a day."

Dr. Himmelstein continued: "These unnecessary deaths will continue under the legislation now before the House and Senate. Those bills would do virtually nothing for the uninsured until 2013, and leave at least 17 million uninsured over the long run. We need a solution that works for all veterans -- and for all Americans -- single-payer national health insurance."

While many Americans believe that all veterans can get care from the VA, even combat veterans may not be able to obtain VA care, Dr. Woolhandler said. As a rule, VA facilities provide care for any veteran who is disabled by a condition connected to his or her military service, and for specific medical conditions acquired during military service.

Dr. Woolhandler said veterans who pass a means test are eligible for care in VA facilities, but may have relatively low priority status, depending upon income level. Veterans with higher incomes are classified in the lowest priority group and are not eligible for VA enrollment.

The Medical Group Management Association (MGMA) is pleased that the House has voted favorably on H.R. 3962 (The Affordable Health Care for America Act) and we look forward to its rapid action on the companion bill, H.R. 3961, which will eliminate the 21.2 percent reduction in Medicare physician payments otherwise scheduled to occur on Jan. 1, 2010. We are pleased that H.R. 3962 addresses four of our six health care reform principles. Favorable action on H.R. 3961 would address a fifth critical principle, elimination of the Sustainable Growth Rate Formula for determining Medicare physician payment rates.

We also applaud the inclusion of comprehensive administrative simplification provisions in H.R. 3962. As a long-time leader and advocate of administrative simplification initiatives, we assert that these changes will significantly streamline the administration of health care. These modifications will, quite literally, transform the health care delivery process.

Our member research indicates that promulgation of rules for the health plan identifier and electronic claims attachment standards, utilization of standardized machine-readable patient identification cards and enhanced enforcement of health plan compliance, in concert with uniform companion guides and operating rules for all administrative transactions, will result in significant, long-term savings to the health care system. For years we have shared MGMA research and member experiences with policy-makers and demonstrated the magnitude of the financial impact caused by these needless administrative burdens. We are pleased to see wide-ranging administrative simplification reforms come to fruition with the passage of H.R. 3962. MGMA will continue working with the Senate to ensure that these and other administrative simplification provisions are included in final health care reform legislation.

I felt the health care reform news out of Washington last week was decidedly mixed. For those of us who have advocated reform for many, many years, the mere fact that legislation made it past the Senate Finance Committee and one step closer to becoming reality is quite historic. A lot of folks never thought we'd even get this close, so it is indeed something that gives one great pause.

The legislation itself is another matter.

The iteration of the bill that the committee passed needs a lot of work to make it affordable before it goes up for a final vote in Congress. By now, most people are aware of the report AHIP released concluding that the current legislation would raise insurance premiums for a family of four by about $1,500. Although its authors admitted having to make simplifying assumptions that made the analysis less than comprehensive, I found it very troubling that the White House was so quick to dismiss the findings simply as insurance industry propaganda timed to derail the Finance Committee's vote. In fact, the existence of a second report that somehow flew much further under the radar not only corroborates the results of the AHIP study, it almost makes the $1,500 premium increase seem acceptable in comparison.

Oliver Wyman, Inc., the renowned actuarial consulting firm, released a more inclusive study saying that the legislation in its current form could ultimately raise rates upwards of 48 percent for approximately 94 percent of the population. Among other things, the Wyman report called for the bill to include market stabilizers to help offset such drastic cost increases. For example, it said, if the proposal calls for the elimination of pre-existing conditions, it should then also make health insurance mandatory for all. As it stands, the bill calls for the elimination of pre-existing condition rules immediately while taking a few years to implement penalties for not having coverage. And even then, the penalties are minimal. This will enable a large number of young and otherwise healthy people to wait until they're sick to buy insurance, driving up the cost of premiums for the remaining population. No proponent of the currently proposed legislation has been able to undermine the analysis, so they've chosen to simply lump it in with the AHIP report as "lies."

This is just one challenge with the legislation. There are other instances in which the bill doesn't properly address affordability, and that's why it needs to be amended significantly before making its way to Congress. It is very important that the folks on Capitol Hill recognize that affordability goes far beyond what people pay for health insurance. It extends into what we as a society can afford to pay and, if the legislation passes as-is, the price may be very steep.

Editor's note: We encourage your comments in response to this blog post; please use the electronic form provided below. You may also contact Mr. St. Clair directly at dstclair@MEDecision.com.

For example, in a report prepared for America's Health Insurance Plans (AHIP), PricewaterhouseCoopers (PwC) examined the impact of the Senate Finance Committee's health reform bill. AHIP cited the PwC analysis in voicing concerns about the bill's cost.

According to the PwC report, the cost of the average family health care policy is approximately $12,300 today and will rise to:

• $15,500 in 2013 under current law and to $17,200 if [the bill's] provisions are implemented.
• $18,400 in 2016 under current law and to $21,300 if [the bill's] provisions are implemented.
• $21,900 in 2019 under current law and to $25,900 if [the bill's] provisions are implemented.

Between 2010 and 2019 the cumulative increases in the cost of a typical family policy under this reform proposal will be approximately $20,700 more than it would be under the current system, the PwC report stated.

The Center for American Progress (CAP) responded with a statement claiming that the AHIP/PwC study is flawed and the results are not credible.

The statement -- signed by Henry J. Aaron, Brookings Institution; David Cutler, Harvard University; Judy Feder, Georgetown University (and senior fellow at CAP); Elliott S. Fisher, Dartmouth Medical School; Arnold Milstein, Institute for Health Policy Studies, University of California-San Francisco School of Medicine; Len Nichols, New America Foundation; and Meredith Rosenthal, Harvard University -- read as follows:

The AHIP study is misleading in several ways. First, it ignores critical elements of the insurance market reforms in the Senate Finance Committee bill that would protect people from many of the problems AHIP purports to analyze; it would grandfather existing coverage, provide reinsurance and risk-adjustment, and introduce special policies for young adults.

More importantly, the AHIP study ignores the many provisions in the Senate Finance Committee's reform plan that would help to streamline medical care delivery and reduce its cost, including changes in payment methods, provisions to encourage use of information technology and comparative effectiveness, and the establishment of insurance exchanges to lower the administrative costs associated with health insurance. In fact, one of the policies that AHIP criticizes, the imposition of taxes on "Cadillac health plans" would, in the view of most economists, be a powerful force to reduce the cost of health care.

Finally, it is important to note that most of the spending in the draft legislation will go for subsidies that directly lower the cost of health insurance for families and individuals with low or modest income. The report simply ignores this massive source of savings for millions of American households.

Important issues are at stake in health reform. There is ample room for legitimate debate. But responsible participants in that debate should avoid selective use of evidence and try to preserve analytic balance.

From another perspective, Joseph Antos, Health Care and Retirement Policy Scholar at The American Enterprise Institute for Public Policy Research (AEI), pointed out budget assumptions built into the Finance Committee's bill. Before joining AEI, Antos was Assistant Director for Health and Human Resources at the Congressional Budget Office (CBO).

According to Antos:

The CBO has calculated that the Finance Committee bill will reduce the federal deficit by $81 billion over the first 10 years, and even more after that. However, the favorable budget score is based on the assumption that Congress will follow through on massive cuts to Medicare providers. Even the CBO questions the reality of those proposed cuts. In particular, the [Finance Committee] bill includes automatic cuts in Medicare payments to hospitals and other health care providers worth $240 billion. Congress is sure to override the cuts in later years.

Similar cuts to physicians have been "deferred" in each of the past five years, and the [Finance Committee] bill once again provides a one-year fix. Raising payments to physicians one year at a time means $217 billion in additional spending through 2019 that is not counted in the bill.

It is likely that the [Finance Committee] bill will add as much as $376 billion to the federal deficit through 2019. A $240 billion increase will result from the proposed -- but most likely never implemented by Congress -- cuts to hospitals, home health agencies, and other Medicare providers. Also not acknowledged in the bill are the $217 billion from higher physician payments if Congress continues to provide relief one year at a time from the formula-driven pay cuts. (That is $217 billion + $240 billion = $457 billion less $81 billion in savings = $376 billion extra cost.)

Amid such divergent views being circulated in Washington, Senate Majority Leader Harry Reid will lead the effort to combine the Finance bill with the Senate Health panel measure. According to an Associated Press report, Reid wants to get health care overhaul legislation onto the Senate floor by the end of October.

Whose numbers would you trust if you were in your senator's shoes?

The Obama administration's "new OSHA" has a simple message for U.S. industry. This message has been delivered loudly and clearly by both Secretary of Labor Hilda Solis and Acting Assistant Secretary for Occupational Safety and Health Jordan Barab. Their message: "There is a new sheriff in town." And we all know what sheriffs do. They aggressively enforce the law. That is exactly what the new Occupational Safety and Health Administration (OSHA) intends to do.

President Barack Obama was elected with the strong backing of organized labor. In return, the new president of the AFL-CIO, Richard Trumka, and other union officials have emphatically promised that organized labor will hold the Obama administration's feet to the fire to make sure that the pro-labor commitments made during his campaign are delivered. One of those commitments is a quick reversal of what the Obama campaign and its union supporters claimed was eight years of the Bush administration OSHA "selling out to big business" to the detriment of worker safety and health, allegedly accomplished through an agenda of lax enforcement, cozy partnerships and cessation of any meaningful standards-setting activities. Through its OSHA appointments, the Obama administration has established that it will, in fact, be delivering on its commitments to labor.

The new OSHA's leadership team

The tone of an agency is set at the top. The leadership team appointed to head the new OSHA leaves no doubt about what the tone of the new OSHA will be.

Labor Secretary Solis is a former member of Congress from California. Before being elected to Congress, Solis served in the California Assembly, became the first Latina elected to the California Senate and worked in the Carter administration's Office of Hispanic Affairs. Her official biography explains that her priorities in Congress included "expanding access to health care, protecting the environment and improving the lives of working families," and that she was the recipient of a John F. Kennedy Profile in Courage Award for her "pioneering work on environmental justice issues."

In a June 2009 speech at the American Society of Safety Engineers' annual conference, Solis said: "There is a new sheriff in town...Make no mistake about it, the Department of Labor is back in the enforcement business. We are serious, very serious." To demonstrate this, one of her first steps was to order an enforcement blitz by OSHA SWAT teams at construction sites across Texas to combat what she said was the state's "dubious distinction of having the most worker fatalities in the nation." Solis also announced that the Department of Labor's budget request includes funding for up to 130 new inspector positions.

The Deputy Assistant Secretary and current acting head of OSHA is Jordan Barab, who previously served as special assistant to the head of OSHA in the Clinton administration. In that position, he helped spearhead the promulgation of the controversial ergonomics workplace safety and health standard that was issued by OSHA but subsequently repealed by Congress. Prior to his appointment as Deputy Assistant Secretary of OSHA, Barab was senior labor policy advisor for health and safety for the House Education and Labor Committee, and before that he worked for the U.S. Chemical Safety and Hazard Investigation Board. Barab was a health and safety specialist for the AFL-CIO from 2001 to 2002, and directed the safety and health program for the American Federation of State, County and Municipal Employees (AFSCME) from 1982 to 1998. In a recent speech at an AFSCME convention, he remarked, "I always tell people that I still bleed AFSCME green." In another speech, he told attendees, "You are not alone. We have your back and your fight is our fight...There's a new sheriff in town."

On July 28, 2009, President Obama nominated David Michaels, PhD, MPH, to be the head of OSHA. This nomination is subject to Senate confirmation. Michaels, an epidemiologist, currently is a research professor at the Department of Environmental and Occupational Health at the George Washington University School of Public Health and Health Services. Michaels is the author of the book Doubt is Their Product: How Industry's Assault on Science Threatens Your Health. In the Clinton administration, Michaels served as Assistant Secretary of Energy for Environment, Safety and Health. In that position, he was the chief architect of an initiative to compensate nuclear weapons workers for occupational illnesses resulting from exposure to radiation, beryllium and other hazards. Key goals of Michaels would be to jump-start OSHA's standards-setting process, with a particular focus on chemical exposure issues and ergonomics. In an editorial, the Washington Times characterized Michaels as a "virulently anti-business epidemiologist." Given the new OSHA's agenda and the OSHA-head nominee's past pointed criticisms of industry, the confirmation hearings will provide early proof of the heated battles that will be fought on the OSHA front during the Obama administration.

Deborah Berkowitz has been named chief of staff at OSHA. Berkowitz is the former health and safety director at the United Food and Commercial Workers' union, and she was very active for the union during OSHA's first round of ergonomics cases in the meatpacking industry in the 1980s and during the Clinton administration's ergonomics rulemaking.

Top priorities for the new OSHA

The top priority of the new OSHA can be summarized in two words: strong enforcement. This will be accomplished in several ways:

• Implementing a "Severe Violators Inspection Program" that focuses on large employers whose histories of OSHA violations demonstrate, in OSHA's view, that they do not take their compliance obligations seriously and need to be targeted for very aggressive enforcement in order to get the message.

• Working more closely with the U.S. Department of Justice to increase the number of criminal prosecutions for workplace fatalities, injuries and illnesses.

• Supporting legislative OSHA reform efforts that include substantial increases in penalties, both criminal and civil.

• Increasing the number of inspectors; the number of inspections conducted; the number of citations issued, particularly for serious, repeat and willful violations; and the amount of penalties proposed for violations -- a more aggressive enforcement approach signaled by OSHA's June 22, 2009, proposal of $1,145, 200 in penalties against a company for combustible dust and other alleged safety violations.

• Focusing on specific enforcement issues through National Emphasis Programs (NEPs), including continuing the NEPs for process safety management compliance (PSM) at refineries and for combustible dust hazards, rolling out the NEP for PSM compliance at chemical facilities, and establishing an NEP for auditing compliance with OSHA's injury and illness recordkeeping requirements, which the new OSHA believes is a seriously flawed system as a result of what it believes is widespread "cheating."

• Decreasing what it believes was the Bush administration's over-reliance on partnerships, alliances and company participation in Voluntary Protection Programs.

What companies must do to prepare for the new OSHA

Given that the current direction of OSHA is so clear, companies have all the warning needed as well as an opportunity to ensure that their OSHA-compliance houses are in order before OSHA arrives at their doorsteps. Here is what must be done:

• Establish a Catastrophe Response and Management Plan. Workplace catastrophes present extremely large risks on a number of fronts. The way in which you manage those risks following workplace catastrophes in both the short and long terms are key to minimizing potentially substantial liabilities. You need a comprehensive, well-thought-out plan to manage the situation, including managing the multi-agency investigations that will follow, that can be triggered and effectively implemented on a moment's notice.

• Verify through compliance reviews that your OSHA-required safety and health programs are in place. Ensure that written programs, which may look good on paper and in binders, are in fact effectively implemented in your workplaces. Ensure that your OSHA-required injury and illness recordkeeping files are accurate and up-to-date. The new OSHA will be focused on looking behind the scenes and talking to employees to get the "real story" about their employers' safety and health efforts.

• Focus on your "key risks," meaning the specific risks at your workplace that are actually faced by your employees on a frequent basis and which present the most exposure to a risk of serious injuries or death. Focusing on your actual key risks in a consistent, demonstrable manner will go a long way toward minimizing your overall risk of a significant OSHA enforcement action.

• Ensure that your safety and health program demonstrates a "top-down" as well as a "bottom-up" commitment to worker safety and health. Without the demonstrated interest and commitment of your company executives as well as your front-line workers, the results of your safety and health efforts will not be maximized.

• Have a plan in place to manage OSHA inspections in a careful, thought-out manner to minimize the possibility that a significant enforcement action will result, as well as a plan that ensures that every OSHA citation that is issued is properly analyzed to determine not only its validity, but also its potential effect on your company's overall OSHA violation history and its other impacts to the company. Because of the potential negative impacts of OSHA citations, decisions as to whether to appeal or accept citations will be increasingly important.

Taking the time now to determine how your company measures up in these key areas will put you in a much better position to effectively anticipate, minimize and deal with the aggressive enforcement promised by the new OSHA.

Mr. Lastowka has practiced exclusively in the field of occupational safety and health for nearly 30 years. He is a recognized authority on OSHA and MSHA law whose practice includes providing compliance counseling, conducting safety and health audits and due diligence reviews, handling the full range of OSHA and MSHA litigation. He can be reached at (202) 756-8245 or jlastowka@mwe.com.

In a recent article on the San Francisco Chronicle's Web site, Dr. Deepak Chopra speculates that a lot of what's wrong with health care today can be attributed to the false notion that more is better. As a society, Dr. Chopra suggests, we've come to believe that by undergoing more tests, receiving additional procedures, taking more drugs and seeing more doctors more often, we'll be healthier. He offers myriad statistics to highlight the inefficiencies in our health care system and underscore the need for vast improvements.

Dr. Chopra's statistics also make clear the need for the increased use of technology as part of our reform efforts. With proper evidence-based clinical support and intelligence tools, physicians would be better able to determine medical necessity, which would help to lower the number of unnecessary procedures and the growing costs associated with them. With electronic medical records providing a more complete picture of a patient's medical background, it's likely we could forego certain tests, medications and specialist visits. With a greater breadth and depth of patient information readily at hand, clinicians could more quickly and assuredly make more informed decisions. That alone would support operational efficiencies and result in considerable savings. We can also extend technology to better educate patients and enable them to make more valuable contributions to the decision-making process. With greater knowledge, they themselves can help decide whether or not a certain test or procedure is in their best interest, or if the rewards of a certain medication are worth the potential risks, and so on.

These types of technologies are readily available and, given the potential return on investment, are relatively inexpensive to implement. While the debates in Washington and around the nation continue to focus on health insurance reform, it is important for all of us to understand that there are other, far less controversial and polarizing ways to generate health care reform. Technology is quite possibly the most promising and certainly a strategy through which we can begin making inroads while we argue the details of a more comprehensive plan.

The hot topic for this summer has been health care reform. It has consumed our Congress as well as most of our national publications and TV/radio talk shows. In spite of all this attention, we still do not have a solution. In my view, we have focused too much on one possible approach -- the national health care option -- and have not focused on the basic problem that we need to address. Please consider a perspective that perhaps has not been advanced as much as it should if we are ever to address the core issue.

From my perspective, the current discussion is far too preoccupied with the question of who pays. And, for many, it is apparent that national health insurance, in some form, must be implemented to ensure that all Americans have access to high-quality, affordable health care. While probably no one quarrels with the goal, it is questionable whether the proposed remedy addresses the real problem. Let me explain.

The awkward dinner party

Picture a group of friends who meet periodically at a posh restaurant for dinner. The food and the wine are excellent and good humor prevails until after the brandy when the waiter discreetly places the check in the middle of the table. It is immediately apparent that the prices have gone up two to three times faster than the incomes of the diners since they last dined together. Uncomfortable jockeying to avoid picking up the check begins.

One diner, an automaker from Detroit, complains that health benefits for his workers now cost over $1,000 per car and are significantly higher than his Japanese and European competitors, and the gap continues to widen. The time when he could pass these increases on through higher prices has ended. Prices are no longer set in Detroit. They are set in Tokyo and Frankfurt. He is now forced to close plants; Mr. Detroit wonders if it isn't time for the small business owner sitting next to him to pick up his fair share.

After quelling the outburst of coughing this suggestion provoked, the small business owner makes his case for avoiding the check. Always hanging on by his fingernails, he is beset by increased regulation, a higher minimum wage, tougher foreign competition and limited access to capital. He reminds one and all that he alone accounts for new jobs in America. He is sorry, but if you saddle him with the bill, you will have to kiss new jobs goodbye. He looks across the table at the woman from Washington.

Ms. Washington stares at the check, slowly shaking her head. Then she explains how the government is caught squarely in the middle of the deficit and the desire to avoid new taxes to maintain any semblance of economic recovery and growth. She's also concerned about international competitiveness as well as recognizing that Medicare and Medicaid programs are running out of money.

The resulting silence is broken only when someone suggests that maybe next time they should eat at a cheaper restaurant.

Nobody notices the people outside looking through the window who apparently have nothing to eat at all.

The debate

Unfortunately, the debate over health care reform is too often limited to the question of who picks up the check. With health care consuming nearly 20 percent of our gross domestic product and continuing to increase, we must start by admitting that nobody can pick up that check. Increasingly, our choices are constrained by the world economy. If we keep arguing about how to divvy up the check, it's likely we will all end up washing dishes.

What to do? The answer seems clear: We must eat at a cheaper restaurant. Figuring out how to do this, still be adequately nourished, and be able to invite hungry people standing outside to join us is the task at hand.

A perplexing case study

Some people have suggested that management deficiencies in hospitals contribute to excessive costs. I'd like to suggest a different perspective: Imagine a manufacturing plant -- a large job shop employing perhaps 2,000 people. On any given day, 300-400 jobs are active in the plant. Any given job takes five or six days to complete. As we study the plant more closely, we discover a curious thing. Every morning, about 100 or so manufacturing planners walk into the plant, write shop orders defining the work to be done that day on their particular jobs by the 2,000 plant workers -- cutting, drilling, milling, grinding, inspecting, assembling, painting and the like -- and then walk out.

We stop several of these shop planners in the parking lot as they are leaving, and discover a strange thing. Indeed, few of the planners are actually employed by the plant; most are paid directly or indirectly by the plant's customers. Although they have implicitly defined almost all of the plant's costs by the shop orders they have written, they bear no responsibility for them nor are they economically affected by them. Upon closer questioning, we discover that, moreover, most are ignorant of the costs incurred by the plant as a result of their shop orders. Asked to guess, their estimates are almost always grossly in error.

If we were to present this story as a case study to first-year students at Harvard Business School, not one would fail to point out the problem. Our plant has broken a cardinal rule of management: Never separate authority from accountability. The students would probably go on to add that they've never seen such an unrealistic case study. But they'd be wrong and you know why -- this is exactly the situation today with hospitals and doctors.

The solution seems clear. We must reassert the necessity to place authority and accountability in common hands. Whose hands? It must be the physicians; there is no other rational choice, because each decision made in a hospital has both clinical and economic implications. Hospitals and doctors are directly responsible for 31 percent of health care costs and indirectly affect much of the remaining costs (e.g. prescriptions for drugs and follow-on services).

The responsibility is ours

I firmly believe there are specific and immediate actions on which hospitals anddoctors can collaborate to drive the cost of healthcare down. These include:

• Making physicians more aware of the hospital costs of commonly ordered drugs and services; monitoring the resources they consume in relation to the quality of their outcomes.
• Creating standard disease management protocols for the chronic diseases (e.g., diabetes and asthma) that consume a very high percentage of health care expenses. These protocols should provide quality and effective care while reducing the wide variation in treatment expense (e.g., unnecessary laboratory tests and lower cost drugs).
• For patients in the last days of their lives, creating standard protocols that emphasize home care and minimize significantly more expensive (up to 10 times more!) hospital care that has no positive effect on quality of life.
• Understanding why many health care costs, such as laboratory costs, are growing at a significantly faster rate than inflation and taking corrective steps.
• Understanding the large variation in length-of-stay among hospitals for similar illnesses and procedures and taking corrective steps. For example, Time magazine recently reported a $40,410 difference in the cost of care for the last two weeks of a Medicare patient's life between Mayo Clinic ($53,422) and UCLA ($93,842).
• Eliminating unnecessary cesarean births.
• Eliminating unnecessary coronary bypass surgeries for patients who gain no increase in lifespan beyond what they would have achieved through medical management of their condition.
• Eliminating unnecessary pacemaker implants.
• Eliminating unnecessary upper gastrointestinal procedures that do not result in any change in treatment.
• Curtailing the ‘arms race' in construction and new services, especially for services where volume is decreasing such as CABGs.

I could go on, but it seems to me that doctors and hospitals have it within their combined scope of authority and responsibility to address the rising costs and to do so quickly. Clearly, they must work together -- either voluntarily or by government mandate. As CIO, you have the wherewithal to provide the tools to facilitate this partnership (e.g., online protocols and evidence-based medicine reports).

As a tangential comment, I do not believe that all of the recent government-provided funding for health care IT will achieve its anticipated result until it is directed toward this critical initiative.

The issue is not who pays for health care, but rather how do we drive down the costs of the (currently very inefficient and expensive) health care delivery system while improving our quality (and not quantity) of care. If we set our minds to it, I believe we can do it and without government intervention and control.

After taking Flomax, used to treat the symptoms of an enlarged prostate, instead of Volmax, used to relieve bronchospasm, a 50-year-old woman was hospitalized.

After he was given clozapine instead of olanzapine, two drugs used to treat schizophrenia, 19-year-old man showed signs of potentially fatal complications.

After receiving methadone instead of methylphenidate, a drug used to treat attention deficit disorders, an 8-year-old died, according to MedicineNet.com.

Getting patient and drug names right is crucial to the success of health care IT.

More than 4.8 million wrong drug errors occur per year in the United States, according to the Journal of the American Pharmacists Association. And as more drugs get approved, this problem can only get worse, making us even more vulnerable.

Physicians, pharmacists, nurses and patients are more likely to confuse drug names that look or sound alike (e.g., ephedrine and epinephrine, Taxol and Paxil, vinblastine and vincristine, Actos and Actonel).

We see errors happen at every stage of the medication process: prescribing, transcribing, dispensing, administration and monitoring. They can occur with handwritten and typewritten prescriptions and they can occur when prescriptions are communicated by phone, fax and computer.

The risks posed by similar drug names are well known, but until recently it has been difficult to do much about it. Historically, the problem has been approached by compiling lists of confusing names, publishing those lists, and warning practitioners (and, to a lesser extent, patients) to be extra vigilant when dealing with confusing names.

Computer systems for ordering and dispensing drugs sometimes come with built-in warnings. Sometimes pharmacists post warning signs on the shelf next to particularly confusing names, or they store such drugs in separate areas of the pharmacy.

Having objective, numerical similarity scores provided by analytics makes it possible to predict and prevent drug-name confusions in new ways such as using similarity measures as the basis for a drug-name search engine.

For example, the manufacturer of a new drug can submit the new drug name into the search engine and retrieve a list of existing drug names, with the new names on top of the resulting list and the least similar names at the bottom.

Now, new drug names can be carefully screened prior to approval, and highly similar, potentially confusing names can be kept off the market. Name similarity software also can be used to look at existing drug names -- for example, all drugs used by a given hospital -- and the most similar pairs can be identified and targeted for error prevention.

And drug name confusion is just one of the problems that threaten patient safety.

A 67-year-old woman received invasive cardiac electrophysiology. The problem was, she didn't need it.  Seventeen discrete errors resulted in a woman receiving a cardiac electrophysiology procedure intended for another patient with a similar last name, according to the Annals of Internal Medicine.

The use of fully digitized medical records has introduced greater consistency in health information systems. But the possibility for rapid propagation of errors can start during data entry of a patient's name. Effective and accurate merging of patient medical records hinges on whether we capture patient information accurately.

As new stimulus investments drive the effort to digitize medical records, we are seeing the need for better analytics to ensure consistent, accurate capture of patient name data at point of intake by flagging potential inconsistencies and miscategorized name-parts (e.g., last name in first name position) while the patient is still present to clarify or correct.

And while collecting patient name data accurately is critical for treatment, accurate data also allows analytic insights into patient demographics. We can glean a higher level of intelligence so hospitals can provide doctors and nurses up-to-date information on specific illnesses and diseases; tracking diagnostic and treatment successes enables more effective treatment of patients.

Improved name-processing techniques for health care also can provide important analytical insights into ethnicity, national origin, native language, and even unanticipated relationships or connections in the entire patient demographic, such as locating an organ donor or rare blood type.

For example, if a hospital sees from patient records that 30 percent of its demographic is Korean, then it can ensure it has staff who can speak the language, a critical factor when working in an emergency room where seconds can mean the difference between life and death.

For larger health care providers, effective strategic use of name analytics can yield valuable insights to detect demographic trends in the surrounding community and to predict where there will be a need for improved customer-care and communications. Outreach, education and prevention programs can be kept fresh and effective by staying in touch with the changing blend of cultures and languages that are being served.

Many medical errors associated with name confusion can be prevented. For instance, alerts can be sent to caregivers when a name has been incorrectly captured into the master patient index (MPI) system, or when there is significant potential for errors due to names shared by two or more patients currently under care within that system.

We need to do a better job of providing the right training to caregivers, and medical intake and record-keeping personnel, with special attention paid to capturing data of patients from unfamiliar cultural/ethnic backgrounds whose names may fit poorly or not at all into the typical First-Middle-Last pattern used in many Western countries.

In addition, extra quality-control must be placed on patient names as they are converted from spoken/recorded to handwritten forms, then converted from handwritten to electronic form. These multiple steps are fertile ground for potentially harmful transcription errors. 

At the same time, key health care information technology (HIT) assets such as master patient index (MPI) systems need to provide state-of-the-art support for searching and analysis of names across all segments in patient demographics.

Sustainable progress in U.S. health policies and medical practices should include a renewed emphasis on getting names right. Driving out unnecessary medical risks and treatment costs associated with drug-name and patient-name errors can have a pervasively life-saving impact; using patient-name analytics can be a key preventive step for both patients and health care organizations. 

There's no denying the importance of health care reform within President Barack Obama's agenda. In a July 28 interview with Time magazine's Karen Tumulty, the president said that in the last two to three weeks, he's been spending at least a third of his time focused on health care.

He explained the detailed level of his policy push:

"Certainly we spend a lot of time with our health-care team talking both policy and politics. I'm reaching out to members of Congress, meeting with them or talking to them on the phone to get their perspectives. Speaking to the public is absolutely critical, and so today, for example, I was over at AARP trying to answer questions of the public. So whenever we're in the middle of a big legislative effort like this, it's going to attract a lot of my attention, as well as my team's attention."

The full transcript of the interview will appear on Time.com on July 30.

In the halls of Congress, in the media, in the coffee shops and restaurants of Washington, D.C. -- health care reform is dominating the conversation, and for good reason. We have an enormous opportunity, and a small window of time, to make the transformational changes to our health system that we urgently need. 

As the health care reform debate unfolds, the National Partnership for Women & Families is working tirelessly to remind Congress of the challenges women face in obtaining high-quality, affordable health care for ourselves and our families. It's our job to remind lawmakers what's at stake for women in health care reform. To that end, we've outlined those challenges along with our recommended policy solutions in a new Issue Brief titled Health Care Reform: What Women Need. 

Unfortunately, when you look at the reality of women's lives, it's clear that our system is in many -- and perhaps most -- ways, failing us. More than many other populations, we experience high costs, inadequate coverage and poor quality care at the same time that we're required to regularly intersect with a broken system. Consider that women are often the primary health care decision-makers for their families -- choosing the providers for family members; making and sharing in treatment decisions; and coordinating and providing much of the care ourselves. Many young women lack access to the primary, preventive, and reproductive health care they need. Women in their middle years who are caring for aging parents are simultaneously developing their own chronic conditions, compounding the already overwhelming job of being a caregiver themselves. 

In our Issue Brief, we provide in-depth analysis of the state of health care for women along with solutions we believe will bring meaningful change to women's lives. These solutions include:

• Affordability. Making care and health coverage more affordable in a number of ways including capping out-of-pocket costs and premiums so that no family pays more than 10 percent of their income on health coverage and allowing more families access to basic and primary health services through Medicaid. 
• Quality. Reforming our delivery and payment systems so that high-quality patient- and family-centered care is rewarded and value of care is compensated over volume of services.
• Choice of plan. Creating a health insurance exchange that allows individuals and families to compare plans, just as they would with any major family purchase, so they know they are choosing the best insurance plan for their needs. 
• Market protections. Applying federal rating rules across the board and preventing insurance companies from denying coverage to someone based on their age, gender, or a pre-existing condition.
• Adequate coverage. Guaranteeing that insurance coverage be comprehensive and at a minimum cover preventive and primary care, emergency services, hospitalization, outpatient services, maternity and newborn care, medical and surgical care, prescription drugs, mental health and substance abuse services, and comprehensive reproductive care, without lifetime or annual limits on any benefits.
• Reliability. Eliminating barriers to enrollment in public programs and offering a public health insurance option so consumers have a high-quality, affordable choice for health coverage.   

Real reform must address the realities of women's lives and the hardships we face in getting quality, affordable care. The health of our families, and our strength and vitality as a nation, depends on health care reform succeeding. 

For more in-depth analysis on each of these areas of reform, please see Health Care Reform: What Women Need.

Medical billing is about to get a lot more complicated. If your medical practice hasn't kept pace with new billing requirements, or if you're bogged down by receivables, it may be time to take action.

As part of its health care reform plan, the Obama administration is calling for a standards- based electronic health information system and the widespread adoption of electronic medical records. The administration says that the expanded use of electronic medical records could save over $77 billion each year in improved efficiencies.

The call for a more robust health information system aligns with the government's plan to overhaul the aging coding system used by medical practitioners to bill insurers. The new coding system, ICD-10, expands on an older version developed in 1977 by the World Health Organization. ICD-10 increases the number of codes by almost ten-fold, from 17,000 to 155,000. The new system includes 68,000 diagnostic codes, up from 13,000, and 87,000 codes for medical procedures, up from 3,000. Practitioners are expected to switch over to the new system by 2013. (Source: Zhang, Jane, "Why We Need 1,170 Codes for Angioplasty" Wall Street Journal, Nov, 11, 2008)

Hospitals and medical practitioners have hailed the new coding system because it will allow them to more accurately describe -- and bill for -- diagnoses and complex medical procedures. But the new system is also expected to create havoc in their billing offices. According to the Centers for Medicare and Medicaid Services (CMS), it's expected that the new system will increase the number of claims returned because of coding errors by 10 percent. And, at least in the short term, health care providers can anticipate greater delays in getting paid.

Then there's the change from Unique Provider Identification Number (UPIN) to National Provider Identifier (NPI), the new numbering system used by CMS to identify providers of Medicare services. All individual HIPAA-covered health care providers (physicians, physician assistants, nurse practitioners, dentists, chiropractors, physical therapists, etc.) or organizations (hospitals, home health care agencies, nursing homes, residential treatment centers, group practices, laboratories, pharmacies, medical equipment companies, etc.) must obtain an NPI for use in all HIPAA standard transactions. Commercial insurance carriers will use NPIs, too. Some practitioners will be required to have two NPI numbers, (one for the individual practitioner and one for the group practice) and many private insurers will still require their own identification number. (Source: www.cms.hhs.gov)

Sound complicated? It is. Medical billing is considered one of the most complicated of all business revenue cycles, with an average of 14 steps compared to the six or eight that are common in other types of businesses. Pre registration, health insurer verification, documentation of services provided, assignment of codes, code verification and review, pre authorization, claim generation, claim review, claims processing, adjudication and payment, collection/claim follow-up and, when necessary, claims appeal are all part of the process.

To manage the complexities of medical billing -- and the sheer volume of claims filed -- many practitioners have moved away from paper claims to an automated system. Of the more than 6 billion insurance claims filed each year, about 60 percent are now filed electronically. Automated claims have helped reduce error rates, but even with an automated system, there's a lot for practitioners and their billing staffs to keep track of.

Billing codes change regularly. Insurers can implement new regulations or change their reimbursement payment policies, often without warning. Staffing and computer problems occur. Small mistakes, such as keying errors, can go unnoticed. The sheer volume of claims makes it hard to catch up, and huge workloads make it difficult to evaluate office procedures. It's hard enough keeping track of medical advances; the huge demands of health care reform and regular changes in claims adjudication can severely tax the resources of many health care providers. To stay in business, it's imperative that health care practitioners adopt more efficient business practices. Outstanding receivables and bad-debt write-offs should not be tolerated in today's modern medical office. Yet even with electronic billing, mistakes still occur that can cost the practitioner or group time, money or both. (Source: Reinke, Thomas W.; Hilbert, Timothy C, "Improving Physician Billing Departments" www.physiciannews.com)

It's understandable, then, that many doctors and other health care providers have outsourced their billing departments.

Outsourcing can help streamline the billing and collections process as most reputable billing companies have experience working with multiple carriers and providers. (In addition to Medicare and Medicaid, there are over 3,000 private insurers, each with its own policies and procedures.) Because billing companies handle more claims than most medical offices, they must stay current on federal and state CMS updates, as well as changes in payment policies for major payers. This expertise can increase revenue by reducing the number of delinquent and denied claims.

Outsourcing can also reduce overhead. Fewer personnel mean less cost in salaries, benefits and turnover. Outsourcing can also reduce the expense of hardware, software and training typically required by in-house billing departments. Billing companies can provide medical practices with a variety of standard and custom reports to make their operations run more smoothly. But above all, outsourcing makes it possible for medical practitioners to spend less time on office operations and more time on the health and well-being of their patients.

How to choose a billing company

 Billing companies range in size from small, independent practitioners to larger firms, and can offer a variety of services. Choose wisely. Not all firms have the expertise to meet the needs of a modern, busy medical practice, or the skills and resources to provide secure, uninterrupted service. Your billing service should have the experience to handle a broad set of requirements, and be able to address the needs of solo practitioners, and small and large group practices. The more experience the company has, the more responsive the company can be to the needs of your practice.

What specifically should you look for when retaining the services of a billing company? Here are some practical considerations:

• Electronic claims submission and payment programs with all major carriers;
• Timely implementation of federal and state updates and changes;
• Denial follow-up and resolution;
• Patient statement preparation and the ability to respond to patient inquiries;
• Access to and experience in using of state-of-the-art billing software;
• Assigned staff and back-up for full-cycle claims submission through collection;
• Electronic claim status inquiries and eligibility capabilities;
• Compliance with HIPAA portability and privacy standards;
• Expertise in managed care rules, regulations and restrictions;
• Longstanding and established contacts in the insurance industry;
• State-of-the-art billing software;
• Standard and custom management reports, prepared in a timely manner;
• Clinical expertise and diversity of practice in a number of specialties;
• Education and training on documentation and billing compliance;
• Periodic internal audit and self-reviews;
• The ability to offer education and training on documentation and billing compliance;
• Banking services and an experienced and recognized management team; and
• Excellent collection rates and competitive pricing.

Ms. Nager is a health care expert with over 35 years of experience in inpatient and outpatient management, strategic planning, marketing, operations, budgeting, fiscal responsibility, medical and behavioral care, regulatory requirements and business development.