Sunday, August 30, 2009

We're All "Meaningful" Now: Expect a Busy Fall for Electronic Health Records

Get ready for lots of news flow on "meaningful use" this fall. The government has set an ambitious yearend deadline for establishing a formal definition, a critical step in its effort to spur electronic health record (EHR) adoption.

"Meaningful use" refers to the way in which the government will expect providers to use electronic health record systems — whether in an appropriate manner or not.

At stake for the provider community are billions of dollars in incentive payments. Starting in 2015, the government expects providers to have adopted and be actively utilizing an EHR in compliance with the meaningful use definition or it will subject them to financial penalties under Medicare.

To defray the cost of EHRs — often tens of thousands of dollars — the government has promised big subsidies ($44,000 per physician), though not without strings attached. It will pay the first incentives in 2011 based on prior performance. A provider not following meaningful use of a certified EHR could risk not receiving any government funding. The American Recovery and Reinvestment Act of 2009 provides a minimum of $19 billion in funds to kick start EHR adoption. Media sources now report a funding level nearly twice the size at $36 billion.

According to the government's website, "The focus on meaningful use is a recognition that better health care does not come solely from the adoption of technology itself, but through the exchange and use of health information to best inform clinical decisions at the point of care." Broadly, meaningful use will encompass different parameters, including patient communication, diagnosis, device usage, patient encounters, specific patient information, laboratory tests, medication usage, physical exam findings, and procedures.

Just recently, the Obama administration announced it would provide $1.2 billion in grants to create 70 HIT centers around the country. David Blumenthal, the president's HIT czar and head of the national EHR effort for the Department of Health and Human Services, meanwhile, has stated that he expects a formal definition of meaningful use by the end of the year. The process began in June.

To put the cost savings opportunity in perspective, about half of health care expenditures constitute waste, whether dollars spent on preventable conditions, redundant tests or back office processing. About half of this waste relates to poor patient behavior: obesity, smoking, non-adherence. A quarter represents clinical inefficiency: readmissions, poorly managed care, medical errors, treatment variance, unnecessary ER visits — the primary target for EHRs.

The remaining quarter reflects operations, or the back office. Of this, claims processing accounts for about half, and ineffective IT a third, staff turnover and paper-based prescriptions the rest. (Note: We have sourced these estimates from a 2008 report by the consultancy PriceWaterhouseCoopers. Click here to view.)


If we exclude from this waste calculation patient behavior, the practice of defensive medicine (more a payment issue than an IT issue) and claims processing (not directly a clinical issue), then we would assume that EHRs would impact about a third of all wasted dollars spent.

In a $2.4 trillion dollar industry, where $1.2 trillion is waste, EHRs could theoretically address about $400 billion of this. A substantial number, it would roughly equal the entire prescription drug market at half this level.

Let’s not forget, too, that each of these numbers is growing at 10% per year. In seven years, $400 billion becomes $800 billion, although — presumably — effectively deployed EHRs would slow this growth rate.

With such a substantial business opportunity at hand, it's no wonder many different organizations are now targeting health IT, and EHRs specifically — including not just traditional technology vendors such as Intel, IBM and Microsoft, but also managed care organizations, plan sponsors, and dozens of venture-backed firms.

Despite this, many problems exist, ranging from cost to lack of a common standard. Even though, for example, several different EHR systems may operate within a single provider setting, one system does not necessarily communicate with another. And for small practices, implementation costs can be prohibitive.

While nearly 40% of physicians report using a full or partial EHR system, only 4% indicate they use a certified, fully functional system, according to a survey by the Centers for Disease Control and Prevention.

Enter the government, and Dr. Blumenthal's mandate to make everything work together. But for EHRs to recoup even the expenditure the federal government is prepared to make, all the different stakeholders must first agree on a definition of meaningful use.

No one anticipates an easy process.

What happens, for instance, if the government defines meaningful use too narrowly — or too broadly? How does the government change the definition? And when?

Providers will also need to submit data that qualifies them for incentives. What does this process entail? How much of a time burden does it create? Also, to what extent will provider inertia drag down future returns?

And none of this includes issues pertaining to the certification process and privacy concerns. Who, for example, owns the data?

In its scoring, the Congressional Budget Office has not allowed significant savings for EHRs simply because the opportunity, while massive, remains highly speculative. Even if the government adheres to its aggressive timeline, EHR savings on a national scale would not occur until well after 2015.

Stay tuned for a busy fall.

Sunday, August 23, 2009

Nearing a Market Top

Nobody wants a good thing to end, especially an historic run in the equity markets. Precedence, though, suggests that we're nearing a conclusion.

From its March 9th low through August 21st, the S&P 500 has rallied 51.7%, the index's best 117-trading-day performance since before 1950. In fact, five of the ten best continuous 117-day periods between June 1950 and August 2009 occurred this month, as the table below illustrates.


January 1983 featured three of these periods, and the end of May/beginning of June 1975 the remaining two. (Both of these periods come closest in showcasing the same type of performance.)

The market has been so strong that of the 14,890 continuous 117-day periods over this six decade time frame, just three periods posted gains over 45%: those ending August 19th, 20th and 21st.

And on only 89 occasions did the market gain more than 30%. That's less than 1% of total. The market, moreover, only managed a 15%-or-more advance during less than 14% of this period.

82% of the time it ranged between -15% and +15%.


Clearly, the current race upwards marks a distinct reversal from the market's nosedive in the first days of March and in November last year. Too far, too fast? Statistically, at least, we've sprinted deep into outlier territory. If we go by our table above, then the more "normal" trend line for the S&P would be the 0% to 15% range.

Let's assume a flat market. It would take 39 trading days at the current 1026 level for the market to mean revert back into the sub 15% range. Under a correction, this could happen more quickly.

On the other hand, for the market to sustain its record-setting 45%+ pace until yearend (for example), it would have to average daily gains of between 0.4% and 0.5%. That would equal a closing level above 1500. Improbable, if not impossible.

While August 2009 showcases trading patterns similar to June 1975 and January 1983, it also features a much different backdrop. These two preceding months actually resemble each other much more closely than either one does August.

In both months, the economy was three months into recovery, after severe, protracted downturns. In both cases, cyclical unemployment peaked exactly one month prior: in May 1975 at 9.0%, and in December 1982 at 10.8%. 10-year Treasurys were yielding 7.86% and 10.46%, respectively, while inflation soared at 8.5% and 6%.

Politically, the Democrats held both the house and senate in 1975, but not the White House. The Republicans under Reagan controlled the White House in 1983 and the senate, but not the house. Unlike today, free trade and capitalism energized a small minority of the world's population.

Tax policy varied, however. Rates sharply declined throughout the 80s. Gasoline prices also varied. In 1975, they were rising, and, in 1983, falling.

Market direction tracked differently, too. The S&P 500 after June 1975 closed the year 5% lower, and would not sustain higher levels for another three years. After January 1983, the market finished the year 14% higher, but had also gained 15% over the subsequent six-month period, equal to the same period-to-end-of-year time frame as 1975. Also, the nearly two-decade long bull run had just begun.

August 2009 is unique in many aspects: the global landscape, the point of time in the economic cycle, the credit and banking systems, the regulatory and legislative outlooks, to name a few.

Whether we're facing a lengthy flat market or a sharp pullback, don't expect the historic resurgence to continue.

Sunday, August 16, 2009

Listen to the Market: "Health Reform Won't Distort the Insurance Business Model"

When it comes to health care reform, it seems the more likely that government will pass legislation, the more sanguine Wall Street gets that nothing will occur. Government-run health care? Won't happen. An evisceration of the private insurance business model? No way.

Consider this. From its March 9th low to August 14th, the S&P 500 surged 48%. Over the same period, four of the five largest commercial health plans (by lives and market capitalization) outperformed the major index.

In fact, during this stretch of 111 trading days – that's five and a half calendar months – Cigna never underperformed the market. Humana did so once, way back on March 11th. And WellPoint dipped below the market on seven occasions, the last time on April 3rd.

UnitedHealth Group stumbled 19 times, mostly during a bad stretch in late March and early April. Now, its shares stand ten percentage points higher than the market average. Even Aetna, which consistently underperformed, is 38% higher on an absolute basis.

See the chart below covering this trading period. The red line is the S&P 500.

Click to enlarge.


The comparison also extends to other components of the health value chain. The maligned health plans have outperformed each of the major stakeholders. The S&P 500 is higher (marginally) than the major pharmacy benefit mangers – Medco, CVS Caremark and Walgreen – and trouncing the drug manufacturers by more than 20 percentage points.

To be fair, it's FDA uncertainty, not congressional power-broking, that's weighing heavily on the drugmakers. And depending on its structure, a pathway enabling follow-on biological products could improve prospects dramatically. Both house and senate bills feature it, and traditional foes seem closer to finding some sort of resolution than ever before.

So, what's the health reform fuss all about anyway? Well, if you're an investor, it's making for good entertainment.

Indeed, the market's great discounting mechanism reveals prospects so strikingly different than the constant news media coverage that it can't be right, right?

Well, no one can ever be sure. But let's just say this. Not since 1994 have lawmakers threatened major overhaul to this extent. With the party seeking to upend private insurance holding majority control, passage would have seemed inevitable – if not a full-on government option, then something damaging, at least, to the current business model.

That, to several high-minded folks, seemed the intent.

Despite this, and except for company-specific issues, investors never marked down the industry's prospects, even during the worst of the mudslinging and the darkest days of apparent unity among the ruling party.

And let's not lose sight of the fact that this is turning into one fine example of market rationality, while total hysteria grips the Hill and many corners of Main Street.

Maybe Wall Street isn't so villainous after all.

Maybe lawmakers should take care in turning their reform plans to that potent discounting mechanism.

It could be the only thing that keeps us sane.