Tuesday, October 28, 2014

Public APIs: The Ultimate Silver Bomb

Congratulations! We have a new buzzword trending in health care IT - Public APIs.  You can say public APIs everywhere you used to say interoperability. You can also replace the very unprofessional “EHRs can’t talk to each other” with “EHRs lack public APIs”. People will nod in solemn agreement, and you will sound very informed and up to date on the latest developments, but just in case you encounter the quintessential child inquiring about the king’s rather scant wardrobe, here is a little background information.

(Very) Brief Introduction to Public APIs

API stands for application programming interface. Yes, interface, like the ones you have with your claims clearinghouse or your lab service provider or pharmacies. There are several ways to classify APIs, but for our discussion, we only need to consider two types of APIs: data APIs and services APIs. Data APIs are the simplest, and go something like this: software A sends a request for information to software B, and software B sends back the required information. Another way is for software A to send unsolicited, but previously agreed upon, information to software B, which will then send back a brief thank you note to software A.

For this exchange to work well, both software A and software B need to agree on a communication protocol and both should share a common understanding of the data. This common understanding of data is called a standard. Standards usually emerge from non-profit organizations dedicated to defining such standards, so for example, your claims interface uses something called ANSI X12 as its exchange standard, your lab interface uses the HL7 standard and your pharmacy interface uses something called NCPDP Script. Turns out you’ve been using APIs all along…

Service APIs are less common in health care, although if you look at the big picture, you could say that claims clearinghouses, labs and electronic prescribing are all really services. A simple example of a pure service API, where software A invokes a piece of code executed by software B, is a warfarin dosing calculator. Here software A sends a few agreed upon parameters (i.e. demographics, diagnosis, medications, INR, genomics, etc.) to software B. Software B performs a highly specialized calculation using those parameters and sends the result back to software A.

APIs are deemed to be public, or open, if the specifications are publicly available on the Internet for anyone to use. Health care APIs are not usually public, and formal business relationships need to be established before any one software developer can use another’s APIs. Google Maps APIs, for example, are said to be public, and so are MapQuest APIs. Note however, that although both serve basically the same purpose, they are not identical or interchangeable, and they are not validated or certified by a public agency. Both Google and MapQuest publish APIs to their mapping software, because it makes business sense for Google and MapQuest to do so.

Why Now?

JASON (as in Jason and the Argonauts) “is an independent scientific advisory group that provides consulting services to the U.S. government on matters of defense science and technology”. JASON was established in 1960 and it “has conducted studies under contract to the Department of Defense (frequently DARPA and the U.S. Navy), the Department of Energy, the U.S. Intelligence Community, and the FBI. Approximately half of the resulting JASON reports are unclassified.” The latest unclassified JASON report, A Robust Health Data Infrastructure, was commissioned by the Department of Health and Human Services (HHS) “to address the nationally significant challenge of developing comprehensive clinical datasets, collected in real world environments and accessible in real time, to support clinical research and to address public health concerns. These datasets could be used to guide clinical research, enhance medical decision-making, and respond quickly to public health challenges.”

The identity of JASON group members is secret, but rumor has it that these are some of the best and brightest scientists in the country and have over the years included several Nobel Prize winners. Although we don’t know who JASON is (or are, or however one refers to an anonymously unaccountable group of advisers), we should note that JASON was introduced to the subject by 18 expert briefers (8 from research and academia, 2 from Microsoft, 2 from IBM, 1 videogames developer, 1 from HIMSS, 1 from Deloitte, 1 from Kaiser, 1 from the White House and 1 from NQF). These representatives of medicine in America guided JASON to useful materials about information technology in health care, and actively participated in subsequent JASON discussions.

Similar to a report put forward by the President’s Council of Advisors on Science and Technology (PCAST) four years ago, JASON recommends that massive amounts of clinical data be collected at the point of care in a format suitable for extraction and combination with non-clinical data, to facilitate large scale “biomedical” research. To that end, HHS should actively engage in the creation of a national clinical data exchange architecture, based on nationally enforced standards and public APIs implementing those standards, and it should engage in these activities immediately and with the full force of a government agency. All the work done to date by HHS and its various initiatives resulted in inadequate proliferation of legacy health IT systems, which should be replaced now, and the aggressive migration path suggested by JASON begins with using those public APIs to extract and reformat clinical data from the vast repositories of legacy systems.

To date, HHS has spent over $25 billion of taxpayer money on partially reimbursing hospitals and physicians for the purchase of health IT systems. The much larger remaining costs of buying, implementing and using these systems is unknown. According to the CMS data, there are close to half a million clinicians and almost five thousand hospitals registered to participate in the Meaningful Use program, all using certified EHRs. Practically all these legacy EHRs have found ways to routinely exchange billing information, medications information, laboratory and imaging information, and more recently, referral information, immunizations information, generic messaging and a host of other document based notifications. This may be a great start for patient care delivered by people who can read, but it is totally and completely unacceptable for global biomedical research.

Faced with distinguished panels of scientists and technology experts stating that medical care is basically a gigantic experimental research project, and a government thoroughly convinced that peace, prosperity and good health are a direct function of the amount of information collected about each and single one of us, what should we do next? Should we immediately start ripping and replacing the brand new legacy systems in use by 80% to 90% of doctors and hospitals, because more powerful vendors would also like to make money in health care? Or should we take a subtler approach and slap a host of new regulations on legacy vendors forcing them to build and maintain a public API infrastructure to benefit all newcomers? After vigorously protesting the JASON findings, the government seems to have chosen the latter.

As Microsoft, IBM, Apple, Google, Facebook, Verizon, Salesforce (I kid you not), and everybody with a registered web address, join the health care feast, you should expect more colorful user interfaces, with interminable scrolling screens filled with extra-large fonts, big flat smoky colored buttons, eye-popping images and practically no functionality, as is fashionable in consumer websites. Most of this “software” will be geared towards your patients, the ultimate generators of marketable biomedical research data. Your current EHR vendor will be exhausting all its resources on creating, maintaining, testing, certifying and publishing mostly data APIs, but in the short term also services APIs, to pave the road for giant technology aggregators and tiny app builders.

If your certified EHR vendor is small to medium in size, expect it to fail and go bankrupt in the next few years. If your EHR vendor is large, expect it to be acquired and decimated by a global corporation. Barring a miracle, the passive-aggressive grumbling of physicians will finally subside, and the march to defragmentation of our “broken”, “stove-piped”, “siloed”, “walled-garden” system (a.k.a. competitive, free-market, let the best man win, type of system), will continue at a brisk pace.

For better or worse, we need to recognize that in this country health care is a business, a very large and profitable business. Perhaps it shouldn’t be, but it is. Health care is being told day in and day out that it should learn from other industries. Well then, how would the banking industry react to a requirement to create public APIs allowing wholesale extraction of fully identified transactional data of their customers and all the communications conducted around such transactions between the banks and their clients? What would be the response of airlines, car manufacturers, restaurants, or even Google and Apple, if the government demanded that they invest in infrastructure solely intended to help other companies put them out of business? Take a wild guess...

Monday, October 6, 2014

How Health Care Went Tabloid

Physicians, whether practicing medicine or not, should not be involved in clinical research. They should never be consulted on development of new drugs and medical devices. Doctors should not invent new treatments, and should never supervise clinical trials. They should not travel to or speak at conferences either, and they should banish all entrepreneurial notions out of their heads. If they insist on engaging in these activities, they should do it all for free, out of the goodness of their Hippocratic heart. A medical degree should immediately disqualify you from making money in the health care industry, which is a privilege reserved for technocrats, business executives and garden variety ex-political appointees.

Matt Bai, a veteran political journalist, wrote a new book titled “All The Truth Is Out: The Week Politics Went Tabloid”, where he is attempting to pinpoint the demise of serious political journalism to the Gary Hart scandal of 1987. If you recall, Mr. Hart, the all but certain Democratic candidate for President of the United States at that time, was railroaded out of politics by a romantic dalliance with, of all people, a very pretty pharmaceutical saleswoman. Matt Bai goes on to assert that since the Gary Hart affair “the entire ethos of political journalism has really changed. Because all the attention, all the kudos, is in taking someone down, is in finding hypocrisy”. Political journalism is arguably the heart of journalism, and as the heart goes, so goes the lesser journalistic body, health care reporting included.

This week, the CMS released a new "trove" of information about payments made by pharmaceutical companies and medical devices manufacturers to physicians and hospitals. The dataset includes millions of records ranging from payments of $0.00 (?) to millions of dollars. Some of the records specify the recipient while others do not, and most list the reason for payment. The data is preliminary at best and lots of cleanup activities are to be expected, since various recipients of funds have discovered errors large and small. A database like this one could eventually be useful for example for cross checking disclosures for published papers and education materials, or for people who are studying the financials of life science sectors of the economy. As expected though, the health care media saw things differently, because these data present ample opportunity to find hypocrisy and take someone down.

To put things in perspective, here is a brief summary of the data from an angle nobody saw fit to print. Below is a breakdown of amounts received by named physicians for the largest category of general payments, which includes food, travel, honoraria, consulting, royalties, licensing fees, and a host of other frivolous activities. In addition to this dataset, there are two smaller sets, one for research payments and one for ownership, or equity, in life science companies. And then there are three parallel datasets where the CMS decided to withhold the names of recipients due to uncertainties regarding data validity. We will disregard the list of payments made to unidentified entities, and concentrate on the largest dataset of payments to doctors. There are 358,686 named physicians in this dataset, and this is how total payments are distributed.


It looks like the median payment value is approximately $100, and 9 out of 10 docs who received anything, received less than $1,000 worth of goods, services and sometimes even cash. The big money went to a fraction of a percent at the top, mostly for royalties and licensing of things they designed or invented. I randomly picked a couple of these folks and looked them up on Google. The first one turned out to be a world famous vascular surgeon who invented multiple devices to fix aneurysms, pioneered various types of surgeries, and even got himself a Medal from the Society for Vascular Surgery. The second fellow is an orthopedic surgeon, also world famous who specializes in acute trauma and posttraumatic reconstruction of feet and ankles, and is the inventor of all sorts of plating and nailing systems for his specialty. He has more credentials than you can count and some very prestigious awards to go with that. At this point I stopped searching.

Now let’s look at how the New York Times reported this data release. The first article came one day before the data was published, giving us a heads up on the impending release, educating us on already existing resources, such as the subtly titled Dollars for Docs database, and plainly stating that “most physicians that are in private practice are touched in some way” by the industry. Yes, only private practice docs are “touched” by the scourge. The next article was just a kneejerk litany of complaints about the CMS database functionality, which by the way, I found to be surprisingly nice.

The third New York Times article was cleverly titled “Detailing Financial Links of Doctors and Drug Makers”, a title as innocent as the 1987 Miami Herald story “Miami woman is linked to Hart”. Linkage implies secretive impropriety about to be exposed. You don’t often see headlines saying “Fireman linked to saving baby from burning building”. The article itself is fraught with equally innocent language such as “doctors reaping over half a million dollars each”, “murky financial ties between physicians and the health care industry”, “lucrative arrangements are just some of the findings”, and in a surreal tale of the doomed, a righteous Cleveland Clinic physician is contesting his own listing because “he had spoken at the event but deliberately skipped the lunch”.

The most recent New York Times article is titled “Financial Ties Between Doctors and Health Care Firms Are Detailed”, just in case you missed the “detailing” pun the first time around. This article opens with a series of dramatic one sentence paragraphs. “For some doctors, treating patients isn’t the only way to make money”. You can pretty much hear the thriller music in your head. “A Michigan plastic surgeon was paid more than $300,000 to travel the world teaching doctors about new cosmetic products like a breast implant”. Impropriety is best served with female body parts. “The retired chief executive of the Mayo Clinic, who once helped write its conflict of interest policy, received more than $237,000 in compensation for serving on multiple corporate boards”. Wow, a retired doctor sits on corporate boards. Even the venerable Mayo Clinic has no ethics.

Following the boilerplate “murky financial ties between physicians and the health care industry”, we are informed that “the typical doctor earned only about $1,750 from August to December 2013”. Actually, the “typical” doctor barely eked out a hundred bucks worth of crappy conference food, unless he or she skipped lunch altogether, or maybe just refused the fake ├ęclairs at the end, but math is a very flexible thing.  And on and on goes the litany of naming names, like a bad Seinfeld take on the McCarthy era.

The rationale for this abject witch hunt is that physicians who ingest pharmaceutically sponsored food are likely to return the favor and prescribe expensive brand name drugs instead of cheap generics. According to an IMS report from April 2014, generic medicines are now representing 86% of prescriptions, and have been steadily increasing over recent years. I seriously doubt that the numbers can get much better, and either way during these days of high deductibles and narrow formularies, doctors are rarely at liberty to prescribe brand name drugs when generics are available. Not to mention that as physicians are increasingly losing their independence, pharmaceutical companies are turning their efforts to hospitals, which are much better at financial wheeling and dealing. And yet, all the headlines and all the articles are about doctors, because taking down a person with a name and a face, using innuendos and baseless allegations, is so much easier than picking on a lawyered up corporation, and it is equally fulfilling, it seems.

Monday, September 29, 2014

Are You an Information Blocker?

The Senate Appropriations Committee has defined a new transgression perpetrated in the committee’s expert opinion by vendors of certified EHRs, as well as “eligible hospitals or providers”. Since the committee has no data or evidence of any kind that this transgression is actually occurring, it requires the Office of the National Coordinator for Health Information Technology (ONC) to embark on a fishing expedition to locate all perpetrators of “information blocking” and devise a “comprehensive strategy on how to address the information blocking issue”. The committee is recommending that “ONC should take steps to decertify products that proactively block the sharing of information”. The Senate committee does not specify which information should be shared, but it unequivocally states that information blocking practices “frustrate congressional intent”.

Interoperability is the means by which computers communicate with each other. It is not necessarily the means by which people use computers to communicate. Lack of interoperability does not mean that patients cannot access their medical records, and it does not imply that physicians are unable to obtain pertinent information at the point of care. Interoperability means that communications between human beings are mediated by a computer that has the ability to parse, process, combine and use exchanged information in multiple ways. It therefore means that the information is formatted as structured and universally standardized atomic elements, translatable into identical 0 and 1 bits of electric current by all computers. Talking on the phone, faxing pieces of paper, exchanging electronic messages and documents, or sending data elements in a proprietary format, do not qualify as interoperability. There is no interoperability, unless all computers everywhere have a thorough “understanding” of everything people wish to say to each other.

Machine interoperability is being touted as the silver bullet in our quest to improve care coordination, and rightfully so. Interoperable computers are the ultimate population managers. There is no better way to ensure that people don’t fall through the cracks of an increasingly fragmented system where continuity of care is being replaced by electronic coordination of services. Computers that are interoperable are immensely better at “remembering” all the services that are needed and the dates when services are due for each individual patient. Computers can also generate reminders and alerts to make sure that everybody is adherent to recommended therapies, and keep track of results and outcomes, particularly for patients with chronic disease and multiple comorbidities. Proper care coordination can thus reduce complications, errors of omission, preventable hospital admissions and unnecessary readmissions, saving the system boatloads of wasted money. No wonder then that the United States Senate and practically all experts in the field are adamant that interoperability should be our number one priority.

The following assessment of financial waste in health care comes from the man who invented the Triple Aim and introduced the patient-centered concept into mainstream conversation, Dr. Donald Berwick, a staunch supporter of the Affordable Care Act who was chosen by the Obama administration to lead the Centers for Medicare and Medicaid Services (CMS), a physician who actually practiced medicine, and a New England liberal.


If you tilt your head to the left at just the right angle, and squint a little while looking at this graphic, you will notice the comparatively negligible waste created by failure to coordinate care.  You will also notice that the majority of wasted health care dollars have almost nothing to do with actual patient care, whether it is coordinated or not.

Nevertheless, care coordination and its managed care alter ego, provided by interoperable machines, has become the battle cry of health care reform. Hospital consolidation, accountable care organizations, vertical integration, narrow networks, the proliferation of managed care, particularly for those dually eligible for Medicare and Medicaid, bundled payments, incentives and team care, all proclaim their goal to be better care coordination. Hundreds of billions of dollars are flying around, in a dizzying Triple Aim dance led by the falsetto of the interoperability orchestra.  Interoperability, and the incessant regulatory deluge aimed at promoting the so called data liquidity necessary for clinical information to flow in a thousand directions, contributes almost nothing to reductions in five of Dr. Berwick’s six wedges of waste, and for administrative complexity, which is the biggest waste of all, it actually makes things infinitely worse.

So why are our government and the overwhelming majority of our industry obsessed with interoperability? Because uniformly standardized machine interoperability is the one prerequisite to the creation and accumulation of Big Data for health care in particular, and for all other surveillance purposes in general.  Once enough Big Data is generated and dutifully allowed to flow uninhibited to entities beyond traditional health care organizations and their old and tired legacy systems, the fresh ideas from innovative entrepreneurs will sweep health care off its feet and transform it into a lean and mean transparent, effective and efficient machine that keeps us all safe and healthy at a fraction of today’s costs, or something like that. And, knock on wood, even immortality is now a tangible option trickling down from deranged Silicon Valley billionaires.

Back on Earth, there are early indications of how this free-flowing Big Data business will actually work. Setting an example for one and all, Medicare has begun releasing huge datasets to the public. A good illustration is the recent release of its physician payment data. The headlines triggered by this liberating act were swift and abundant: “Medicare Millionaires Emerge in Data on Doctor Payments”, “Top Medicare Ripoff Doc Is Dominican”, “Political Ties of Top Billers for Medicare”, “Sliver of Medicare Doctors Get Big Share of Payouts”, “Medicare pays hundreds of millions to Maryland providers”, “Florida has most doctors with $3 million in Medicare claims”, “Millions paid to Medicare doctors in Memphis”, “Is your doctor one of the 340 in Texas to make more than $1 million from Medicare?”, and my personal favorite, “Medicare Records Provide Tantalizing New Details Of Payments To Doctors”, plus thousands of more of the same.

Being tantalized is an integral part of being safe and healthy, and it seems that a good old fashioned witch-hunt is also highly recommended for rabble morale, not to mention the ad revenues generated by all this mindless click bait. Once interoperability is widespread and data flows freely, entrepreneurial companies may decide that it is in the public interest to be tantalized not only by millionaire doctors, but also by the million dollar babies who are feeding their habit. And since this is after all Big Data from certified EHRs, we can build very nifty HIPAA compliant databases to shed some light on the demographics of top health care spenders (e.g.  “Millions Paid by Medicaid for Out of Wedlock Births in Mississippi”, “Sliver of Children Spend Big Share of Health Care Dollars”, “Retired Millionaires Deplete the Medicare Trust Fund “, “Sexual Preferences of Top Spenders for Medicaid”, etc.).

If I may venture a guess though, wide scale interoperability is not blocked by antiquated moral or ethical concerns some of us may have. It is blocked by money. All serious EHR vendors are perfectly willing and fully capable of opening the database floodgates to release most clinical information out into the wilderness, but doing that costs lots of money. There are labor costs, hardware costs, maintenance costs, various certification costs, and practically no return on investment, and no other tangible benefits, for their clients or their clients’ patients. Industry captains, who beat the data liberation drums the loudest, charge small fortunes for interoperability, including transaction fees for every liberated medical record. Contrary to popular belief, interoperability is good for EHR vendors’ business, and it does not alleviate the so called “vendor lock in” problem one bit, which may explain why the most respected interoperability experts hail from the largest EHR companies.

So who are the true information blockers? You are. You, and all other people who are stubbornly refusing to pay EHR vendors for allowing you to collect irrelevant data, and for transferring these data to those who are creating a tantalizing new market for the personal information of your patients, are frustrating congressional intent. You should expect stiff penalties and punishments for noncompliance, because interoperability is not about technology or the sharing of pertinent clinical information at the point of care. Universal and comprehensive interoperability of machines is about the transfer of power and wealth, from patients and doctors, to large corporations.

Monday, September 15, 2014

BREAKING: Patients Are Not Stupid

In a new Forbes article, David Shaywitz ponders whether patients are the best judges of physician quality. This is a very interesting question, not because the answer is elusive, but because the question itself is rather unusual, and may prove to be the harbinger of a new way of thinking about health care. The question raised by Dr. Shaywitz is not whether patients have enough damning information to select their doctors, which is the common drivel in the media right now. The question is whether regular people are mentally competent to make that decision. Responding in the negative to this question implies that someone, or something, other than the patient should be empowered to judge physician quality, and pick your doctor for you. 

It seems that Dr. Shaywitz was inspired to write this article in the wake of an opinion piece in the Wall Street Journal, where a practicing physician, Dr. Mark Sklar, is railing against the oppressive bureaucracy engulfing his medical practice today. Dr. Sklar offers several opinions, one of which is that “the patient should be the arbiter of the physician's quality of care”. Unfortunately for Dr. Sklar, his other prescriptions seem to be in opposition to some Obamacare tenets, and this is guaranteed to elicit kneejerk responses from Affordable Care Act supporting journalists, who have long ago ceased to even pretend to be impartial in matters of politics.

What I find exceptional about this Forbes piece is that Dr. Shaywitz’s first instinct is to solicit a response to Dr. Sklar’s complaint not from a famous Obamacare supporting physician (of which there are many), and not from the purveyors of rules and regulations at CMS, but from none other than Mr. Vinod Khosla, the billionaire venture capitalist who insists that 80% of doctors are middling and should be replaced with his computer driven algorithms. Of course, once Mr. Khosla gets his wish (and he will), Dr. Shaywitz’s question will become moot, and we will be relieved of another mental burden on our way to perfection, or perdition, depending on your point of view.

Perhaps, we shouldn’t be surprised by the appeal to Mr. Khosla’s informed opinion, since Dr. Shaywitz admits to sharing the modern disdain for physicians in general: “doctors don’t know what they don’t know, they often provide manifestly suboptimal care, and can get away with it so long as they sweet-talk the patient”. Sweet-talk? I thought we were going for the abrupt, dismissive, inconsiderate, aloof image, but either way they can get away with it, because we are all too dumb to know the difference (present company excluded, of course). Among some random thoughts about data collection, Dr. Shaywitz poses another quintessential question which never fails to materialize in this context: “Why should I know more about my mechanic than my doctor?” Note that as always this is a rhetorical question and an answer (other than duh…) is not deemed necessary.

I don’t really know what your car mechanic experiences are, but I can tell you that I know nothing about any of the various people who worked on my cars over the years. I don’t even know if they were mechanics. I don’t know if and where they went to mechanic school, and I have no idea how long they have been practicing mechanics (I assume that older ones have been in the business longer), I have no data regarding how many Jeep carburetors they fixed well and how many they broke, I don’t know how many times people had to come back for the same problem, and I have no idea if it takes six hours to replace ball joints, or maybe just two. Heck, most of the time I don’t even know their last name, and I certainly have no idea if they worked on my car themselves or delegated the work to some trainee on his first day on the job.

And yet, I would insist that I am the best judge of mechanic quality for my car, and I use information to render my judgment. I ask people I know for recommendations, and I ask the grease covered guy at my favorite gas station about the best body shop that’s not too far from my house, and then I pick one, go over and talk to the “guy”, and if I get a good feeling that the “guy” knows his stuff and is trustworthy, I let him fix my car. I have yet to make a truly horrific mistake. The tools and data I use to make my decisions were invented hundreds of thousands of years ago and honed to perfection by every human interaction over the millennia. I use similar tools all day every day, and I like that sometimes they are fuzzy, and I like that they are my tools to shape and alter as I please.

I use my tools to pick my lawyers, my accountants, my hairdresser, my plumber, my air-condition guy, painters, fence-builders, the tree guys, dry-cleaners, the lady that that does alterations, the fresh fish store, the stands at the farmer market, and a gazillion other products and services. Sometimes, I use customer reviews on the Internet in lieu of asking friends, but not very often, and never for personal services. I make lots of mistakes and sometimes I learn from them, and once or twice I rushed into some serious blunders, or procrastinated my way into disaster. It’s called life, and I insist on my right to make bad decisions, because it’s the only way for me to make the right decisions.

The Constitution of the United States of America gives us the right and the duty to judge the quality of the most powerful person on this planet, and we have to do that without any prior performance data and without ever meeting the candidate. We also have to judge the quality of the future executives of our respective States and towns, and from time to time we are called to actually judge the guilt or innocence of one of our peers. These are difficult decisions to make, and in spite of the seemingly egregious errors we are now making, I am not too terribly inclined to delegate these rights and responsibilities to Mr. Khosla’s computers, or the supreme intellect of the ProPublica editorial team.

We may be down and out. We may be disenfranchised right now, and plagued by broad daylight robberies, which we can’t fend off just yet, but we are not stupid. We know that the $2.8 trillion in our health care purse is enough to blind the righteous, and more than enough to attract the wicked. As a group, doctors are taking home a large chunk of that money, because we allowed them to do that in return for an ancient commitment, that means nothing to purveyors of machine ethics, but means a lot to us. We know that there are thieves and murderers among doctors, and some of us fall prey to those disturbed individuals, but as a group, physicians have proven worthy of our trust, and certainly more so than the corporate organized crime consortium and the sensationalist media outlets that serve them.

We don’t seem to be the best judges for picking our occupations, our food, our sports, our houses, our financial investments, how we educate our children, how we speak, and now how we pick our doctors and medicines. It would be so much more convenient and so much easier for all involved, if we just quit squirming and allowed the billionaires, with their computerized and biological overseers, to help us make all these complex decisions. For our own good, of course, so we can all lead happy and productive lives.

Tempting to be sure, and a merciful way to dispose of western civilization, but I’m afraid that the Reverend Dr. Martin Luther King's famous long arc of the moral universe is still bending towards justice, and away from slavery by any other name.

Wednesday, September 3, 2014

The Fallacy of Value-Based Health Care

Value-based health care is antithetic to patient-centered care. Value-based health care is also diametrically opposed to excellence, transparency and competitive markets. And value-based health care is a shrewdly selected and disingenuously applied misnomer. Value-based pricing is not a health-care innovation. Value-based pricing is why a plastic cup filled with tepid beer costs $8 at the ballpark, why a pack of gum costs $2.50 at the airport and why an Under Armour pair of socks costs $15. Value-based pricing is based on manipulating customer perceptions and emotions, lack of sophistication, imposed shortages and limitations. Finally, value-based prices are always higher than the alternative cost-based prices, and profitability can be improved in spite of lower sales volumes.

Health care pricing is currently a smoldering mixture of ill-conceived cost-based pricing with twisted value-based pricing components. For simplicity purposes, let’s examine the pricing of physician services. As for all health care, the pricing of physician services is driven by Medicare. The methodology is neither cost-based nor value-based and simultaneously it is both. How so? Medicare fees are based on relative value units, which are basically coefficients for calculating the cost of providing various services in various practices, of various types and specialties. The price, which is also the cost since it includes physician take home compensation, is calculated by plugging in a dollar value, called conversion factor. The conversion factor, which is supposed to represent costs, is not in any way related to actual production costs, but instead it is calculated so the total cost of physician services will not exceed the Medicare budget for these services. Buried in this complex pricing exercise is a value-based component. A committee of physicians gets to decide the requisite amount of physician effort, skills and education, for each service. Whereas in other markets the value decision hinges on buyer perceptions, in health care it is masquerading as cost.

The commercial insurance market adds a more familiar layer of complexity to the already convoluted Medicare fee schedule baseline. Unlike Medicare fees, which are nonnegotiable, private payers will engage in value-based negotiations with larger physician groups and health systems that employ them. Monopolistic health systems in a given geographical area can pretty much charge whatever the market can bear, just like the beer vendor at your favorite ballpark does, and brand name institutions get to flex their medical market muscles no differently than Under Armour does for socks. This is value-based pricing at its best. Small practices have of course no negotiation power in the insurer market, but as shortages of physician time and availability begin to emerge, a direct to consumer concierge market is being created, providing a new venue for independent physicians, primary care in particular, to move to a more profitable value-based pricing model.

Unsurprisingly this entire scheme is not working very well for any of the parties involved, except private insurers who thrive on complexity and the associated waste of resources. Upon what must have been a very careful examination of the payment system, Medicare concluded that it does not wish to pay physicians for services that fail to lower Medicare expenditures, and Medicare named this new payment strategy value-based health care, not because it has anything in common with value-based pricing, but because it sounds good. Another frequently used term in health care is value-based purchasing, which is attempting to inject the notion of quality as the limiting factor for cost containment. However, since Medicare is de facto setting the prices for its purchases, there is really no material difference between these two terms.

We need to be very clear here that value-based health care is not the same as quality-based health care. The latter means that physicians provide the best care they know how for their patients, while the former means that physicians provide good health care for the buck. To illustrate this innovative way of thinking, let’s look at the newest carrots and sticks initiative, scheduled to take effect for very large medical groups (over 100 physicians) in 2015. Below is a table that summarizes the incentives and penalties that will be applied through the new Medicare Value-based Payment Modifier.


There are several things to note here. First, if your patients receive excellent care and have excellent outcomes, you will receive no perks if that excellence involves expensive specialty and inpatient services, whether those are the accepted standard of care or not. You would actually be better off financially if you took it down a notch and provided mediocre care on the cheap. The second thing to notice is that you will not get penalized for providing horrendously subpar care, if you do that without wasting Medicare’s money.

Another intriguing aspect of this new program is that you have no idea how big the incentives, if any, are going to be. The upside numbers in the table are not percentages. They are multipliers for the x factor. The x factor is calculated by first figuring out the total amount of penalties, and that amount is then divided among those who are due incentives. If there are few penalties, there will be meager incentives. Lastly, those asterisks next to the upside numbers, indicate that additional incentives (one more x factor) are available to those who care for Medicare patients with a risk score in the top 25 percent of all risk scores.

As with everything Medicare does, this too is a zero sum game. For there to be winners, there must be losers. One is compelled to wonder how pitting physician groups against one another advances collaboration, dissemination of best practices, or sharing of information, and how it benefits patients. Leaving philosophical questions aside, the optimal strategy for obtaining incentives seems to be transition to a Medicare Advantage type of thinking: get and keep the healthiest possible patients, and make sure you regularly code every remotely plausible disease in their chart. Stay away from those dually eligible for Medicare and Medicaid, the very frail, the lonely, the infirm, or the very old, and don’t be tempted to see a random person who is in a pinch, because there is always the chance that he or she will be attributed to your panel following some hospitalization or other misfortune.

The Value-based Payment Modifier is for beginners. It is just the training wheels for the full-fledged risk assumption that Medicare is seeking from physicians and health care delivery systems in general. The grand idea is not much different than providing an aggregated and risk adjusted defined contribution for a group of assigned members, and having the health care delivery system absorb budget overruns, or keep the change if they come in under budget. There is great value in such a system for Medicare and commercial payers certain to follow in its footsteps, and perhaps this is why they decided to call it value-based. Ironically, the equally savvy health care systems are fighting back precisely by building the capacity to create a true value-based pricing model for their services through consolidation, monopolies, corralled customers, artificial shortages, confusing marketing, and diminished physicians.

It is difficult to lay blame at the feet of health systems for these seemingly predatory practices, because transition to a perpetual volume-reducing health care system is by definition unsustainable. The infrastructure and resources needed to satisfy all the strategizing, optimizing, counting and measuring activities required for value-based health care, whether the modest payment modifier or the grown up accountable care organization (ACO), are fixed costs added to health system expenses year after year. However, the incentives or shared-savings are temporary at best, because at some point volumes cannot be reduced further without actually killing people. Either way, in the near future, and for already frugal systems, in the present, all incentives will dry up leaving only massive outlays for avoiding penalties coupled with increased risk for malpractice suits. 

And as these titans are clashing high above our little heads, two outcomes are certain: individual physicians will be paid less and individual patients will be paying more for fewer services. This is how we move from volume to value. Less volume for us, more value for them.

Tuesday, August 26, 2014

The Study You’ll Never Hear About

According to a new Commonwealth Fund sponsored study published in Health Affairs, “Small Primary Care Physician Practices Have Low Rates Of Preventable Hospital Admissions”. The study of over one thousand practices of various sizes and ownerships, conducted by some of the most respected names in health care, found that the smallest independent primary care practices, that are physician owned, provide better care at lower overall cost. Considering the current, and rather belligerent, advocacy and policy efforts to eradicate small independent medical practice, and the massive move of physicians from private practice to hospital employment in the name of efficiency, quality, value and economies of scale, this study should have created quite the furor. It has not, and chances are excellent that it never will.

The study, consisting of 1045 practices and 284,000 patients, is a combination of survey responses regarding practice characteristics, and Medicare claims data used to calculate rates of ambulatory care-sensitive admissions (ACSA). As the title implies, Lawrence Casalino and colleagues found that practices with one or two physicians had 30% lower rates of these presumably preventable admissions. But this was by no means the only finding, because in general, physician owned practices, as opposed to hospital owned practices, regardless of size, had lower ACSA rates. Furthermore, the study also found that all sorts of innovative practice models foisted on physicians nowadays have marginal and sometimes negative effects on ACSA rates: “Neither the patient-centered medical home score, nor pay-for-performance incentives, nor the acceptance of risk for the cost of hospital care for the practice’s patients was significantly associated with the ambulatory care–sensitive admission rate … . Practices exposed to public reporting had somewhat higher rates.”

We should clarify here that the study uses a proprietary definition of “patient-centered medical home scores”, which is a narrow electronic-industrial subset of the broadly accepted comprehensive definition of the Patient Centered Medical Home (PCMH), and as such, unlikely to be implemented in small practices. Important PCMH aspects that are widespread among small practices are not included in these “scores”. For example, enhanced access to care is measured exclusively by availability of group visits and e-mail communications with physicians, without accounting for the more conventional same-day or after-hours appointments, and two fundamental aspects of classic PCMH, personal physician and whole person orientation, are inexplicably left out altogether. In addition, practices with 1 or 2 physicians are handicapped right out of the gate for being automatically deemed to lack “primary care teams”. Small practices also get dinged for lack of “rapid-cycle quality improvement strategy” and not participating in “quality improvement collaboratives”.

Another thing that should be noted is that this new study is based on 2008 data, so six years ago, physician owned practices were providing better care at lower costs, and the smaller the practice the more efficient it was. Between then and now, we enacted legislation and a slew of regulations pushing for massive consolidation of health systems, which in turn triggered a most spectacular shopping spree for private practices, converting large swaths of the health care delivery system into a less effective and more expensive model of care. To top it all off, we added, and are still enthusiastically piling on, regulatory requirements for all the things that Casalino and colleagues found largely inconsequential, and in the case of public reporting, somewhat detrimental to the outcomes we seek. We are spending billions of dollars on transforming our health care system into one that is more expensive and arguably of lower quality.

Previous studies (that you probably never heard of either), are somewhat inadvertently supporting the findings published by Casalino and colleagues. For example, a 2011 study by John Kralewski and colleagues showing that investment in improved quality of care for patients with diabetes can indeed reduce costs of care, reached several secondary conclusions that may have gotten lost in the shuffle. The study found that “[p]hysician-owned practices had significantly lower costs than hospital-owned practices”, and that “[l]arger practices and those with more on-site support services had significantly higher costs”. It also noted that neither the presence, nor the advanced expertise in use, of electronic medical records had significant influence on costs for the studied patients, while a “higher ratio of nurse practitioners and physician assistants in the practice increased costs”. Finally, a closer look at the results indicates that physician-owned practices “achieved more of their cost savings by providing higher-quality care than practices owned by hospitals or other agencies”.

In spite of the pretty straightforward evidence presented by Casalino and colleagues, and others before them, the authors seem troubled by the “unexpected” results, “since small practices presumably have fewer resources to hire staff to help them implement systematic processes to improve the care they provide”. And here we arrive at the crux of our health care dilemma. For decades, brilliant minds in health care have been consistently driving policy changes based on the assumption that health care is a “system”, and as such, it should be improved by well-established methodologies borrowed from other systems (e.g. Deming cycles, Lean Six Sigma, etc.). Small practices were obviously ill suited for such endeavors and hence the tacit agreement that most physicians should transition to larger medical settings, preferably hospital owned, so that improvement cycles can be uniformly applied across the factory floor. As a variety of integrated health systems began reporting success with these methodologies, the issue was considered settled and the “system” began moving full steam ahead.

Except that the baseline was all wrong. While millions and billions of dollars were being diverted from direct patient care and spent instead on industrializing health care, the much derided Marcus Welby model of care, in its stark simplicity, was running circles around the heavy machinery with gazillions of moving parts, put in place by health care reform. The only question remaining now is whether the damage is reversible. Obviously, the large amounts of money that were sent down the drain are not recoverable, but perhaps it’s not too late to cut our losses and stop throwing good money after bad. The Casalino study is a snapshot of the situation in 2008, but sadly the same may not be true today.

After years of trying to keep up with regulations, incentives, penalties, mandated clunky technology, performance reporting, overt and covert price discrimination, and increasingly untenable reimbursement complexities, all of which were shown to do nothing for effectiveness and/or efficiency, many physicians in small practice are demoralized, frustrated or have completely given up. As a group, independent doctors are getting older and medical schools, turned trade schools for “health care systems which are now the major employer of doctors” are busy preparing students “to focus on populations of patients rather than individual patients”, with full support from the American Medical Association..

It may very well be too late to recover what was lost, but this realization does not explain the conclusions reached by Casalino and colleagues from this, perhaps too little too late, study. In spite of the data presented, we are told that “[s]mall practices have many obvious disadvantages”, where none were discussed in the body of the article, and that “[i]t would be a mistake to romanticize them”. The article also suggests, and rightly so, that more research is needed, and perplexingly also that small practices should be helped with resources and services to implement precisely the processes that two paragraphs above were shown to make no difference in outcomes.

I do understand the difficulties inherent in reversing position on a long held belief, but just like romanticizing the country doctor of days gone by is indeed a mistake, dismissing the data based on romantic notions about Toyota’s car manufacturing business, is an equally grave scientific error. And in response to this study, the silence of the health care research community, as well as the mainstream media, which is supposed to act in the public interest, is outright deafening. I wonder why....

Wednesday, July 23, 2014

Introduction to Hypoliquidemia

The venerable University of Texas MD Anderson Cancer Center in Houston will accept patients with traditional Texas Medicaid health insurance, and some patients in Medicaid managed care plans. Memorial Hermann, another large health system in Houston, will accept traditional Medicaid patients and also those in Medicaid managed care plans. Neither institution will accept the Blue Cross Blue Shield HMO silver plan sold on the Affordable Care marketplace, according to NPR, and as clearly outlined on the MD Anderson website. As it turns out, the conservative state of Texas is able to obtain best in the world health care for its poorest and sickest citizens, while the private market representative, Blue Cross Blue Shield in this case, is barring its “customers” from the best and most popular Houston hospitals, including the public system (!), and all the doctors that go with these hospitals. This situation is hardly unique to the Lone Star state.

The Affordable Care Act (ACA) is mandating that insurance companies take as much money from people as they are presumed to be able to pay, then proceed to top it off with taxpayer subsidies to make up for any shortcomings, and engage in these activities without discrimination based on formerly diagnosed illnesses. For their part, the people are mandated to make these payments, whether collectively through the government, or individually through their own pocketbooks, or most often both. While the ACA prescribes in great detail the mandatory flow of money from the people to health insurance corporations, and the services due to the people in return, it leaves the definition of the means by which these services are to be provided largely to the wisdom of the corporations, as long as they can show that, theoretically, the services can be provided. And indeed in many cases, many people, in practically every state, are now receiving excellent theoretical coverage for theoretical medical services.

If you happen to have cancer, and are looking to purchase health insurance, no insurer can turn you down or charge you more because of your preexisting condition. Thanks to the generosity of the ACA, you can select any one of the diverse insurance plans offered by each payer. You can choose a plan with a tailored, high-performing network focused on keeping you healthy, which includes almost no cancer hospitals and no cancer specialists, or you can buy a lusher and more expensive plan that includes some cancer facilities and doctors, or you can buy an exorbitantly priced health insurance plan that includes the likes of MD Anderson Cancer Center. If your cancer is found after you enrolled in that affordable plan for healthy people, you can always decide to switch to a plan that treats cancer and pay the difference. It’s all up to you, and the cash in your wallet, because now you have choices you never had before the ACA was enacted. This has absolutely nothing to do with preexisting conditions. It has to do with high-performance, tailoring, focusing and all sorts of other patient-centered features and benefits.

With great choice, comes great responsibility. All but the most expensive plans available for your selection on the Affordable Care marketplace, and most employer based insurance plans as well, are consumer driven. Basically you get to make all the big decisions regarding your health care and you need to empower yourself to rise to the occasion if and when disease or accidental misfortune materializes in spite of the system’s best efforts to keep you healthy. For those with little expertise in insurance jargon the best illustration may come from the home mortgage market. See, your affordable health insurance plan is very similar to the pre-2008 affordable mortgage for your pre-2009 home. In addition to your affordable monthly payments, there is a balloon payment due the day you are diagnosed with cancer, heart disease, or just slip and fall while cleaning the gutters. This payment is also known as your high deductible, and unlike your mortgage balloon payment, your high deductible is a self-renewing source of anguish, which springs back to life every January 1st.

There are handy calculators available to let you estimate the size of your balloon payments, and hospitals are setting up specialty services to evaluate a new vital sign called “liquidity” before any procedures are undertaken. Think of it as an expanded pre-op clearance. If your liquidity is lower than the price of your treatment, hospitals may help you elevate liquidity levels through various financial instruments, such as credit card debt, and refinancing for your balloon payment. It is not by accident that entities with brilliant track records in financial markets, such as Citigroup, are seizing the emerging opportunities in the brand new health care financing market, and are introducing innovative solutions “designed to simplify and enhance the healthcare payment experience”.  Be on the lookout for more innovation here, since this market is projected to run into the hundreds of billions of dollars by the end of the decade.

To bridge the gap between our vibrant financial industry and our old and tired health care system, a new diagnosis seems to be in order. Hypoliquidemia is a disease of the financial system. It is characterized by low levels of liquid cash in your bank account, low credit scores and low socioeconomic status (SES). Other signs and symptoms may include anxiety, depression and various phobias. Hypoliquidemia is diagnosed through a series of evidence based standardized screenings, ported from the financial industry and administered by your whole-person oriented care team. Moderate hypoliquidemia is severely exacerbated by prolonged encounters with the medical system, and although not a life threatening condition in otherwise healthy individuals, it may be lethal when comorbid with other severe illnesses.  The secondhand effects of hypoliquidemia can be extremely debilitating to hospitals and physicians who fail to take the necessary financial stewardship precautions when treating large numbers of hypoliquidemic patients.

Physicians, primary care docs in particular, are at increased risk of being affected by the spread of hypoliquidemia, since they are usually the first point of contact for patients entering the health system, and also because they lack the sophisticated diagnostic tools needed to measure liquidity levels before medical services are provided. The most likely effect of treating low liquidity populations consists of increasing levels of uncollectable bad debt. The only known protection mechanisms for individual physicians are to require cash or credit card payments at the time of service, or to avoid encounters with potentially hypoliquidemic patients altogether, i.e. those with ballooning high deductible insurance plans. Finally, according to a must read article in Managed Care, hospitals are already setting up “financial screening techniques that stratify access to their services” because “having an insurance policy will not guarantee access to care in the future”.

Hypoliquidemia is reaching epidemic proportions in the U.S. and there is no cure in sight, and there will be no mercy either. For the desperate, there is an old folk remedy which has been used successfully by inadequately liquid citizens in need of nursing home care in their old age. To attenuate the effects of hypoliquidemia on serious comorbid conditions, you need to counterintuitively drive your liquidity levels to zero. You need to quit your job, assuming you have one, and deplete any and all meager assets you may still have. Since regulatory climate is extremely important to treating hypoliquidemia, you may have to move to a region with suitable environmental controls. Once all these steps are executed successfully, you should be able to qualify for Medicaid and gain access to academic centers of excellence, including places like MD Anderson Cancer Center, if that’s what you need to survive. The most common side effects of this remedy are: premature death before the course of treatment could be completed, persistent exacerbation of hypoliquidemic symptoms, suicidal ideations and universal health care delusions.