Adam Smith would disagree, Karl Marx would be appalled, and heck even Milton Friedman and Ayn Rand would be raising objections. But for some peculiar reason, there are enough contemporary lesser economic minds scattered throughout the entire philosophical spectrum, that are advocating for, and enabling the execution of, a government induced transition of our health care system to an oligopoly model of business. It all started with someone stating that our health care system is broken, and my guess is that a multitude of otherwise very intelligent people took that to mean literally broken into a multitude of useless shards of uneven size and quality. Hence the frantic attempts to glue the “fragmented” Humpty Dumpty system together again, and unlike the legendary efforts of all the King’s horses and all the King’s men, it seems that we are well on our way to putting together something that never was, and arguably never should be.
Consolidation is the name of the game. Health systems are buying each other and are morphing into insurers. Private equity is buying whatever it can buy. Insurers are buying each other and are buying health systems and everybody is buying physician practices. In health care nowadays, either you are buying something, or you are selling yourself, and sometimes you do both. While these unholy matrimonies are executing, those who sell technology for health care are following a similar consolidation path, because small firms are rarely able to service large corporations adequately. The government who initiated, or wholeheartedly endorsed, all this fragmentation rhetoric, kicked off the consolidation bonanza by chartering Accountable Care Organizations (ACOs) and by imposing a slew of regulations favoring large health systems, not the least of which is the acquisition and prescribed use of very expensive and very complex health information technology.
And the early, anecdotal, results are beginning to trickle in. Last week the New York Times published an article about the consolidation battles of two saintly health systems in Idaho (St. Luke and St. Alphonsus), waging holy war on each other for the right to acquire more physician practices, and with them, more patients to refer to more services within the system. Area doctors seem distraught and the prices of medical services in the larger St. Luke system seem to have tripled following each acquisition. The hundreds of comments to the article include many more similar stories from all over the country. The NYT article is not the first one to highlight the inflationary effects of mending our broken health care system, and you can find plenty more anecdotal stories here, here and here, and for those insisting on being surprised, there is always the early 2010 Health Affairs study of California-style defragmentation effects on the price of health care, and a grim warning regarding the implications to health care reform.
The fascinating part of this process is that health information technology is being cited by all players as a major driver for consolidation itself and also for the subsequent increase in costs of services. Information technology, if you remember, was supposed to reduce costs for the health care industry just like it did for other industries. Instead, it seems that the complexity and unaffordability of technology is driving small providers to sell themselves to the highest bidder, and the ensuing oligopoly is then justifying its immediate price increases by the need to outfit its newly purchased assets with state of the art information technology. It seems that the fancy brand-name buckets of glue used to put the health care Humpty together are way too expensive. The apologists for the consolidation trend observe that this is just an upfront investment and soon we will be reaping the benefits just like all those other industries. These editorial opinions ignore the fact that Walmart never increased its prices to account for the world’s most sophisticated supply-chain software system and neither did anybody else in those other industries. They also ignore the Kaiser experiment in our own backyard, where billions of dollars in technology, over many years, may have resulted in better quality (according to Kaiser), but had no beneficial effect on consumer premiums for Kaiser plans, which are keeping pace with all other less integrated and less technologically advanced entities.
Many health care technologists are accusing doctors of misusing technology to emulate the inefficient paper chart process and hence are failing to realize the benefits of new technology. My guess is that we have a very similar problem with health care reformers, who are envisioning technology as the glue needed to create 19th century business models for health care, because it worked so well for railroads, banks and car manufacturers. And to that end, the technology paradigm forced on health care is big, heavy, slow, expensive and in every way corporate and duly regulated by government. It feels like iron from an era that has ended about 10 years ago. The disgruntled physicians, who are complaining about health information technology not being like their iPhones or their Facebook, are instinctively recognizing that both the technology and the business models it enforces are dead.
From a technology point of view, the information age is over. This is the collaboration age and information availability is assumed, just like electricity is assumed. When I can sit in my kitchen and casually chat with a colleague in Karachi, while we are both working on the same Google document and can see each other’s edits in real time, as if we were in the same room, huddled around the same table, and at zero cost to both of us, there is suddenly no ability to comprehend why having two (or seventeen) physicians coordinate patient care necessitates the formation of a new corporate structure supported by technology yet to be built and standards yet to be defined. We have the technology to support all the lofty goals of true health care reform, and the technology itself is dirt cheap, which makes economies of scale, once available from physically owning and controlling as many means of production as possible, insignificant in modern service industries. Those dwindling economies of scale are of course outweighed by the monopoly’s age old ability to set prices, which may be nice for the conglomerate, but not so nice for the rest of us.
The assumption that a corporate office must control everything, including customers, through computerized means, in order to create efficiency and accountability is only true if that efficiency is to be reflected in the corporate bottom line, and said accountability is to corporate shareholders, or the corner office. The assumption that government must dictate and regulate every aspect of the business and its technology tools in order to protect consumers is only true if the business is a large monopolistic corporation. It doesn’t matter how greedy you think doctors are, a million doctors running hundreds of thousands of small businesses cannot do a fraction of the damage one monopoly can do with a proverbial stroke of a pen. Thousands of hospitals operating independently, largely as contractors for those independent doctors, can never muster the necessary clout to unilaterally raise prices or hoard information, and hundreds of insurers (or fund administrators) negotiating separately, can never drive hospitals, doctors or patients into bankruptcy. And government’s job is to ensure that everybody plays by a clear and simple set of rules.
This is what we mean when we say that health care is local. This is what Adam Smith’s books were all about. And this is what we should be doing (with or without a single payer). Instead of erecting regulatory barriers to simple collaboration, we should be smashing any large pieces left over from times when Humpty Dumpty was ruling the walls on which it was sitting, because health care is not literally broken or fragmented. It is distributed.
If this were a business concerned with bottom lines, cash flows and sustainability, this would be a good time to begin planning one of those posh executive retreats to evaluate current strategy. People would be feverishly working on pulling data for Power Point presentations, summarizing market research and deciding whether to select the vegetarian meal or not. If this were a better business, lots of little meetings would take place in preparation, and resolute department heads would be soliciting original thought from those not invited to the big executive retreat, but whose jobs are now on the line along with the department heads and maybe even the executive suite. But this is not a business and it is unclear who the executives are, or if there are any at all, so there will be no strategic retreat. There will be no retreat at all because we are witnessing the birth of a new religion, and the true faithful don’t ever retreat.
Once upon a time, two three decades ago, health care businesses attempted to utilize computers, just like everybody else, in their daily work. And just like everybody else, those green-eyed early computers were found to be pretty good for administrative health care tasks previously conducted by means of forms and ledgers. Those were just big (really big) calculators and typewriters rolled into one, with the added benefit of being capable of storing and recalling their work. With the advent of the Graphic User Interface and the Internet, computers were increasing their charm and capabilities by leaps and bounds, and almost every business sector found utility in transitioning administrative and drudge work to computers, and health care was no different. The bigger and more complex the business entity, and the more repeatable and uniform its processes were, the more returns on investment could be extracted from computerization. You would be hard pressed today to find any business of any size that is not using some sort of computer software for accounting, scheduling and inventory management purposes, and health care is no different. Mass production and mass consumption industries were able to extract returns from a much deeper integration of computers into their business, and sometimes even a competitive advantage from proprietary ways of utilizing their proprietary software.
Some industry sectors though seem to have been left behind, not because their administrative tasks are not computerized (they are), but because they were unable to make computers part of their core service or business. Most of these sectors are in business to provide local personal services, where the service itself is highly dependent on client preferences and circumstances and/or the service requires manual labor touching the client or his/her property. For example, there is no software for arguing in front of the Supreme Court (or even a night court) via standard vocabularies arranged in structured data fields and transmitted over standard Internet protocols. Legal services are just one example. Hair styling, fresh flower arrangements, restaurants, yard work, house cleaning, fitness coaching and medicine are other examples of businesses where standardization is difficult. In recent years, some of these industry sectors experimented with mass production of their offerings, some over the Internet, and others through computerized supply chains of human labor, and quite a few were successful in increasing market share by creating cheaper, limited in scope and quality, standardized service offerings.
Presumably based on these experiments and perhaps on other insights, medicine, which is the only not-yet-automated sector to come to national attention (for obvious reasons), is now being ordered to computerize and standardize itself. The belief is that computerized, standards-based medicine will be cheaper and better, not just good enough, but actually better. This is a bit strange, but it’s very difficult to argue with beliefs. For example, when CMS published its final Meaningful Use Stage 2 criteria, the document contained over 300 references to the authors beliefs (We believe = 219; we continue to believe = 29; our belief = 10; we do not believe = 60), and very little evidence to support the proposal. Fortunately, the evidence is beginning to hobble in from all sorts of conflicting sources.
The newest report comes from a JAMA study performed at Kaiser facilities in Colorado and it shows that patients with computerized access to their medical providers increased their utilization of in-person medical services by a little bit. One could and should argue that these patients were self-selecting for computerized access and obviously all hypochondriacs must have chosen such access. One could also argue that these patients are now actively engaged in their care and chances are that in the long-term their health will be better and their care will be cheaper. Previous studies at Kaiser found the exact opposite effect, but we can’t infer the opposite now without shooting the new theory in the foot. Perhaps in Colorado, Kaiser advises those who email with vague symptoms to come in or go to the ER, and in other locales Kaiser may be suggesting that the email sender takes two aspirins and email again next morning, or maybe some other mysterious factor is at play. Another experiment with posting medical records online showed that patients like it that way and doctors were fine with it too. So why not? There you go.
And then there is the shocking billing problem. As the New York Times reports, Medicare is wringing its hands in despair because we just figured out that computers itemize charges exceedingly well and thus allow Medicare’s contracted providers to bill more like lawyers than doctors. Since Medicare can only look back at two year old claims, I would venture a guess that they are in for another rude awakening in a year or two, when the full effect of the intentional herding of independent doctors into hospital employment hits Medicare’s slow like molasses accounting system. Why? Because Medicare agreed for some peculiar reason to pay hospital employed doctors twice or three times as much as they pay private doctors for the same exact service. So in order to cut costs, Medicare is upgrading to larger and more expensive contractors, in the belief that those can provide better care, and better care is believed to be cheaper care, for which we agreed to pay more. Don’t ask me….
Back in March, Health Affairs published a study showing that computerized medical offices tended to order more expensive tests. But that study too was resting on shaky grounds and was loudly disputed and contrasted to other equally rickety studies showing more inconclusive results. Surveys of medical professionals stating that computers take them away from patient care are routinely dismissed as growing pains of an older generation, or anecdotal evidence at best. One such anecdotal evidence is an ER doc who took the trouble of doing a time-motion study on his shift and found that during a 420 minutes shift, he spent 156 minutes interacting with patients and 237 minutes interacting with the computer. But that’s just one doctor and he was using one of those terrible legacy software products. No doubt newer programs, yet to be developed, will be much more efficient. For right now though, if this physician is salaried, the cost of his services just doubled.
Speaking of new and improved computerization, Meaningful Use will increasingly emphasize clinical decision support in an attempt to make sure that medicine is practiced the right way. To that end, Meaningful Use is proposing to remind both doctors and patients of a multitude of preventive care screenings that should be done for asymptomatic patients. Screening for breast cancer, colorectal cancer, cervical cancer, elevated blood pressure, high cholesterol, just plain being fat, chlamydia, unhealthy alcohol use, tobacco use…. you name it. And sanctioned preventive care is now pretty much “free”. This must be a good thing for people’s long term health, right? Well, at least regarding breast cancer, a brand new NEJM paper (reiterated by the New York Times) contends that around 1.3 million women were actually harmed by treatments for cancers they didn’t have, over the last 30 years of breast cancer screening religion. And how do people think utilization of medical services will be affected by computerized reminders for every (insured) person to present at the nearest clinic to be screened for fatness, hypertension, high cholesterol or drinking too much beer? You’d think people will probably ignore these reminders, but now that the Secretary of Health and Human Services is officially empowering your insurer and your employer to levy financial penalties if you, or your children, don’t get screened and don’t get “necessary” treatments for your “condition”, chances are that we are all going to become engaged patients, or a nation of medicated hypochondriacs, depending on your point of view. And this is the true power of standardized computerization of medicine.
Computers as their name indicates are best at computing, and in order for computing to commence, enough computable data needs to be supplied to the Computer. If we could tag every person, living or dead, with a unique identifier, and if we could model every person in terms of a finite set of elements, and if we could define a finite set of possible actions to be taken on each modeled element by external and internal forces, we could then unleash the infinite power of the Computer. The Finite Element Method (my first and true love), or its stochastic cousin, has been successfully applied to many previously incomputable phenomena, and conceptually it could be applied to biological organisms. Computers then, would tell us what works and what doesn’t, what costs more than it’s worth and what is a great bargain, where every modeled person is and what every external actor does at any given point in time. Better yet, the Computer could tell us what every modeled person, and what every externally applied intervention, should do in every modeled circumstance to elicit predefined outcomes.
The crude modeling of current clinical decision support rules is irrelevant. How people react to having email access to their medical providers is irrelevant, and whether a doctor orders a couple more MRIs, bills a couple more dollars per visit, or spends a couple more hours wrestling with primitive software, is also irrelevant. The only relevant thing in this quest for imposing order on the seemingly chaotic human condition is the collection of computable data. The rest will follow in good time, or we’ll run out of money, whichever comes first.
While most folks are busy trying to keep up with Meaningful Use Stage 1, and Meaningful Use Stage 2 only recently emerged from the customary rulemaking process, those who plan for distant futures are providing us a glimpse of what is being considered for Meaningful Use Stage 3 and here and there a hint at the possibility of a never before mentioned Stage 4 and beyond. Since Stage 2 is still somewhat theoretical, there is little value to enumerating the proposed measures of Stage 3, which is not due to take effect until 2016, but it may prove instructive to take a general look at the overall direction that seems to be favored by policy makers for future design and use of EHR technologies. To that end, several new proposed measures seem most enlightening.
The New US Census Bureau
Stage 1 of Meaningful Use added language, race and ethnicity to the customary demographic information collected from patients, such as name, address, date of birth, gender, etc. Stage 2 proposes to add language, race and ethnicity to clinical summaries provided to patients or sent to other providers of care. So the patient header of a Stage 2 clinical summary might look something like this:
Stage 3 proposes to require the collection of Occupation, Sexual
Orientation, Gender Identity and Disability Status in structured,
codified format. A futuristic clinical summary header may look a bit
It’s anybody’s guess how long Ms. Doe will be able to keep her minimum wage janitorial job at the little church preschool, once her clinical summary gets circulated among neighborhood providers. The good news of course is that the IOM suggested research agenda on LGBT issues will be significantly advanced, which should eventually benefit Ms. Doe by shading light on disparities she is experiencing a bit more frequently than she expected. With a few more additions to the demographics recording section, perhaps in Stage 5 or 6, we could also save serious federal expenditures on the National Census which should become obsolete following full harmonization with a person’s EHR.
Clinical Decision Surveillance
Meaningful Use Stage 1 began the process of introducing evidence-based advice into clinicians’ workflow and Stage 2 is proposing to broaden availability of helpful alerts and notifications regarding disease management, preventive care and potentially harmful errors. Meaningful Use Stage 3 is contemplating a surge in such activities and is aiming to triple the number of EHR enabled clinical decision “interventions” to 15. To ensure a uniform approach, there seems to be a trend towards externally supplied “interventions”. For example, Stage 4 is mentioning externally maintained drug-drug-interaction (DDI) lists, which is a bit strange since EHRs currently do receive DDI from external sources, such as First Data Bank or Wolters Kluwer anyway, but considering the new ONC sponsored Health eDecisions workgroup and similar other activities, it seems that a centralized approach may be in the works. Thus, Stage 3 is making the initial foray into prescribing clinical decision interventions to include renal dosing checks and “appropriateness” checks for lab and radiology orders. Beginning with Stage 3, it is envisioned that EHRs are able to record and track clinicians’ response to prescribed interventions and in some cases mandates that clinicians view certain information “before” administering immunizations, for example. I think we could save boatloads of money if we required clinicians to install keyloggers on all devices where they might use an EHR from.
On a slightly different note, I find ONCs tortuous grappling with bringing formulary advice from the Pharmacy Benefits Management (PBM) industry into the EHR workflow, somewhat perplexing, since every Surescripts certified electronic prescribing module is already ensuring that PBMs formularies are clearly marked and physicians cannot prescribe anything off formulary without first staring at a screen detailing the PBM’s formulary alternatives (retail, mail-order, copays, etc.), and moreover, the PBMs (who own Surescripts) reserve the right (and exercise it religiously) to approve the actual screen designs for the entire prescribing flow. There is no need to pretend that the Surescripts monopoly doesn’t exist. If ONC needs to make the PBMs happy, Meaningful Use EHR certification should require Surescripts certification, just like CCHIT did in the past.
Bad EHR Design
Meaningful Use Stage 1 logically started with a requirement for EHRs to maintain problems and medications lists. These basic data points have been rolled up into a Clinical Summary requirement in Stage 2, but Stage 3 is proposing advanced ways to improve the accuracy of these lists which are at the heart of a medical record. In Stage 3 EHRs are supposed to be reviewing test results and prescription lists and suggest to physicians additions/edits to the problem list, and in parallel check the current problem list and come up with advice regarding changes to the medication list. The examples given in the Stage 3 document are for the EHR to suggest a diabetes diagnosis if it finds hypoglycemic meds, or to express concerns if it finds an antibiotic lingering around without some appropriate diagnosis. This sounds like the beginnings of magical artificial intelligence, IBM Watson style, because you can only imagine how many diagnoses the EHR could suggest for a particular med or lab test. But then, one question comes to mind: what are these meds and tests without a diagnosis doing there in the first place?
A good EHR should not allow anyone to order a test or prescribe a medication without associating it with a diagnosis even if it’s just differential, rule-out, etc. Besides, you need this association if you, or the lab, or the patient, want to get paid for the effort. If we enforce this clinically sound, basic design rule, there should be no need for Watson to weed through garbage data and fix it, and the government should not force such sloppy convoluted design on software products, many of which are already designed correctly. As to finding antibiotics floating around the medication list for no good reason, I wonder if the government is aware that good electronic prescribing systems are either asking for a stop date or are calculating it based on the prescribed quantity (including refills), after which the medication is removed from the active med list. So why should a conscientious EHR designer be forced to implement extremely expensive and fraught with ambiguity algorithms to clean up something that should be clean and buttoned up from the get go? Wouldn’t it be much simpler, more logical and infinitely cheaper to require that all CPOE orders have a diagnosis associated with them when originally entered into the system? And either way, wouldn’t it be wiser to let software builders and their clients make these micro-design decisions on their own?
The Road to Hell
One of the most wasteful and aggravating activities in a medical practice is obtaining prior authorizations for various orders. In a valiant effort to come to the rescue, Meaningful Use Stage 4 and beyond is proposing to automate the process, by having physicians enter the necessary information in the EHR and through “web services” automatically receive “real time” authorization (or denial) from payers. Sounds pretty straightforward, but someone should notify the payers. Prior authorization requirements are put in place by insurers to discourage ordering of expensive items, and to that end the process is made so onerous as to make physicians think multiple times before attempting to order something that is not automatically covered. If you look at something as simple as Medicaid drug formularies, there are 50 different sets of rules, one for each State, and then as many more as there are managed care plans in each State, and the rules are different for various medications. Some require stepping through a complex phone triage protocol and are dependent on covered diagnoses (Oregon), some have a special form for each drug, and others have generic forms for all brand names, except a subset of specific brand names. Some specify exactly what supporting documentation is required, while others have nebulous “medical records” requirements. Some have requirements that patients actually suffered an adverse event from stepping through cheap drugs, and in an extremely patient-centered manner are specifying that “client said” or “client reports” is unacceptable (Utah). So much for patient engagement….
To incorporate automated prior authorization into a nationally marketed EHR in a meaningful way, the software would have to computerize thousands of perpetually changing perverse decision trees, with no assurance that the payers will reciprocate the effort. You can make an educated guess regarding the increase in EHR complexity, brittleness and consequently price tags. Wouldn’t it be better for CMS to first standardize the rules for prior authorization across payers, or at least across itself (Medicare/Medicaid and all commercial derivatives thereof)?
The notion that EHRs and health information technology can be used as a “lever” to alter the business of health care delivery is basically flawed. To date, the only business changes occurring in the health care delivery system are the demise of small private practice and the transformation of health systems into increasingly monopolistic entities, and while the Meaningful Use complexity and expense is not the main driver, it is certainly playing a non-negligible part in this development. Besides, health care delivery is largely dictated by health care financing models, and while I appreciate the difficulty of imposing anything on an industry that spends billions of dollars on lobbying, perhaps CMS can lead by example.
Would CMS consider making its databases available to EHRs through “web services” to obtain demographic and clinical information in “real time” on all Medicare and Medicaid patients? Maybe we won’t be able to get the patient’s BMI or Sexual Orientation, but we should be able to get a pretty accurate (and medical necessity validated) list of problems, medications, procedures, hospitalizations and whatever else CMS paid for, along with the most accurate demographic data (inaccurate claims are denied). Wouldn’t that be a perfect first step in “information exchange”, for the sickest and most expensive patients? And if technology is then shown to cut costs for CMS, wouldn’t private payers follow suit at short notice? Every EHR vendor I know will be fighting to be the first to connect its clients to this data. Perhaps it’s time to impose some meaningful technology and openness rules on the payer side of the house. All the query-response standards for exchanging a minimal, yet extremely valuable, dataset are in place, and all Meaningful Use certified EHRs should be able to process this dataset. How about downsizing and elevating Meaningful Use Stage 3 out of the weeds and branching out to Meaningful Access Stage 1 in 2016?
I was headed to a meeting downtown yesterday, and finding a place to park in the city is always a challenge. Luckily, there is a little old lot right next to the office building, which is a bit more expensive and does not accept any ticket validation, but it’s very clean, well lit and convenient. Up until last year the lot was owned and operated by a “mom and pop” type of business. You pulled in, found a good spot and by the time you grabbed your stuff and stepped out of the car, an elderly gentleman was standing there writing your receipt. You gave him some cash, took the little pink receipt and went about your business. When you were done, you came back, got in your car and drove away. No automated barriers, no buttons, no credit cards and no hassles. Yesterday, my little parking lot was different.
The first thing I noticed was that the parking spots were numbered, with big white digits imprinted on the freshly resurfaced asphalt. The second thing I noticed was that it was a bit harder to park because the spaces seemed to have shrunk a few inches on each side, and the third noticeable difference was the absence of the always cheery old attendant with his perennial pink book. Looking up and down the small lot, I saw a big sign at the entrance sporting the logo of some “Parking Lots R Us” company, and at the far end I saw a group of men wearing suits engaged in animated conversation. Maybe the attendant is now wearing a suit too. I headed over to the group and asked to pay for my parking. They were business men from another town trying to figure out the same thing, and right behind them was a brand new machine, looking very much like an ATM, about 4 feet tall, with lots of buttons and stickers on it explaining the process. Piece of cake.
I’m a technology geek, I travel quite a bit and I’ve seen similar machines before. I walked through the befuddled small crowd of what must have been potato farmers with no access to computers (or so I decided), which parted reverently like the Red Sea did for Moses, and approached the machine. It had a credit card slot, so I pulled out a random card and inserted it in the slot. Nothing. Pulled it out, and put it back in. Still nothing. Circled the machine slowly, and saw a picture of the exact card I inserted on the colorful sticker on the back of the machine. It should accept it, and there was no place to insert cash. I decided to try another card and this time, the machine came alive with a “Processing….” message on the huge screen on its front. I guess it has preferences the manufacturers didn’t know about. My potato farmers were happy with the progress, and digging through their wallets for a similar credit card. Then the machine requested that I use its buttons to enter my number. It was a credit card, so I had no idea what number it was asking for. Engineers don’t ever read instructions, but at this point, I felt a departure from customary behavior was acceptable. The big sticker with small fonts said that I needed the parking spot number. Aha. I looked back to my car, but the big white digits on the asphalt were hardly visible now, so I started walking towards my parking space. Luckily some spaces on the near side of my car were empty, and using advanced mathematics, I figured out that my number was 23. I yelled it out and the youngest potato farmer punched it into the machine. Of course he didn’t hit the “Enter” button, so nothing happened until I went back and completed the transaction. The machine printed out a big ticket, and flashed some advice on its screen saying that the ticket must be visible through the windshield, or a $50 fine will be assessed, which is twice what I had to pay today and 5 times what I used to pay the old attendant with the pink book. Then it said “Thank You” for parking with “Parking Lots R Us”. The potato farmers were cheering loudly, and emboldened by my success, proceeded to pay for their parking amongst much excitement and running back and forth to their cars to find their “numbers”. Technology can be so satisfying.
Good thing I had to go back and place the ticket in a visible spot on my dashboard, because I found that I had forgotten to roll my window all the way up, and you never know when it will start raining on a bright and sunny day. On my way out of the parking lot, I almost stumbled on a potato farmer, bending down to catch a better glimpse of his parking space number, and sticking out of his shoulder bag was a spiffy MacBook Air shining in the sun. Maybe they weren’t potato farmers after all. Oh well, I was 20 minutes late for my meeting and for some reason had trouble concentrating on “The Barriers and Benefits of CPOE Adoption in Community Hospitals”. So I wrote this blog instead. I'll write about Meaningful Use Stage 3 later.
Obamacare is here to stay, and with it a host of initiatives small and large, some intended and some not so much so, targeting massive transformation of the health care delivery system. One of those initiatives involves the adoption of the principles of a Patient Centered Medical Home (PCMH) for primary care as formulated by the primary care medical associations, and to a large extent, as translated into operational processes by the National Committee for Quality Assurance (NCQA). There are other implementations of the PCMH put forward by public and private organizations, but NCQA’s Medical Home recognition program is considered the gold standard for PCMH. The PCMH concept is also here to stay, and as is the case with Obamacare, the Medical Home model has its supporters, its detractors and all sorts of misconceptions and implementation missteps.
If you randomly ask a primary care physician about his/her opinion on the Patient Centered Medical Home model of primary care, you will most likely get one of the answers listed below in order of increasing prevalence:
Absolutely fantastic way to practice medicine. We’ve been doing this for a while and are a Level III recognized Medical Home.
The idea is good and we are currently making the transition and working on obtaining NCQA recognition. It’s not easy, but we are hopeful.
We are part of a PCMH pilot in our state. It’s a lot of work and I am not convinced that it will have any benefits for my practice.
I read about it, but I can’t afford to hire dieticians and social workers and spend time on all the paper work.
I don’t have time for this. Just a bunch of government regulations that do nothing for patient care.
This is the final nail in the coffin of primary care. It’s going to drive all remaining independent physicians out of practice, which is what the government wants anyway.
My mother-in-law is in an assisted living facility, but other than that I don’t have any patients in nursing homes….. I don’t take Medicaid.
Say that again….?
Just like Obamacare is not something invented by overzealous socialists, but the brainchild of extremely conservative thinking, the PCMH is not a government invention, but instead it is based on a statement made by physician associations attempting to define good primary care and the need for insurers to pay more for such excellence. The devil of course is in the details. It’s been said that the “official” NCQA PCMH requirements consist of too many details, and that some of those details are bureaucratic in nature, burdensome, expensive and contribute little to patient care. It’s been said that true quality of care and practice transformation, whatever that may be, is largely independent of counting points, formal testing, certifications and recognitions. Granted, all these contentions seem reasonable, but before deciding to walk away, how about a quick bird’s eye tour of what NCQA PCMH recognition really is?
The six parts of formal NCQA 2011 PCMH recognition are called Standards. Let’s take a critical look at each one and note the order in which they are arranged.
Standard #1 - Enhance Access and Continuity – Continuity here refers to people having a personal physician instead of seeing whoever happens to have time that day. I don’t know many practices where this is not the case anyway, but it’s hard to argue against the need to build a long term relationship between patients and their doctors, and it’s even harder to argue against this being the #1 foundational requirement of delivering high quality longitudinal patient care. Note that by definition solo practices are automatically set up to care for patients this way (just saying…). The second part of this Standard is a bit more problematic from a physician’s point of view, because it does require availability after hours and seeing patients the same day as much as possible. It is not an easy task to start tinkering with your schedule, if you are not currently offering same-day appointments, and done haphazardly, it may have serious financial implications to your practice. How about being available after hours, particularly for a solo or very small practice? How about your family and personal life? If you are one of the new concierge docs with a tiny panel of well-behaved patients, this is obviously not an issue. If you have 2500 patients, or so, on your panel, some creative thinking may be required. How would your patients react if, say, every Tuesday you’d start seeing patients from 12 pm to 8 pm? Or if you closed early on Wednesdays and twice a month you saw patients on Saturday mornings? Or if you had an arrangement with a couple of other practices to provide urgent care at odd hours on a rotating basis?
A recent study in the Annals of Family Medicine found that total health care expenditures were 10.4% lower for patients who had access to extended hours of care. This is great news for the “system”, but how about benefits to you and your practice? Whether you like it or not, you are now competing against business models with extremely low overhead, such as grocery store clinics and virtual tele-medicine clinics, offering pseudo-primary-care to your rushed and hurried patients for simple needs, leaving you to deal with complex visits that cost you a lot to deliver, but pay as much (or as little) as the simple ones. Unless you start thinking outside the box, your model of business is destined to become obsolete. Offering some electronic visits, providing hours for urgent care needs and collaborating with others on extended coverage may very well be a matter of survival. Interestingly enough, another recent JAMA study, although limited to community health centers, finds measurable correlation between access and continuity and lower operational costs per unit of service. There should be very little doubt at this point that Standard #1 is the place to start work on the viability of any practice, or ignored at significant peril.
Standard #2 - Identify and Manage Patient Populations – This one sounds onerous and a departure from individualized patient care, but is it really so? The “populations” term notwithstanding, all this Standard requires is that you document patient demographics and clinical information in the chart (seriously?), that you take good histories and that you send reminders to your patients to mind their chronic and/or preventive care needs. There is really nothing here that a good primary care physician doesn’t already do, and probably to a much greater extent than the NCQA standards specify. The one thing that may be different is that this Standard talks about proactive reminders to patients that don’t come in to see you on their own. Good for business and definitely good for patient care on an individual level.
Standard #3 - Plan and Manage Care – Another statement of the obvious, but this standard uses terminology that may raise some eyebrows. For example, it asks that your care is evidence-based. Is your care not evidence-based? Surely you decide how to treat patients based on your education, what you learned along the years, books, articles and latest research, instead of throwing darts at a random treatments list hanging in your office. And this is really all there is to this Standard, other than practicing medicine, i.e. seeing patients, evaluating conditions, planning care, talking to patients, and generally speaking, being their doctor.
Standard #4 - Provide Self-Care Support and Community Resources – This may sound like the new age fluff of patients taking care of themselves, and granted, there is some of that here, but the details are again pretty straightforward in their intent to have patients understand their conditions and do something about it. Primary care docs don’t usually fit the much publicized portrait of aloof and paternalistic doctors who won’t give you the time of day. It is the time constraints in fully loaded practices that may prevent some from fully engaging with their patients, and no certification process will change that without proper shift in reimbursement, or a change to a more direct practice model with smaller patient panels. This Standard’s feasibility is also highly dependent on patients themselves, but there are simple things you and your staff can do to better enable patients to take some responsibility for their own health (most of which you are probably doing already), and this is all this Standard is about.
Standard #5 - Track and Coordinate Care – Do you send patients to specialists and then forget all about them? Do you order lab tests and don’t care if the results come in or not or if they are normal or not? Do you get calls from the hospital notifying you that one of your patients was admitted, and you hang up thinking that this is not your problem? No? Then you are tracking and coordinating care. Can you do more? Probably, but here you are largely at the mercy of specialists and hospitals in particular. You most likely already have tickler lists to help remind your staff about getting specialists notes and test results, but it is extremely difficult to have the hospital contact you if you are not admitting your own patients (and sometimes even if you do). There is effort (and costs) involved in better tracking and better coordination and payers are starting to take notice as evidenced by the latest care coordination CPTs added to the Medicare physician fee schedule.
Standard #6 - Measure and Improve Performance – Here it is. This is the measuring, reporting and all administrating bag of requirements, complete with patient satisfaction surveys, sending data to payers and using electronic medical records. While most items here are optional, a medical home is required to set some improvement goals for clinical measures (just goal setting, not necessarily outcomes). So after doing everything outlined in previous Standards, this is where the assumption is implicitly made that a medical home should be able to continuously improve the care it provides. Perhaps you believe that you are already providing excellent care, and no doubt most of you do, but is there anything more you can do? This Standard is asking you to consider this question, and if you have an answer, begin acting on it. And yes, this too may take more time and more effort on your part, and thus be dependent on payments to support these efforts.
Did I leave anything out? If your opinion of the PCMH was something along the lines of #6 above, you are probably wondering about some “strategic” omissions. How about all that “team care” and nurse practitioners? How about those case managers and dieticians? What of the need to buy, implement and use an expensive EMR? Well, for starters these things are optional in nature. Unless you are a team of one, you already have people helping you out with patient care and administration, and you are not required to use or augment your staff more than you are comfortable with. A good EMR should help, but it is not mandatory either. And yes, NCQA will recognize nurse practitioner led practices as medical homes, but this is reflective of legislation at State levels, and it should be appropriately addressed at a policy and legislative level as well. As to the infamous amounts of paperwork involved, yes, there is plenty of that, but there is also plenty of help out there and you just need to find it.
On the surface the NCQA PCMH recognition process is an administrative test for primary care, but if you look at it carefully, you can see that it is also a logically ordered roadmap for quality primary care and a tool for you to take a fresh look at your practice and position it to change with the times without having to sacrifice your ethics and your principles. Some things in this roadmap are at the heart of what you do every day, others are things that you may want to do if time and finances allowed, and few are in the realm of “forget it”. Unlike Meaningful Use, the NCQA PCMH “test” is not an all-or-nothing proposition and there is reasonable freedom for you to discard those “forget it” items, or postpone the wishful thinking for a better day. There should be financial benefits accruing from just doing some of the things on this roadmap (such as Standard #1), and there are financial incentives from payers for doing other things or from just “passing the test”.
The medical home is a timeless model of care, repackaged for these troubled and technology driven times, and as such, it is also a business model for the future of primary care. You could approach the entire exercise as yet another payer and government mandated intrusion, or you could make this roadmap your own, and look at it as a means by which to refine and sustain an already excellent practice. It is ultimately all up to you.
[Disclosure: I am the founder of BizMed, a company whose mission is to support the viability of independent medical practice, and to that end it offers free software tools to reduce administrative complexity in private practice in general, and PCMH recognition in particular]
Every time someone publishes an article or a paper or a blog post that has anything remotely to do with Electronic Health Records (EHR), there is usually a flurry of reactions in the comments section, now available in most publications, and these always include at least half a dozen anonymous statements, usually from clinicians, decrying the current state of EHR software, best summed up by a commenter on THCB: “It is the user interface stupid!... It has to be designed from the ground up to be an integral part of the patient care experience”. Can’t argue with that now, can you? Particularly when coming from a practicing physician.
And why argue at all? The user interface in any software product is the easiest thing to get right. All you need to do is apply some basic principles and tweak them based on talking to users, listening and observing them in their “natural habitat”. Having done exactly that, for an inordinate amount of time, and being aware that most EHR vendors were engaging in similar efforts, I found the growing discontent with EHR user interfaces somewhat inexplicable. The common wisdom in EHR vendor circles is that doctors are unique in how they work and whenever you have two doctors in a room, there are at least three different preferences in how the EHR should present itself. As a result, you will find that most mature EHRs have dozens of different ways of accomplishing the same thing. These are called “user preferences” and are as confusing as anything you’ve ever seen. Hence the notion that if you spend enough time configuring and customizing your EHR upfront, you will increase your chances of having a less traumatic EHR experience down the road. We were an industry like no other, doomed to build software for users with no common denominator, or so I came to believe, until one afternoon in the summer of 2006…..
My personal moment of Zen occurred in an unremarkable little primary care practice somewhere in the Pacific Northwest, where a kind and wise physician offered me a chance to play doctor, right there in his cramped exam room. He handed me his shiny new tablet and sat in the patient chair across from my rolling stool. I saw that as the perfect opportunity to teach the doctor how to use “my” software. I designed large portions of it and I’ve done hundreds of “live” demos of patients with diabetes, hypertension, COPD and “by the way” to showcase the ease of use and uncanny abilities of the EHR to simplify the most onerous tasks. And then he started talking. A simple visit. A little bit of gout. Some stiffness when climbing stairs and he didn’t like his new blood pressure meds. I couldn’t keep up. I couldn’t find the right templates fast enough. I couldn’t find the right boxes to click on. I tried typing in the “versatile” text box. I am a lousy typist. I tried to write stuff down with the stylus in the “strategically located” handwriting recognition box. I kept making mistakes and couldn’t erase anything. I tried to type code words for completing the note later. My head was down and I was nervously fumbling with the stylus and the tablet keyboard and my rolling stool kept moving unexpectedly. I would have killed for a pencil and a piece of paper. I finally looked up in total defeat and saw the good doctor’s kind smile, “now you get it”. Indeed.
A recent Tech Crunch article is quoting Prof. Christensen’s (of Innovation fame) assertion that “Understanding the customer is the wrong thing to do — it’s confusing”. It seems that Prof. Christensen believes that “what’s really important is understanding the job that customers are trying to accomplish, and only once an entrepreneur truly understands the need that a product or service fulfills for the buyer can they optimize their business or product”. I couldn’t agree more. So what is the job that EHR customers are trying to accomplish? What need does the EHR fulfill for the buyer? Are the job and the need one and the same? They are not, and the difficulty in creating an interface that satisfies EHR users arises because doctors love the job and hate the need. The job is to heal people and the need is to be properly paid for services rendered, including an escalating system of regulatory incentives and penalties for activities not immediately related to patient care.
Most physicians would describe their job to be the provision of medical advice to patients seeking their help and, to paraphrase Sir William Osler, most doctors will probably agree that observing and understanding the patient who has the disease is much more important than understanding the disease itself. So what can a contemporary software program contribute to observing and understanding patients? Nothing of any significance. Someday we will have intelligent software accessing sensors plastered on patients’ organs and clothing and perhaps then software will be able to assist with observation and understanding. But right now software can only offer protocols for simple and self-evident conditions. If the original electronic calculators were only able to multiply single digit numbers, nobody would have bought anything from Texas Instruments in those early days. How about the other parts of a physician’s job? Can EHR software help with delivering babies? Or performing surgery? Or at the very least, can it assist with a physical examination? Maybe an EHR can help with formulating treatment plans and ordering therapies? Mostly an EHR cannot do any of these things, and the little it can do comes at great inconvenience to physicians, when compared to methodologies it aims to replace.
But doctors are buying EHRs at increasing rates, so perhaps EHRs cannot help with the job itself, but they fulfill a need after all. The original need EHRs were designed to fulfill was the simple need for one to be paid for the job one was doing. This is the same universal need that drives every business to acquire and use accounting software. Generating proper invoices for services rendered (claims) was the first rationale for buying software in a medical establishment. As the rules and regulations for payments became more and more complex, the need for software increased and in parallel the software began interfering with the job. And although most physicians realized that they must allow the software to interfere if they wanted to get paid properly, it didn’t require that they like this interference. Most of us pay our taxes, but this does not stop any of us from complaining about the complexity and lack of user friendliness of the tax code. Later on, Meaningful Use and other “quality” reporting initiatives introduced regulations directly into the job of physicians and their staff. EHR software, still unable to contribute much to the job, is now fulfilling a much larger and more onerous compliance need, and at least from a physician perspective, it still has to do with being paid appropriately for services rendered.
Designing an EHR from the ground up to be an integral part of the patient care experience, as the anonymous commenting physician suggested, was never in the cards. EHR software was born to fulfill externally imposed needs, and as such it was destined to be regarded with suspicion and when those needs started invading every aspect of the job, even early supporters of computerization became disenchanted with EHRs. It doesn’t really matter how many user centered usability experts the government regulates that EHR vendors employ, because it’s not about the buttons and the clicks, it’s about what the buttons do. At a recent conference I saw a presentation delivered by two primary care doctors who found a way to restore happiness to the practice of medicine. Every slide had a picture of an exam room where in addition to a happy doctor holding the hand of a sweet patient, there was a third “team member” in the background fumbling with a tablet.
Shouldn’t there be a better way? At one point shortly before the advent of Meaningful Use, there was a slight buzz in the industry regarding something called EMR Lite. A brand new notion of creating software humble enough to take on the peripheral portions of the job that could be automated with existing technology. That seed of innovation was killed off by the perpetual onslaught of Meaningful Use requirements. Should it be revived? And if so, what should it look like? Stay tuned…..
It was 10 AM and the unmarked glass door was locked. A woman in a brightly colored dress with a big smile on her face waved from inside, disappeared for a brief moment and returned with a key, unlocked the door and welcomed us to Dr. Elliott’s brand new solo practice. The small rooms were brightly lit, sparsely furnished and smelled of fresh paint. There were two elderly patients in the waiting room and one empty chair. In the next room there was a desk with a big monitor, a new printer and lots of framed pictures of happy people holding little children in their arms. Unpacked boxes and crates were stacked up in one corner and across from it the exam room door was closed. Dr. Elliott was with a patient. Mrs. Elliott, the lady with the brightly colored dress, produced a couple of extra chairs from thin air and told us all about the happy people and the little children in the framed photos, while answering phones, making appointments, checking authorizations, printing all sorts of papers, preparing charts and arranging for referrals, all at once. It was 10:30 AM and the exam room door was still closed. I was beginning to understand why Dr. Elliott’s finances were less than stellar. The door finally opened a few minutes later and a tall and gaunt gentleman with a thin colorless ponytail sticking out the back of his green baseball cap walked out of the exam room holding some papers in his hands. Dr. Elliott walked right behind him finishing an unfinished conversation with his patient and starting a brand new one with us. The patient decided to hang around and participate and somehow this looked and felt just right.
Dr. Elliott is a bubbly fidgety man in his mid-forties, and this little practice was his desperately brave response to rejection after rejection from organized medicine. Dr. Elliott was either invited to leave, or quit on his own, several health systems due to his inability to meet productivity quotas. Somehow I was not surprised, and the patient with the thinning ponytail had a toothless grin on his face. Turns out Doc wants to know everything, even what he had for breakfast today and maybe Doc should pay him for doing most of the talking. He slowly pulled a $10 bill from his stiff jeans pocket and handed it to Mrs. Elliott who thanked him and handed him a receipt which he stuffed back in the same pocket, shook hands with everybody in the room and left escorted by Mrs. Elliott who unlocked the door for him and locked it behind him. I just had to ask…
“I take insurance, but if they don’t have insurance, they still need a doctor, so they pay what they can”. My partner mumbled something about chickens. Dr. Elliott walked back into the exam room and closed the door behind him. Mrs. Elliott, still doing five things at once, told us about the new EMR they just bought and how they are working on becoming a medical home, and maybe soon she’ll be able to get a good phone system so she doesn’t have to forward calls to her personal cell phone. There was someone knocking at the door. Two teenage girls came in and one wasn’t feeling well. Can she see the doctor? Sure. The girl who wasn’t feeling well had no insurance either. Another half hour went by and Dr. Elliott walked out from the exam room behind a perky little old lady with huge glasses and cropped white hair. Miss. Sally also decided to stay and chat with us for a bit.
Miss. Sally was suffering from congestive heart failure and was in and out of hospitals for most of last year. She was pretty sure her time has come until she found Dr. Elliott, and he found a cardiologist for Miss. Sally and together they worked things out for her. She is as good as new, or so she tells us. No more hospitals for her. Instead she visits with Doc once a month and sometimes he sends her to see the cardiologist. Miss. Sally was having a grand time being the center of attention. Doc saved her life.
The teenage girl who wasn’t feeling well looked up from her cell phone for a brief moment and agreed to wait a few more minutes so Dr. Elliott can complete his oration on evidence based medicine, the importance of primary care and his great expectations from his soon to be installed state of the art EMR system. He gave Miss. Sally some education materials she will never read, and walked us to the locked door. This time I didn’t have to ask. There were some “incidents” close by and “once they walk through that door, they are my patients, and I am responsible for their safety”, said Dr. Elliott as he unlocked the glass door. As we said our goodbyes I caught a glimpse of the office hours painted on the glass in a soft gray font. The last line read Saturday 9 am – 7 pm.
The rain stopped and a hot Alabama sun was baking the dusty row of little storefronts. A distraught woman walked by looking for a bathroom. We drove back to the city passing by a cinderblock hospital with fat pipes sticking out in every direction, and I wondered how many little old ladies with congestive heart failure are in the process of dying there now. It was getting dark outside.
Note: In order to protect their privacy, the names of all people mentioned in this post have been changed, as have certain physical characteristics, quotations and other descriptive details.
Wherever health care reformation and transformation is discussed, sooner or later the imperative of patient engagement is sure to materialize. Patients, it seems, are no longer content to be passive spectators while care is administered to them, and instead are demanding to be active participants in their own health care decisions. Gone are the paternalistic days of doctor knows best, replaced by informed and educated patients on an equal footing with physicians when it comes to diagnosing conditions, selecting therapies and managing illness, or preventing disease altogether through judiciously chosen lifestyles and preventive measures. And what makes this tectonic shift in attitude possible? Technology, of course, and specifically the Internet and the iPhone. Patients today have access to troves of medical information on the Internet, and social media allows for informal research on any condition you can think of, and some you cannot even imagine. The iPhone, turned medical instrument with the assistance of thousands of apps and add-on devices, is allowing everybody to carefully track and monitor their lifestyles, biometrics, medications and whatever else they wish to quantify. iPhones are already providing some diagnostic testing and it’s probably not too soon for Quest and LabCorp to start paying attention to these engaging developments.
The Government is also very interested in promoting patient engagement, since engaged patients who can monitor and maintain healthy lifestyles, and if already sick can self-manage their chronic conditions, will presumably utilize less medical resources and should cost the system less than their apathetic predecessors. And for similar reasons, private insurers and employers are fully supportive of patient engagement as well, and are diligently working to provide patients with educational tools and resources for engaging in their own care within the cost optimizing care management universe. Patient engagement is also one of the pillars of Meaningful Use and as such it is creating the necessary infrastructure and associated regulations to ensure that patients have meaningful access to all medical records previously locked up in providers’ information vaults. This is extremely important because patients cannot truly engage in lifestyle improvements and self-care on a level playing field with their physicians without complete knowledge of their medical conditions as documented by a physician, and as augmented, translated and analyzed by iPhone apps and the Internet at large.
Earlier this year Chef Mario Batali, an extremely engaged and empowered individual, decided to engage himself and his family in an innovative lifestyle change experiment of his own. For a full week, seven days, Chef Batali and his family went on a SNAP diet. The Supplemental Nutrition Assistance Program (SNAP), a.k.a. Food Stamps, diet consists of eating whatever you can buy for $31 a week. Of course, being handy around the kitchen, gave Chef Batali a bit of an advantage, but all in all, according to the Huffington Post, his description of the experiment was "I'm (expletive deleted) starving".
There are 46.2 million Americans living in poverty today. Poverty is currently defined as less than $23,021 per year for a family of four. There are 47 million people in the SNAP. 22% of American children live in poverty and in our Nation’s Capital, next door to Congress and the White House, 35% of children are poor. According to the USDA, 17.9 million households were food-insecure in 2011 and 6.8 million of those had very low food security, which translates to 49 million Americans who don’t know where their next meal is coming from, or if it’s coming at all, and 16 million of those Americans are children. A fairly new study from the University of Michigan and Harvard concludes that at the start of 2011, “2.8 million children were surviving on $2 or less in income per person per day in a given month”. And NCFH reports that in 2010, 1.6 million American children were without a home.
What does this have to do with patient engagement? Well, for starters when you are “(expletive deleted) starving”, it is a bit more difficult to muster the mental prowess required to engage your health care provider on a level playing field. The landmark “quasi-experimental” study on inviting patients at several elite health care institutions to view their visit notes, published earlier this month, did not measure the level of hunger amongst participating patients and/or their children. So, if you are building patient engagement paraphernalia and expect to be paid for your efforts, your target market excludes the 49 million food-insecure Americans and in all likelihood excludes most of the remaining 50% of Americans living on less than the $50,054 median income, and probably the vast majority of the more fortunate 50%, some of whom may be able to afford your products if they were chronically ill or actively preparing themselves for medical disaster, which most are not. This is probably why patient engagement is something thrust upon the health care scene from above, just like EHRs, and not a market demand sprouting from unfulfilled needs of would be buyers. And this is also why, patient engagement campaigns, just like EHR adoption efforts, are financed by the middle-men of health care (i.e. those who use our collective health care dollars to purchase medical services on our behalf), in the belief that somehow patient engagement fueled by technology will reduce the costs of medical services. These “purchasers” of health care services are the most likely target market for patient engagement tool builders, service providers and the quintessential consultants.
This is not an entirely bad idea, just like covering a gaping wound with a Band-Aid is not an entirely bad idea, and there is plenty quasi-experimental and quasi-scientific research to show mild correlation between costs and technology, and it doesn’t take a genius to figure out that if patients managed their own care, and if they did it well enough, we would need to pay less to medical professionals for doing the same. The new iPhone and Internet based care management products are certainly promising to dramatically improve lay patients’ abilities to take care of themselves. The mountains of patient education tools and materials written at a “culturally appropriate” 4th grade literacy level with lots of colorful pictures and big fonts are presumably targeting, amongst others, those who are on and off “(expletive deleted) starving”, and may even help avoid a trip to the ED for some asthmatic children surviving on $2 a day. But this type of palliative approach to poverty is not likely to have significant impact on costs of care, because instead of shrinking away and perishing, poverty seems to grow and expand by leaps and bounds, and since 1/5 of our future generation is infected, the growth of expenditures well into the foreseeable future is pretty much guaranteed. Why? Because poor people are disproportionately sicker than rich ones (see CDC numbers below), and no amount of colorful pamphlets and free apps is going to change that.
If you are one of the many talented and passionate people working diligently to improve health and health care in this country, you may want to quit the Band-Aid public-private industrial complex that is squandering billions of taxpayers’ dollars in a futile attempt to provide cheaper care to poor people, and perhaps consider redirecting your efforts towards solving the underlying problem of poverty, and reducing to zero the number of Americans, particularly children, who are “(expletive deleted) starving”.
For the first time in this election campaign Mitt Romney came up with a useful “zinger”. During the first Presidential debate Romney suggested that we should examine our various expenditures and ascertain if the item we spend taxpayers money on is “important enough to borrow money from China”. Unsurprisingly, the first thing that came to Romney’s mind was a public service providing small children with education on racial diversity and basic literacy skills. And although, we are not directly borrowing money from China to pay for things, it wouldn’t hurt to go through our expenses, including the many small and apparently insignificant ones, and see if there’s anything we can do without. It actually may be less painful to make a thousand additive little cuts than to locate one large silver bullet that is certain to cause commensurately large pain. Of course, such exercise would be fraught with controversy, since what may look frivolous to one party, could look worthwhile to another. But if we approach this with an honest intent to generate some savings, would there be some Big Birds that we could all agree to do without for now?
A day after the Presidential debate the Republican Chairs of the Ways and Means and Energy and Commerce Committees published a letter addressed to the Secretary of Health and Human Services asking that Meaningful Use payments and penalties be suspended, and the program be reevaluated because it failed to reach its stated goals of having EHRs “talk to each other”. As political and misguided as this letter is, perhaps there is an opportunity here nevertheless to go looking for Birds. The Meaningful Use program is costing taxpayers around $35 billion, and it has been said that this is just a drop in the bottomless bucket of public health care expenditures, but Meaningful Use has other costs associated with it. Technology vendors subject to these new regulations are spending money to make their products compliant, or certifiable, which is increasing the price provider organizations pay for technology, which is then increasing the prices health care purchasers are charged. These new regulatory activities, consisting mainly of data collection, aggregation and reporting, are imposing additional operational costs on providers, which are then also passed down to purchasers, and since nobody is running a charity in health care these days, all these costs are trickling down to taxpayers in various ways.
The original idea behind Meaningful Use was that EHRs will eventually pay for themselves in the form of enterprise efficiency that will reduce costs and improve quality of care simultaneously. So far it looks like enterprise efficiency is translating mostly into higher revenues for providers and higher costs for health care purchasers, and as far as quality is concerned, the jury is still out. So should we ditch Meaningful Use because it does not pass the Romney litmus test for keeping Big Birds alive? Not necessarily. Meaningful Use is not a monolithic program than can, or should, be evaluated in one swoop. Some parts of Meaningful Use look reasonably fit for purpose while others look more like clusters of big yellow feathers randomly slammed onto the main regulatory body, and perhaps those should be removed.
Let’s start with the basic assumption that complete medical records, when made available to clinicians and patients at the point of care, can indeed improve the quality of care for individual patients, and when used for outreach and research, can improve population health and reduce costs. This same assumption, made by Dr. Henry Stanley Plummer in 1907, prompted the revolutionary transition from physician ledgers to today’s patient chart, so this should be a pretty reasonable assumption to make. If that’s the case, does Meaningful Use have any unessential feathers that we can safely remove and thus lower the costs of this program without hurting its main intent?
Yellow Feathers Cluster #1: Both the architects of Meaningful Use and the authors of the letter asking for the program to be suspended, assume that figuring a path through the deep weeds of futuristic technology is a prerequisite to providing physicians with useful information at the point of care. So the regulators deemed it appropriate to require that 50% of discharge summaries, for example, should be produced in a specific format while 10% should be sent out using the latest standards and technologies. What about the remaining 90% of patients? And how do you decide who the lucky 10% should be? If we put aside the technology centric approach to solving problems, we could require that 100% of discharge summaries are sent out to primary care doctors, nursing homes, patients and other care givers, by any means and in any form or shape available. So maybe EHRs can’t really “talk to each other”, but they can make it possible for doctors and patients to “talk to each other” more efficiently. Would any hospital stand up and argue that generating and sending discharge summaries by secure email, electronic fax, plain fax, FedEx, carrier pigeon or whatever, is a hardship? I don’t think so, and if they did, they would probably pressure their technology vendors to automate the process.
Yellow Feathers Cluster #2: Meaningful Use was supposed to have 3 stages: data collection, information exchange, quality improvement. Since Stage 4 is already in discussions, I would assume that Meaningful Use is envisioned to have transformed from a temporary tool to spur technology adoption to a perpetual mechanism for enforcing policy through technology. Either way, the starting point was presumptuous, ineffective and wasteful. Clinicians in all settings were already documenting what they thought was necessary to document in the patient chart. Before endeavoring to let information be exchanged, the Meaningful Use architects decided to enforce their vision of what should be documented and subsequently exchanged. Thus we now have smoking status on every piece of paper, along with race and ethnicity, and in Stages 3 & 4 we will have disability status, sexual orientation and gender identity in the header of every clinical summary, and armies of disenchanted doctors and nurses clicking away at boxes. What would happen, if instead of defining the fields required in “clinical summaries”, we would ask that 100% of referrals (and consults) be accompanied by at least the last visit note, a referral letter and the last test results, if any? Again, by any means available and in any format the referring (consulting) physician can produce.
Yellow Feathers Cluster #3: Other than complex attempts at new venues for information exchange, Meaningful Use is chock full of a veritable smorgasbord of little features and functionalities, which may be nice to have if money was no object, and doctors’ time was unlimited, and others that are ridiculously self-evident, such as creating visit notes and recording family history (seriously?). Should we “borrow money from China” to ensure that every doctor stares at the insurance company formulary for a few seconds before he prescribes Amoxicillin? How many dollars should we take out of the ailing Medicare trust fund in order to pay hospitals and doctors for sending a “failed message” to an immunization registry? How many kids should we kick out of Medicaid so that the militant app developers can dupe patients into “transmitting” their medical records to their marketing machines on the physician’s dime and infrastructure? It’s easy to come up with ever increasing complexity when there are no real constraints. It’s called scope creep and it’s been the death blow of many good projects, even for those who don’t need to “borrow money from China”. How about picking two or three realistic things that will give us the biggest bang for the (limited) buck and just concentrate on doing those really well, so we can build from there?
Yellow Feathers Cluster #4: This last cluster is impossible to completely remove. The Meaningful Use incentives structure is just plain unfair and exceedingly wasteful, although more than likely intended to be so as a means to a policy end. There are no published numbers from CMS or ONC indicating the number of incentives recipients that bought and implemented an EHR long before Meaningful Use was created. Most of those “early adopters” were big systems like Kaiser and financially comfortable medical groups. Even if we accept the assumption that Meaningful Use of an EHR can improve quality of care, why would we borrow money from China to pay businesses for investing in their own bottom lines of their own accord? Whenever I ask why it is that Kaiser’s premiums are not much lower than its less “effective” competition, I am reminded that Kaiser must recoup its billions in technology investments. By my back of the napkin calculations, they should have recouped that already, so why should taxpayers deplete their old age medical funds to throw a few hundred millions more in Kaiser’s way? If we really want to improve quality of care, shouldn’t we concentrate on bringing up the rear, and shower Critical Access Hospitals, Rural Health Clinics and small practices everywhere with technology funds? Every study out there shows that these small providers are struggling financially and technically. Meaningful Use incentives should have gone exclusively to these small and needy establishments, most of which are serving equally impoverished patients, instead of padding the pockets of large systems so they can more easily buy these small providers and create the currently preferred “too big to fail” model of health care delivery.
I’m sure you can think of more feathers and clusters, and Meaningful Use is just one health care program that lends itself to productive plucking. Shall we begin applying the Romney China Test to all other sacred Big Birds in health care and start adding up the billion dollar drops in the bucket? Or will that make us look dumber than we would like to look?
The health care crowd is abuzz with The New York Times revelation that Medicare billing rates seem to have increased by billions of dollars in parallel with increased adoption of EHR technologies for both hospitals and ambulatory services. The culprit for this unexpected increase is the measly E&M code. Evaluation and Management (E&M) is the portion of a medical visit where the doctor listens to your description of the problem, takes a history of previous medical issues, inquires about relatives that suffered from various ailments, asks about social habits and circumstances, lets you describe your symptoms as they affect your various body parts, examines your persona and proceeds with diagnosing and treating the condition that brought you to his/her office or hospital. The more thorough this evaluation and management activity was, and the more complicated your problem is, and the more diagnostic tests are reviewed, and the more counseling the doctor gives you, the more money Medicare and all other insurers will pay your doctor. Makes perfect sense, doesn’t it?
In 1995 and again in 1997 Medicare has specified exactly how to measure a doctor’s thoroughness by creating 5 levels of visits and defining each level’s complexity in terms of an exact number of questions a doctor asks, and an exact number of organs and body parts that are addressed during a visit. The more sanctioned questions and body parts are addressed, the more money the doctor gets from the payer. During the olden paper days, no physician in his right mind would go to the trouble of actually writing down all these largely irrelevant things, and since Medicare always threatened to audit physician billings, most doctors practiced “defensive billing” and consistently charged less than they should have, because the hand written documentation was rarely indicative of the actual level of service. Enter Electronic Medical Records.
Since before the HITECH act and before the Meaningful Use epidemic, EHR vendors promised doctors an automated way of documenting a visit, so they can spend more time with the patient and not have to constantly write things down. Instead, a click on a couple of boxes would do that for them. Furthermore, physicians won’t have to waste money on expert coders to go through their scribbled notes and figure out a visit level. The software will automatically calculate the appropriate E&M code, based on boxes clicked. Structured data can be very useful for calculations. To make the entire process most efficient, three methods of documentation have been developed to replace hand writing and to efficiently minimize the need for extensive box-clicking.
Documentation by Exception – Every EHR has this “feature” allowing the documenter to click on ONE box usually at the top of the page which generates a professional sounding clinical sentence for each organ or body part stating that everything is perfectly normal, or that all your histories are unremarkable in any way. This is a great efficiency to be applied presumably after the interviewer ascertained that all is well with your past and present relatives and body parts. If something is wrong with one or two organs, the clinician can click the Normal button and then edit the exceptional few organs that are affected today, thus obtaining documentation for a complete review or examination of all your systems. Remember that every organ and family member documented is worth a few more dollars according to Medicare’s fee-for-documentation model of reimbursement. No wonder then that this is now a basic feature in every EHR.
Pre-filled Templates – These go by different names, but they are a huge time saver for simple and common problems and here is how they work: Let’s say you see a patient with an URI and it is flu season. You document the visit de novo starting from a blank URI template, use all the previously described efficiencies and generate a lovely visit note for this patient. It then dawns on you that you are likely to see hundreds of similar patients in the months to come, and that you always go about these things the same way asking the same questions and getting the same answers. You can save this visit note as a pre-filled template sans patient demographics and histories (really just the HPI, ROS, Exam and for the brave also Assessment and Plan) and when the next URI patient shows up, you can load this pre-filled template and edit exceptions, if any. Since technology is magical, EHRs will also load the patient specific histories and merge them into your brand new note automatically. Two or three clicks will get you enough documentation to allow your EHR to calculate a very nice E&M code and generate enough documentation to keep the payers at bay.
Bring Forward – This is really sweet for complex patients with chronic disease that come to see you every few months or so. We all know that not much changes in a few months and most likely everything you will be documenting today is exactly what you documented six months ago. Instead of starting from scratch every time, EHRs have created great efficiency by making it possible for the documenter to bring forward, or load, the previous visit note and allow him/her to edit and make changes based on today’s visit. This beats the old “copy & paste” by a mile, and with a click of a button you have all the organs and relatives and complexity of decision making documented in minute detail. You can now make a few changes here and there as necessary, and the EHR will calculate the appropriate E&M code.
There are other features in most EHRs that are designed to improve reimbursement, but these are the most popular. There are also administrative functions embedded in larger EHRs that allow those who employ physicians to ensure that the docs click on all the necessary things to ensure optimal billing and payment. It is very easy to be critical of clinicians in these scenarios, but let’s remember that if Medicare wouldn’t have defined the value of a doctor visit to be proportional to the amount of text generated during the visit, none of this would have happened.
So the “unintended consequences” of pushing physicians to use EHRs seem to consist of doctors actually using EHRs, as effectively as possible, to document all the little details Medicare wants to see. This can only surprise people who had no clue what EHRs are, how they work, and how they are used in everyday practice, which did not (does not) prevent said people from proclaiming themselves as health care experts, best suited to set the national agenda for EHR design and adoption.
Bonus Tip: Now that everybody has been properly shocked by the E&M coding efficiency introduced by EHRs, I would suggest examining the efficiencies introduced by the variety of “smart” order-sets.
In his dissenting opinion on the health care law, my least favorite Justice, Antonin Scalia, argued that Chief Justice Robert’s opinion stating that the “individual mandate” is simultaneously a tax and not a tax “carries verbal wizardry too far, deep into the forbidden land of the sophists”. Perhaps this is unusual for the legal system in general and the Supreme Court in particular, but in everyday health care conversations verbal wizardry is now the preferred method of communications. However, health care is much more complicated than the law (with deepest apologies to my attorney friends and family), and health care lacks a supreme authoritative source of truth, thus our verbal wizardry cannot be carried out by proclamation alone. Persistence, as they say, is the most important requirement for success, so in health care we are resorting to the tried and true method of repeatedly employing our verbal wizardry in conversation and in writing until it is wizardry no more.
But verbal wizardry is not a random act of confusion. In the Supreme Court opinion, it was most likely a deliberate construct to avoid calamity. In everyday health care discourse, the sustained verbal wizardry seems to serve as a tool for resetting our expectations from a profit driven health care system run amok. When it comes to medical care, most folks have very simple expectations. We want to stay as far away as possible from medical establishments when we feel fine, and we want someone to fix what’s broken when we are sick. It seems that this humble desire is untenable in our current system. It seems that we must frequent health care facilities when we are healthy, but should temper our expectations regarding medical care when afflicted with disease.
And it seems that this is all for our own good, because how would we know that we are fat, out of shape and depressed if the clinical team on duty didn’t educate us about these things. Armed with electronic prescriptions for generic statins and anti-depressants, an armful of personalized education materials and our damn data, we should finally understand what our 48 size jeans and our skinny bank accounts have been trying to tell us all along. Properly medicated and educated we should now take charge of our health. And if we fail somehow and get sick anyway, we should make allowances for this cost-effective and well-meaning new health care system and stop insisting that the doctor fix everything that’s wrong, because health care is about being healthy not about sick care.
Overriding grandma’s advice to eat an apple a day, in favor of regular visits to a job-creator sponsored clinic to assess your current and future productivity, and maybe even check your teeth, is easier said than done. And it is practically impossible to convince folks that demanding sick care beyond certain limitations is unfair, ungrateful and downright immoral. Here is where well-coordinated verbal wizardry comes in handy. There are many linguistic acrobatics in what seems like a perpetual marketing campaign from government officials, semi-officials and all sorts of stakeholders deriving direct and indirect incomes from health services, but the following three terms seem to be at the cold hearted center of it all.
Everybody seems hell bent to put the patient at the center of something they sell, but the term “patient-centered”, coined some thirty years ago (thank you for the reference, Rick) was really limited to describing a preferred style for the doctor-patient interview, where doctors actively solicit patient opinions and input. The study showed that patients were more satisfied and were more likely to take their meds after a patient-centered interview with their family doctor. Twenty-five years later, Dr. Berwick imported the term to the US, giving it a more expansive definition to include “choice in all matters, without exception” for each patient. Since then, the term patient-centered has been prepended to whatever is on the agenda du jour. We have patient-centered legislation from the left, patient-centered market-based health reform from the right and our path to prosperity seems to depend on patient-centered reform. You want your bill to look good? Name it ‘‘Patient Centered Healthcare Savings Act of 2011’’. You want to be elected to public office? Start by promising that “I won’t stop working on patient-centered solutions to our health care crisis”. Seeking funding from the brand new Patient Centered Outcomes Research Institute? All you need to do is “adapt recommender systems frameworks that are widely used by innovative businesses outside of healthcare” to “an adaptive computer system that will assess a patient's individual perspective, understand the patient's preferences for health messages, and provide personalized, persuasive health communication relevant to the individual patient” [emphasis added]. Basically as long as you can “identify patient-centered factors” and come up with something that “measures patient-centered constructs”, the funding is yours. To round things up, we now have “patient-centered health insurance”, “patient-centered clinical trials” and everything from health care consumerism to health IT is proudly “patient-centered”.
Like a colorful hefty piñata, the patient finds itself now surrounded by well-wishing guests speaking softly and carrying big sticks. The only end in sight is when the last dime finally drops to the floor and there is nothing left to extract from the patient hanging at the center.
Fee for Service
Unless it’s something your mom does for you, the expectation is and always has been that a fee should be paid for work other people do for you. Sometimes you buy services in bulk, such as subscriptions or yearly contracts, but in all cases the fee is calculated, and discounted for volume, based on a preset number of services. Another way to obtain services is to purchase warranties and insurance. In this model there is no preset number of services owed to you and you are paying for the seller to assume your risk, and as you probably know, those contracts are full of caveats and small print, because nobody wants to provide you services worth more than your payment.
Historically doctors were paid a fee (or a chicken) each time they did something for you. They were paid directly by you and later you could buy insurance to pay you back a portion of medical expenses. The latter model is still very much alive in European countries with strict price controls and better and cheaper health care systems. In the US, we decided to leave the fees to insurers and doctors to figure out on their own. For a while, when most hospitals were run by selfless nuns and most insurers were mission driven non-profit organizations, this worked well and we were relieved of all that tedious paperwork. As medical care became more advanced, the increasingly large flow of money between all parties attracted the interest of corporate America. Doctors became “providers” and patients became “consumers”, prices started climbing towards what the market can bear and insurers began looking for ways to minimize what they have to pay out in medical loss. Since there is a limitation on how much risk can be returned to the consumer before insurance becomes meaningless, the next best thing was to discharge some risk to the new “providers”. For that to happen, the small doctor shops that are not financially capable of taking risks, had to go away and the remaining “providers” needed to start selling insurers warranties on their “populations”. Where the doctor was once mostly aligned with patient interests, the “provider” is now mostly aligned with the insurance plan with which it shares the risk. I wonder at what point “providers” will begin referring to their operating costs as “medical loss”.
To achieve this wonderful outcome, insurers (public and private) needed to convince the populations involved that fee-for-service is the source of all evil and that their trusted doctors are not to be trusted anymore. Thus we must stop paying for volume and instead pay for outcomes. It makes perfect sense because all of us know that paying the hair stylist on a fee-for-service basis, for example, leads to an explosion in the number of haircuts and we only pay the salon if most patrons like their haircuts. The fact that fee-for-service is the most common model of health care payment in developed countries, and the fact that small practice is both more efficient and much preferred by patients, and also widely used in countries with better and more cost-effective systems, is largely irrelevant to the business model of America’s health care industry, which is now salivating at the prospect of shared “savings”, i.e. splitting what they manage to accountably squeeze from patients through value-based and patient-centered cuts to quality and utilization.
The final piece in this shell game is to impress upon common folks that in spite of the best patient-centered warranties for our health, there simply isn’t enough money to honor these contracts, and warranties will have to be severely limited. To that end, every self-respecting health economist is somberly announcing that our “resources” are “finite” and sooner or later we will have to responsibly ration medical care (for the poor, of course). Unfortunately, the term "finite" is a mathematically defined term. Only the universe, time itself and God’s wisdom are infinite. All resources on this flying rock are finite. The rock itself is finite and so is the life sustaining energy from its sun. The number of grains of sand on a beach is also finite. The number of cucumbers in your fridge is finite, but that doesn’t mean you don’t have enough cucumbers for a large salad, unless of course your potbelly pig pet is helping himself to a heap of fresh veggies as we speak.
Providing for all medical needs of a finite number of people, with a finite number of organs, who live a finite number of years does not require infinite resources. It does require adequate resources. It may be that almost $3 trillion in “resources” is not adequate to meet the needs of all US residents, although it is a bit unlikely considering that this is double of what other rich and pampered countries spend on their medical care. The explanation to this puzzle is that only a portion of those seemingly lavish resources is going to actual medical care in the US. The rest is going elsewhere, and when our potbelly buddies are done taking their unearned share off the top, we are left with insufficient amounts of cucumbers to make a decent health care salad.
The Verbal Wizardry Dictionary and Thesaurus – Health Care Edition will be available soon at www.verbalwizardry.org
If you are a Primary Care Physician and would like to express a thought, an opinion or describe an experience, this blog page is at your disposal. It could be a short note, a long dissertation or anything in between. Write it down and email it to me. It will be promptly posted here as is, unedited, uncut and anonymously if you so desire. You can send one or as many notes as you need. All are welcome!