Thursday, October 31, 2013

Meaningful Use of Obamacare was “experiencing technical difficulties” again yesterday, but the system is up now. Thirty days after it went live, the Federal insurance marketplace, the flagship of Obamacare, is still hopelessly broken, much to the delight of those who predicted that Obamacare will be the end of our way of life, and to the equal chagrin of those equating Obamacare to LBJ’s Medicare, or even FDR’s New Deal. In one of a long string of interminable Congressional hearings, the Secretary of Health and Human Services is taking full responsibility for the broken website. A broken website, is what our entire government is now busy dissecting. How was it designed, how was it tested, how was it paid for, and above all whose fault is it, because we need to hang somebody, preferably the President, and the entire Obamacare legislation with him. All this moaning and groaning won’t work. Obamacare will be adopted, and we have data to support this assertion.

So Obamacare has some seriously faulty and unusable software that they want us to use, and it peddles a whole bunch of new products that we are supposed to buy with government subsidies, or face a penalty. The products themselves have very complex specifications, many of which are not evident before the buyer pays and attempts to actually use the product. Does this remind you of anything?

The Promise

Meaningful Use – Ultimately, the goal is to reduce the cost of health care. The reason the costs are so high is that providers are not willing or able to provide proper care because they are not using intelligent technology to augment the care process. So the Federal government will create a set of requirements for EHR technology that will ensure that care provided through these certified instruments is evidence based, measurable and cost effective, which should increase the health of populations and decrease per capita costs. And the Federal government will of course subsidize the purchase of private products in a vibrant technology marketplace. The program was said to be entirely voluntary, with only a small financial penalty for non-compliance.

Obamacare – Ultimately, the goal is to reduce the cost of health care. The reason the costs are so high is that people don’t receive proper care because they don’t have good insurance. If everybody buys health insurance, the risks will be equitably spread out, and so will the expenditures. Furthermore, the program was designed with all sorts of quality checks and balances (e.g. free preventive care, provider payment reform) so people will be healthier, and this should greatly reduce aggregate costs of care. And the Federal government is going to impose certain regulations on insurance products sold in the marketplace, and subsidize the purchase of these products from a variety of competing private businesses, because free market competition fosters innovation, quality and low consumer prices. The program was said to be mandatory, but only carries a small financial penalty for non-compliance.

The Purchase

Meaningful Use – The Federal government is maintaining a website listing all certified technology products, and information regarding certifiable features for each product. Initially the website was a usability nightmare, impossible to navigate, with incomplete information and practically no ability to compare products. Today, the website is much nicer and provides much better searchable information on thousands of certified and partially certified technology products. Providers who purchase a proper mix of listed products are eligible for subsidies based on their particular business circumstances. Although providers must purchase products directly from private sellers, and not through the Federal website, obtaining subsidies (or incentives) requires registration and attestation on another Federal website (operated by CMS), which has gone from bundle of horrific bugs to fairly usable and streamlined software over a period of two years.

Obamacare – The Federal government just launched a website listing all approved insurance products, and information regarding compliance with regulatory components, such as premiums, copay, coinsurance, deductibles and out of pocket maximums. The website is chronically broken and is malfunctioning daily, but this website is infinitely more complex than the technology websites because it combines all three functionalities involved in the purchase of an insurance product: listing of approved products, actual purchase from many private sellers, and verification of eligibility for subsidy. Also, the number of shoppers is larger by several orders of magnitude. Nevertheless, this is just a website, and it is reasonable to expect that in a couple of months, or couple of years, it will function smoothly.

The Product

Meaningful Use – Even before they actually purchased anything, providers complained about inadequacy, irrelevance, overpricing, lack of transparency and government interference. After purchasing certified products, many discovered that products did not work as advertised and hidden costs blamed on regulations kept popping up behind every corner. Providers complained about having to switch from products that were not Meaningful Use compliant to those that are, and having to pay inordinate amounts of money for features they had no use for (e.g. why should a dermatologist have to pay for an immunization interface). Predictably, as providers began using their new technology products, two major problems surfaced at very short notice: the designers gave no thought to usability of user interfaces, and interoperability between products was practically impossible, in spite of it being a certifiable feature. 

Obamacare – The Marketplace insurance products are set to be activated in about two months at the earliest, but even before anybody actually used any of these new plans, people are complaining about government dictating what type of coverage one should have, how much risk people can safely assume, the unexpected high prices and inability to browse and compare apples to apples. People are irate about having to switch from non-Obamacare plans to the new plans, which may be a lot more expensive, and they complain about having to pay for things they have no use for (e.g. why should a 32 year old guy have to purchase insurance for pregnancy). Predictably, as people begin using their new insurance plans, two major problems will surface at very short notice (particularly since early adopters will be poorer and sicker than most).
  • The first problem lies in the financial design of exchange plans, which were built to have deceptively affordable premiums, with very high deductibles and out of pocked limits. Yes, the government will help the poorest of the poor, and yes, those who had some sort of insurance prior to Obamacare, most likely had the same out of pocket problem, but let’s face it, most people who are shopping on the exchange can’t possibly come up with thousands of dollars before the insurance even kicks in. True, preventive screenings come with first dollar coverage, but the free screening does not in and of itself prevent anything, and any treatments for what was found during screenings will cost money people don’t have. An insurance executive, I greatly respect, referred to this emerging group of citizens which will soon include most of us, as the “functionally uninsured”. Obamacare is not addressing this problem in any way, and may even exacerbate it by making these hollow insurance products part and parcel of the law of the land.
  • The second problem is the narrow networks. Good luck finding out which doctors and which hospitals are included in your affordable Bronze, Silver, Gold or Platinum plan. This is not just about “keeping your doctor”. This is about access to care, and frankly, it is about access to quality care. The model is spreading quickly and quietly all over the country. In my home town, no serious insurer would dare offer a plan that excluded the local academic health system. Until now. Not only did Anthem (one of the largest insurers in the state) drop BJC HealthCare from all its exchange plans, but to my utter dismay, while researching this blog post, I discovered that BJC HealthCare is being dropped from all individual Anthem plans, on & off the exchange, including the one I have. Just like that, on the QT. Strangely enough, narrowing the network by dropping the presumably expensive academic center, made Anthem more expensive than its one and only competitor on the exchange. Greed is good. Government sponsored greed is better.

The Results

Meaningful Use – Following a slow and rocky start, providers began purchasing certified technology products and attesting to their usage in increasingly larger numbers. The government continued to run a huge marketing campaign to sustain and accelerate adoption. It worked. The agencies in charge of this program began releasing numbers on a monthly basis showing how many providers attested and how much money the government paid out in incentives, as indicators of great success. Health care costs did not decrease, and quality of care did not improve, but we are told that these are coming any day now. As time went by, many providers discovered that their certified products are useless at best or about to go under, and hence a second wave of spending is injecting more money into the health IT industry. As technology improves, and the program is further tightened up, it is expected that the flow of cash from health care services to technology companies will become perpetual to the tune of many billions of dollars each year.

Obamacare – Following a slow and rocky start, people who are seeing their existing, and way too cheap, insurance products withdrawn by insurers and/or employers, will be purchasing subsidized products in increasingly large numbers. The government will expand its aggressive marketing campaign to sustain and accelerate adoption. The agencies in charge of this program will begin releasing numbers on a monthly basis showing how many people purchased products on the exchange and how much money the government paid out in subsidies, as indicators of great success. Health insurance costs will not decrease, and quality of care will not improve, but we will be told that we need to give the program time to work and improvements are due any day now. As time goes by, people will discover that their insurance is useless, because all the good doctors and hospitals are out of the “rubble only” networks, and the plan doesn’t really pay for anything until you’re half dead and destitute. Following a public outcry, the government will kill off some of the smallest plans, and people will be asked to buy new and improved products from a shrinking number of mega insurers, which of course will be more expensive because they’re so much better. The already perpetual flow of cash from individuals, and taxpayers in general, to health insurance companies, will grow nicely over the next few decades.

Back in 2008 when this whole thing started with talk about a public option, I said that I would happily pay more for health insurance to ensure that everybody gets quality health care regardless of ability to pay. Five years later, it looks like I will indeed be paying double for health insurance, while ensuring that everybody gets low quality health care regardless of ability to pay, except of course the recession-proof Political-Industrial Complex and its financiers.

Monday, October 21, 2013

Transforming Health Care: Values and Cultural Preferences

On his campaign trails, Harry Truman used to call on citizens to go out and vote for themselves, in their own selfish interests. It may sound shallow and divisive, but Harry Truman believed that the individual interests of the people should trump the special interests of the powerful few, and that’s how Democracy should work. Those were simpler times, but the logic still applies today, although it’s becoming increasingly difficult for people to figure out where their selfish interests lie, not because interests have changed, but because the art of spinning messages and the sheer amounts of cash thrown at it have grown beyond what Harry Truman could have imagined. Take for example the controversy around the Patient Protection and Affordable Care Act of 2010, a.k.a. Obamacare, which was spun into one little question: do we want the government to give more poor people health insurance, while forcing everybody else to pay for it? If yes, vote Democrat. If no, vote Republican.

But Obamacare, which is now the “law of the land”, has a few more pieces in it, pertaining to its affordability and patient protection goals, and those pieces where never up for public debate. Some of these pieces have to do with the definition of health insurance itself: Do people know what an Accountable Care Organization (ACO) is? Do they understand the concept of narrow networks built into the majority of new insurance products? How about high deductibles which seem to be the only game in town, rendering almost all the newly insured to be functionally uninsured? Other pieces have to do with care delivery itself: Who will provide medical care? Who will decide which medical care should be provided? How will care be provided and administered? In the inner sanctum of health policy experts, all these questions, and many more, are answered by a prerecorded message: We are transforming health care from a wasteful, volume based, provider centric, sick care system to a health care system that is value based, patient centered, and fosters the health of populations. What’s not to like? If however, we insist on nitpicking, then perhaps we would like to better understand who does “we” refer to, and what does “value” mean, and maybe some information on how to get sick care, in the unlikely event that fostering the health of populations does not prevent us from falling off a ladder while cleaning the gutters.

Every definition of patient centered care concludes with the observation that such care must conform to patient values and cultural preferences. This is good, because it means we decide what care we want to get. Gone are the days where insurers could interfere with our wishes, and doctors would force us to do things just because they can. Now they have to ask us first, in Farsi or Vietnamese if we so desire, and be respectful about it too: Ms. Patient, would you prefer to take this very expensive brand name capsule once a day, or would you rather take this cheap uncoated pill that will dissolve in your esophagus almost immediately, three times every day? Our call. And if we choose to not take either the capsule or the pills, that’s our prerogative as well. But that’s not all. This goes much further than choice of pills or even diagnostic tests. In a recent NEJM article, two Harvard researchers tell us that “[w]hile some patients may seek greater odds of survival, others may seek a faster return to work or lower out-of-pocket costs. These options are at the core of “patient-centered” care.” [quotation marks in the original] So if, say, you have a tumor on your brain, you may choose to have surgeries and long convalescence times, or you may choose to stay productive until you die while staring at the computer on your desk, or you may choose to pay the rent and purchase food for your children for a few more months. It’s all up to you.

If your cultural preferences are biased towards staying alive and if you have above average values that can easily get you over the high deductible hump, you may want to choose option one. If you have publicly provided or heavily subsidized values, you may still choose to stay alive, although that would entail extreme selfishness on your part, and it may collide with your cultural preference to feed your kids for as long as you possibly can. If it’s not you with a tumor, but your child, the exercise of values and cultural preferences gets a bit more complicated, because children in most cases have negative values which should be balanced with projected future values, and if your cultural preferences lead you to have many children, the value calculation will need to be distributed across all of them. As you can see, with great freedom of choice, come great responsibilities, and this is at the core of patient centered care.

But patient centered care is not only about putting patients in charge of all their medical decisions. It’s also about transforming the system itself to preemptively account for patients’ values and cultural preferences. Care coordination during transitions of care is an excellent example of customer centered service, based on evolving cultural preferences. Informed by their personal cultural preferences, health care transformers know fully well that modern Americans move around the country every few years, from high-powered job to better-compensated job, or just for fun, so having a continuous relationship with one doctor is pretty much impossible. Furthermore, medicine is very complex nowadays, so you can’t expect primary care doctors to keep up with empowered consumers picking and choosing hospitals and specialists all day long, according to their values and cultural preferences. You can’t expect busy primary care doctors to do much of anything really, so the transformers are building all sorts of smart computer systems to automatically track and coordinate the billions and trillions of care transitions from sea to shining sea. This is beautiful indeed, but there’s one small problem.

A Pew survey conducted in 2008 found that 37% of Americans spend their lives in the same town they were born, 57% always lived in the same State and only 15% lived in more than 3 States over their lifetime. According to the U.S. Census Bureau approximately 7 million Americans, or a little over 2%, moved across States in 2012. By comparison, during the heydays of Marcus Welby, 3.4% of Americans moved across State lines, and those numbers have been steadily declining since the glorious sixties. Similar to our health care transformers, those who move around today are more likely to be younger and/or college educated. Another Pew survey finds that the vast majority of Americans prefer living where the pace of life is slow, not fast, and where neighbors know each other well. Only 23% would like to live in the city, with all others indicating a preference for small towns, suburbs and rural areas. Considering these mobility numbers and the clearly expressed values and cultural preferences of the nation, you may be tempted to conclude that maintaining a long term relationship with a doctor is both desirable to most Americans, and also perfectly feasible in a country where most folks die in close proximity to where they were born, but then again, you would be missing the point.

Confused? Not sure how to apply/solicit values and cultural preferences when considering/providing medical care? No worries. We will discuss these things next time. For now, be aware that proper utilization of a transformed system requires that patients are turned on (activated), and that physicians are reeducated.

Tuesday, October 8, 2013

The Wishfully Fresh Future of Health IT

Health IT is booming, or so they say. The hotly debated and highly politicized health care reform, a.k.a. Obamacare, has been shining bright lights on a segment of our economy that is quickly approaching $3 Trillion per year, and is in dire need of improvement, or so they say. Depending on who you ask, some say that health care resources must be redistributed in a more equitable manner, while others contend that health care must be made more parsimonious, or both. But regardless of nuances and variations, all seem to agree that health care must cost less in aggregate.

Somewhere around the turn of the 19th century, give or take a few decades, we figured out how to make things cost less in aggregate, and we have been applying the same principles to an ever increasing array of things that went from being luxuries reserved for Kings and magnates, to being household items taken for granted by every pauper. And we’re not done yet, not by a longshot, but our cost reducing tools have changed from the chemical fumes and big iron of the early 19th century to the clean and minuscule silicon chip. Computers will make health care cost less in aggregate. We just need to figure out how. 

Fortunately, the cost of making people is pretty much zero, because people are a renewable resource. Unfortunately, we have very little ability at this point in time to enforce some sort of quality control on an entirely spontaneous production system, so we are stuck for now with high variability in our inputs. Health care is the part that deals with maintenance for all these non-standard people, and hence the high aggregate costs. Exacerbating the problem is that in a fragmented system, those who provide health maintenance services and products are on an innovation spree of their own, with new and expensive products coming to market every day. We could tinker with controlling prices of health maintenance providers, like other developed countries are doing, but frankly that’s just a band aid on the fundamental problem of aggregate costs of health care, which are growing by leaps and bounds all over the world.

To reduce maintenance costs, we need to reduce the need for expensive services, and we need to devise service paradigms that are cheaper to deliver. Since the factory floor is the entire planet, or at least the entire nation, the former requires incredible amounts of computable data, and the latter requires ability to control all aspects of service delivery under one roof. And this in a nutshell is health care reform, not to be confused with health insurance reform and its poster goal of providing “coverage” for the poor and the sick through exchanges, subsidies and expansions. The vertical and horizontal consolidation of health maintenance services has been going on for quite some time, but is now accelerating to the point where there is hardly a day when health corporations merging and buying each other are not in the news. The servicing of these consolidated entities and all other cost reduction tasks fall to Health IT. Just like master craftsmen in the 18th century did not lead the transformation of their respective industries, and just like more recently butchers, bakers and candlestick makers did not build, clinicians will not be leading health care reform. Those who make, and program the machines, always did and will do so now. Health IT will dictate how health maintenance is provided in the future.

So what’s Health IT up to? Health IT is lagging behind IT in other industries, because until now Health IT did not recognize its own strength. Like young superheroes in blockbuster movies, Health IT is blowing things up randomly, while trying to understand how it should apply these newfound powers. But Health IT is not a single minded monolithic being. There are factions, competing ideologies, politicking, and lots and lots of money flowing in, both from customers and more recently venture capital. Generally speaking though, Health IT, as the leader of transformation, has two immediate jobs to do. 


This is absolutely necessary if we are going to reduce the need for expensive maintenance services, and a two prong approach is emerging. First, if we have enough information, we can stop people from using their bodies (and minds) in ways that are known to lead to disease, and we can have people engage in early and continuous self-maintenance. Here you find all the little health and fitness tracking apps and gizmos, supported by an emerging common wisdom that the medical profession should play its part in nudging people to hook themselves up to these devices, because it’s about staying healthy and a doctor’s job should be to keep people healthy, not to treat sickness. Who needs yucky sickness anyway?  Sure, for a while, we will have to contend with legacy people that are already sick, or on a path to sickness, so for them we have slightly different tracking apps that will help minimize the damage (and costs), one way or another, depending on a variety of factors. These are the feeders, or data suppliers, and in this category we also have involuntary data collectors, such as social media data collectors, shopping/leisure data collectors, financial data collectors, communications data collectors, and even electronic medical records collectors.

Second, we have the large (and not so large) aggregators of big data, which are now sprouting like mushrooms after the rain. These applications go by the name of population management or analytics software, and here is where the magic occurs. By combining all data streams, these software programs can identify need for preemptive maintenance. For example, did you know that people that like minivans tend to be obese? If we can combine car purchasing data with food store data and maybe entertainment data, we can red flag people for wellness interventions. And just so we don’t waste our precious resources, we can add health risk assessment data to eliminate those who are not amenable to intervention (why throw good money at lost causes?). No, this is not an Orwellian futuristic state, because nothing is more important than health, and being healthy is the wish of every person in their right mind. As the revolutionary generation used to say, “Give me health, or give me death!” We can finally make this yearning a reality.


But all this big data collection and analysis cannot really work because most people are too stupid to voluntarily see the brightness of a healthy future. So we need to enforce prevention of escalating maintenance costs for the public good, and as always, compliance in a free society, can only be enforced by someone that is bigger, stronger and better armed. If a mom and pop doc tells you to buy and use a Nike+ FuelBand and in your infinite pedestrian idiocy, you decide not to spend money on that, you can always avoid the doctor by simply going to a different one next time your diabetes “flares up”. But, if all doctors in town work for the same outfit, and every single one of them is aware of your obstinacy, because it’s in your permanent medical record, you’re out of luck. And just buying the thing and tossing it in a kitchen drawer won’t work either, because the doctor-employing outfit will be expecting your data from Nike soon enough.

Consolidation of the entire continuum of health maintenance services is therefore a must, and since we are now talking about huge businesses, Health IT must come up with enterprise software, which is a far cry from little consumer apps, and even from medium size population management applications. Here we are running into the most hotly debated Health IT issue – large integrated software systems vs. little interoperable apps. The common wisdom (have you noticed how all wisdom is now common?) argues that the big iron enterprise systems are expensive, horrible for users and not given to selfless data sharing (interoperability). Yeah, they are, so what? Have you by any chance seen the horrendous software used by bank employees? Not the cute web/mobile apps for bank customers, but the grey 1950s model used inside the bank, that freezes and crashes and has more boxes and screens than anything I’ve ever seen in Health IT. Does anybody give a damn that the “financial advisor” hates the computer? Nope. And when we have our health equivalents of Citi Bank, JP Morgan and Bank of America, nobody will care about physician dissatisfaction or productivity or burnout or any other feelings reserved for upper management.

How about interoperability, the battle cry of small apps builders wishing to get into the game? There’ll be plenty of interoperability, but not the kind people think they need. Enterprise Health IT will open the gates for all the little data feeders to come in, and all the population management analyzers to come and do their thing, but nothing of substance will ever get out. A corporation cannot honestly provide efficient health maintenance to people floating around specialists and hospitals whenever they want to, and Health IT will be erecting the electronic portion of the barriers to changing health maintenance providers. Yes, we will have Health IT ATMs where we can get a little information when stranded in a strange city, but when was the last time you walked into a Chase bank and cashed a B of A check? And when was the last time your Fidelity financial advisor was able to peruse your various accounts at your current bank and all banks you used in the past, to better advise you on saving for retirement? Come to think of it, when was the last time you switched banks? And how much transactional history was interoperated between your old bank and your new bank?


Health IT is hot and Health IT will be leading the revolution and Health IT will transform itself and health care. The big (and rather comfortable) enterprise Health IT will just get stronger and bigger to better support industry consolidation. The little data feeder and analytics Health IT will service the big Health IT. It is very possible that some of these new consumer apps will gain huge market share and become big Health IT (just big, not enterprise), and most likely this is why venture capital is investing. Take home lesson for little Health IT: you can’t beat them, so the best strategy is to join them. And if you think something is missing from this (too) long dissertation, like patient empowerment for example, think again.