As Health Care Learns and Grows…

While grappling with the costs and imperfections of our health care system in recent years, a multitude of experts in the field found it useful and enlightening to compare health care to a variety of more familiar industries, and to suggest that health care should adopt operational models that have been shown to work well in those other industries. From the financial industry, we learned that health care must be computerized. From the restaurant industry, we learned that health care must be standardized. Observing Starbucks, we concluded that clinicians must be taught a few things about customer service. Aviation brought us safety manuals for medical procedures, and NASCAR informed us about the superior power of disciplined teams of workers. The history of agriculture provided important lessons on government’s role in creating bigger and more efficient producers, and from the history of manufacturing we learned everything else we needed to know, from Six Sigma to Lean Toyota to focused factories, and how innovation must begin with cheap products and services that are good enough for all but the wealthy and the narrow minded.

As many of the lessons learned from these industries are being applied to health care, the results are starting to come in and most are shockingly disappointing. A group of researchers from Stanford University is reporting in the May issue of Health Affairs that “an increase in the market share of hospitals with the tightest vertically integrated relationship with physicians—ownership of physician practices—was associated with higher hospital prices and spending”.  A Harvard University paper in the same issue of Health Affairs is predicting that “ACA reforms could result in an additional 4.4-percentage-point increase in profit margins for hospital-based EDs compared to what could be the case without the reforms”. A very large study in Canada recently published in NEJM, found that “[i]mplementation of surgical safety checklists in Ontario, Canada, was not associated with significant reductions in operative mortality or complications”.  And yet both vertical integration and ACA reforms are continuing at a brisk pace.

Back in 2012, a large national study from UC Davis, published in JAMA Internal Medicine, found that “higher patient satisfaction was associated with less emergency department use but with greater inpatient use, higher overall health care and prescription drug expenditures, and increased mortality”. A more recent JAMA Surgery study from Johns Hopkins “suggests that patient satisfaction is not related to standard process-of-care measures that have long been used as markers of surgical quality”.  Also in JAMA Internal Medicine, researchers from the University of Chicago reported that in their study “71.1% of patients preferred to leave medical decision making to their physician” and the remaining 28.9 % of patients who preferred to make their own decisions “had increased LOS of 0.26 day and increased costs of $865”. Patient experience surveys are quickly becoming mandatory and the “patient decision aids” industry is booming.

Yes, the findings in almost every article cited above have been disputed, and a few generated notable literary altercations, none more acrimonious though, than the technology wars. Two years ago a study funded by the Agency for Healthcare Research and Quality (AHRQ) found that physicians in hospitals spent approximately an hour and a half each day interacting with EHRs, and that 16% of their notes along with 38% of nursing notes were never read by anybody. A year later, the American Journal of Emergency Medicine published a study showing that great strides have been made, and in the ED, 43% of physician time was spent interacting with EHRs and 28% was spent interacting with flesh and blood patients. A fascinating new paper from researchers at Northwestern University studied the gazing patterns of doctors during office visits and found that “physicians with EHRs in their exam rooms spend one-third of their time looking at computer screens, compared with physicians who use paper charts who only spent about 9% of their time looking at them”. The market for analyzing all the data collected in lieu of patient care is “poised to skyrocket” from the current $4.4 billion to well over $21 billion by 2020.

In a hot off the presses opinion piece in JAMA Internal Medicine, paid for by a charitable organization controlled by Sutter Health, the venerable Dr. Thomas Bodenheimer is advocating more substantive delegation of clinical tasks to medical assistants who, as a group, are “ethnically and linguistically diverse, and culturally concordant with a variety of patient populations” (I absolutely adore the English language), in order to meet increased demand for primary care and allow clinicians to “see more patients per day”. Predictably, Dr. Bodenheimer concludes that the “enhanced roles for medical assistants is an innovative approach”. Another innovation that is so new and exciting that University of Chicago researchers decided to write a Health Affairs paper about it even before study results were available, consists of primary care doctors who will be admitting and caring for their own patients when hospitalized. The grand innovation here seems to be that patients must first become very sick, presumably for lack of proper medical care, and then and only then, do they get a Comprehensive Care Physician to follow them through the numerous hospitalizations awaiting them. It is comforting to read that this oddly retrograde approach is not posing any theological difficulties with the Holy Scripture of health care reform – The Innovator’s Prescription – which is the embodiment of all we need to learn from retail, manufacturing, technology, etc.

There is no need to shake your head in utter disbelief, because there are very simple explanations to this cacophony of Casino style fun and games, where we all serve as chips and tokens. Yes, money is one explanation, but not the only one. It seems that in a headlong rush to fix things, many people with basically good intentions overlooked a few salient linguistic details.
First, the Marx-Schumpeter paradigm for capital accumulation is called “creative destruction”, not destructive creation, which means that before you take the wrecking ball to what is already there, you must have the new and tremendously improved stuff, working and spreading like wildfire. 
Second, “disruption” is a retrospectively affixed label to a novel business idea that worked surprisingly well, not a prospectively self-ascribed title used for everything people do after they have coffee in the morning. 
Third, business models conceived with an intention to defraud the public are commonly referred to as embezzlement, corruption, larceny or felony in general, and only rarely are they hailed as “innovations”. 
With so many divergent opinions on what ails health care and how to best provide a cure, can we maybe start by agreeing on the terminology we use to disagree with each other?

Translucency with Turbid Clouds

Did you ever read a seemingly inconsequential sentence somewhere and it then just refused to leave your mind for days on end, triggering avalanches of thoughts way beyond the original intent, if there even was one? It just happened to me a few days ago when I read one more industry article about the recent Medicare data dump. The following remark was attributed to a primary care doctor: “The U.S. is entering an era of more accountability and transparency in all aspects of people's personal and professional lives and “medicine cannot be excluded,” he said”.  Back in 1996 a science fiction author by the name of David Brin, published an article in Wired Magazine, where he too prophetically argued that the era of transparency is no longer preventable. Ignoring an entire branch of physics, Mr. Brin suggested that the only antidote to the floodlights shining on each individual consists of a “flashlight” we can use to point at the elites running the lightshows. But Mr. Brin forgot another time honored use of flashlights: we can start pointing them at each other, no doubt to the great amusement of floodlight operators. This has the twofold benefit of keeping us from staring at the floodlights overhead, and of illuminating any subatomic particles that may have eluded the big lights. And there is no better, or more entertaining, place to begin playing with flashlights than medicine.

I won’t belabor personal transparency, since it is tantamount to invasion of privacy, which should be illegal, but it is not. Invasion of privacy in the U.S. is becoming a business model and a method of governance. If you missed the 60 Minutes segment on data brokers on April 9th, here is a link. In the now customary incestuous relationship between big business and government, the Institute of Medicine (IOM) is proposing to help data brokers clean up the dossiers they are compiling on people. Utilizing the Meaningful Use program lever, the IOM will be delegating this task to physicians, so a doctor visit will include detailed interrogation regarding such things as the ethnic/racial composition of the neighborhood you live in (geocodable, of course), sexual practices, exposure to fire arms, employment, country of origin, previous incarceration, and all sorts of important stuff for the Internet business. It will also help employers do a much better job with hiring good people since your doctor will have to note now if you are a conscientious, optimistic fellow, or alternatively a stressed out hostile, angry and dissatisfied individual. The IOM would have liked to add more of these hard to get data points, but they couldn’t find the faintest indication that those things have anything to do with medicine at this time. I’m sure they eventually will.

Professional transparency on the other hand, is a much more complicated issue. If you offer to sell a service or a product, you should expect some scrutiny of the value you provide for the buyer, unless of course, you have the means by which to force people to purchase your service or product. Legal systems have always endeavored to create moral frameworks for protecting buyers from unsavory sellers, and vice versa. The best buyer protection is full disclosure, or transparency, regarding the service or product being sold, coupled with legal accountability for negligent and intentionally fraudulent practices. With this in mind, shouldn’t it be the government’s responsibility, indeed its duty, to provide the public with as much information as possible regarding services provided by physicians? Particularly since medical services are most often not elective, and one could argue that the medical profession, as a whole, has the ability to force people into buying its services under duress. Let’s assume for a moment that the answer to this question is affirmative, and move on to a couple of more specific questions.

First, what is it that people buy from doctors? Roughly two types of things: expert advice or skilled repairs. When you are considering the purchase of these services, it would be very helpful to have an independent assessment of the level of expertise and proficiency at repairing items similar to yours. And of course, you would want to know how much the service is going to cost. In the pre-transparency era, we did our best to infer the level of physician expertise or skills by asking very simple questions: Where did he go to school? How long has she been in practice? What do my friends think about this doctor? Is he “affiliated” with the shiniest academic center in town? Are his other patients smart, educated people, or maybe even doctors themselves? We didn’t ask about cost, but more often we did ask if the doctor accepts our insurance, because doctor fees were a sunk cost for most people with health insurance.

You don’t have to have a Masters in Health Administration to see that even if we managed to obtain answers to all our questions, the dataset would be incomplete and fraught with inconclusive and even misleading subjective information. The Internet made it easier to both ask and get answers to some of our questions, but hasn’t done a thing to improve the quality of information available to us, and maybe the opposite is true, seeing how we are all perfectly willing to take advice from anonymous strangers who have nothing better to do other than to rate things online (when is the last time you rated something on a vendor site?). If the government is to step in and help us pick doctors, it would have to do much better than facilitate availability of social media gossip about this or that physician.

For example, what type of information could assist young parents with picking a pediatrician? Let’s be honest and admit that in addition to simple facts, such as education, years in practice, location, hospital affiliation, you would want to know what other parents think about this doctor, and what other doctors think about her as well. But in order to provide context to these opinions, you would need some objective measures. Do I get the doctor on the phone if I call with a concern, or do I get someone else? Will she always see my kid, or will we have to deal with a bunch of random people? Does she offer well-child appointments that fit my work schedule?  How difficult it is to get an appointment? If my child needs hospitalization, will she be there, or will I be on my own? How good are the physicians that cover for her? How good are the specialists she usually refers to? How often does she refer and for what reasons? How much time will she spend with my child?

And here are the things we wouldn’t need to know, not because these things are not important, but because they are largely implied and too granular to be indicative of substance. How many kids is she testing for pharyngitis and is she properly treating them? How many kids get weighted and have their height measured? How many are asked about smoking or whether they are depressed? How many girls are screened for Chlamydia and how many kids in her practice got all their shots?  And yet, the government is in full swing to deliver exactly this nitty-gritty information, and absolutely none of the answers most people seek, not because the answers we want are not available, or impossible to generate, but because keeping everybody busy looking at the trees may just be enough to detract our attention from the massive forest being erected in our health care backyard. 

You can easily extrapolate this example to adult primary care and specialty care of all types, including tertiary care. How about prices though? Since health insurance has evolved into indemnity insurance for errors in lifestyle, doctor fees are no longer a sunk cost for the majority of Americans.  Most everybody now, has to pay full price or at the very least a percentage of physicians’ fees in addition to insurance premiums. Our young parents may want to factor the cost of seeing a pediatrician into their decision making process for a variety of good reasons, not just because they are looking to care for their baby on the cheap. And here is where the most absurd facet of our health care system makes its appearance. The prices for seeing a doctor are meticulously defined and used by insurers, but doctors are prohibited from divulging them, and the government is doing absolutely nothing to change that.

What the parents in our example need is a simple table with rows listing all the pediatricians they are considering, and columns across, listing what each insurance plan in their area has decided that parents will have to pay each doctor, at least for the most common services (including facility fees, if any). Using this and similar tables for their own health care needs, our little family could make an informed decision not only about which doctors to see, but also which insurance plan they should enroll in. Unfortunately for them, and for their doctors, and for us all, such tables are detrimental to the moneyed interests of big health care businesses, and therefore will not be forthcoming anytime soon. Instead, the government is throwing out bunches of dollar numbers that have nothing to do with anything, implying that there is great wisdom to be found in partial truths, and that we should get busy trying to find the secret keys to said wisdom. 

Armed with irrelevant quality measures about their doctors and deliberately misrepresented price information, patients recently turned consumers are expected to take on the medical industrial complex, very much like mice are expected to attack the cat amusing itself before dinner. Transparency, we are told is a very powerful tool for an enlightened citizenry, and it is. Translucency by design, and turbidity by negligence, which is what we are being served here, are very powerful tools too. Different objectives though….