Teachable Moments: Be Thankful for Gruber

So there is this guy from MIT or Harvard, or some other place where they teach our leaders how to lead, and his name is Jonathan Gruber. Mr. Gruber, it seems, was hired to consult with the Obama administration during the time the Affordable Care Act (ACA) was created because of his extensive expertise in designing the Massachusetts health care system. In recent weeks, people who don’t particularly like our President, and his Obamacare health insurance reform, began floating video snippets of Mr. Gruber publicly discussing the stupidity of the American electorate and the purposeful lack of transparency that in his learned opinion enabled the enactment of the ACA.

The rightwing conservative media savored their “I told you so” moment with great gusto. The leftwing media immediately rose to the occasion reiterating the litany of Obamacare benefits, which should not be forgotten just because this one guy said that we are all idiots. Mr. Gruber himself expressed “regret” for his “off the cuff” remarks. Perhaps they don’t teach linguistics at MIT, but “off the cuff” is not a synonym for erroneous. David Axelrod declared on Twitter that Mr. Gruber is the one who is stupid and the White House assured us that nobody there shares Mr. Gruber’s opinions. Some Congressional leaders, seemingly afflicted by the Iran-Contra syndrome, couldn’t remember who Mr. Gruber was, while others decided to bring Mr. Gruber in for questioning. Reality TV doesn’t get much better than this.

But what if Mr. Gruber is right? What if we are stupid? Not each and single one of us, and not all day, every day, but every two years or so when we come together to form the American electorate. Here is a dirty little public secret: many of us share Mr. Gruber’s opinion, albeit in a more eclectic format, and many of us have no problem publicly broadcasting our views. Liberals believe conservatives are too stupid to understand that Medicare is a Government run program, too stupid to understand scientific concepts, and stupid enough to go to war over imaginary threats. Conservatives believe liberals are too stupid to understand the Constitution, too stupid to grasp the basic concepts of freedom & liberty, and stupid enough to hand over our democracy to a fascist communist Islamic emperor on a platinum fundraising event platter.

Perhaps instead of gleefully watching the Gruber spectacle, we would be better served by trying to figure out why our collective actions look stupid when viewed from the elevated vistas of our rarefied intelligentsia. Using health care reform as an example, although there are many more equally instructive subjects, here are a couple of recent teachable moments that could explain our tarnished image.

California Proposition 45

On November 4th, California voters “soundly rejected” a proposition “that would have halted excessive health care insurance rates”. It seems that California voters like paying excessive prices for their health insurance, and if you like your excessive prices, you should be able to keep them. Alternatively, one could be tempted to surmise that California voters are too stupid to understand what they are voting for. Earlier this year, Californians expressed massive support for Proposition 45. Between then and Election Day a $43 million media blitz, financed mostly by insurance companies, descended upon California to convince voters that allowing health insurance corporations to steal their money, unencumbered by public regulations, is a good thing. It worked.

It may be worth mentioning that the non-profit Kaiser Permanente poured almost $15 million of its tax exempt revenues into defeating Proposition 45. Back in 2009, while the Affordable Care Act was being shaped, President Obama held out Kaiser Permanente as “one of the models of high-quality, cost-efficient care” that “would have solved our problems”, based on the experience of his grandmother in Hawaii. We may need to broaden the usage of epithets beyond the plebeian electorate.

But the one thing that breaks my heart in the Proposition 45 surreal, yet typical, chain of events is that almost without exception, California medical associations chose to align with and actively support the insurance industry. The same insurance industry that is treating doctors like commodities, firing them from networks at will, and is routinely robbing them of professional autonomy. TV commercials featuring real physicians, sporting white coats and stethoscopes, abusing their trusted relationships, reciting outlandish prophecies that no one can verify, littered the public airwaves in California this fall. Practically every organization whose members are paid with health care dollars threw its support behind this willfully deceptive campaign to defraud the people of California.

Insider Trading

Back at the start of 2013, the Centers for Medicare and Medicaid Services (CMS) indicated that payments to Medicare Advantage plans are “likely to decline by 2.3 percent in 2014”. On April 1st of 2013, CMS reversed its decision and released final Medicare Advantage rates for 2014 that showed an increase in payments following a “change in methodology”. Turns out that a Congressional staffer provided information to a lobbyist, who passed it on to an analyst, triggering a buying spree of health insurance stocks prior to the CMS announcement and lots of rich people got richer. The New York Times dutifully published an article in its business section outlining the insider trading investigation recently initiated by the Securities and Exchange Commission for this event.

Leaving this particular outrage aside, one might wonder about the nature of this “change in methodology” that triggered an increase in Medicare Advantage payments. Did the CMS revise its calculations? Did the original figures contain arithmetic errors? As it turns out, this is not about math. An email from the lobbyist to the analyst indicates that rates were changed because “a deal has been hatched to increase Medicare Advantage rates in order to smooth the confirmation of Marilyn Tavenner as the new head of Medicare”.

Unlike her predecessor, Dr. Donald Berwick, who is a staunch liberal with a long record of public statements to that effect, Ms. Tavenner was an uncontroversial appointee, with no political (or any other) damning baggage, and as such enjoyed the support of large swaths of the industry, as well as powerful Republican officials, such as Sen. Chuck Grassley and Rep. Eric Cantor. But that was hardly enough. It seems that today in America, the lawfully elected President of the United States, and the lawfully elected Congress, in order to perform the most mundane functions of their respective offices, must first grease the palms of health insurance companies. And the saddest part is that neither The New York Times, nor any other media outlet, thought this to be newsworthy.

Other Grubers

Mr. Gruber is just the latest public figure to express regret for being caught. Back in 2012, Gov. Romney had to stage a tortured apology for calling half the country irresponsible bums. Last year, the powerful Director of National Intelligence James Clapper, apologized for blatantly and intentionally lying to Congress about covert surveillance of most Americans. Just a few days ago, Uber’s CEO Travis Kalanick, staged a ridiculous Twitter apology for explicit threats to unfriendly journalists made by another Uber executive behind closed doors. Facebook apologized for experimenting on its users and Google constantly apologizes for snooping around without permission. We now have an entitled class that regrets only the inconvenience of having its business and opinions exposed, and subsequently used by their opponents in the power games played by the rich and famous.

Mr. Gruber rightfully did not apologize for his remarks, because they were authentic and truthful as most “off the cuff” utterances are. From the vantage point of our elected government and its diverse assortment of greedy consultants, the American electorate must indeed look pretty stupid. And from the higher perches of billionaires and corporate interests, both American voters, and their seemingly elected officials, must appear as the sheer embodiment of laughable stupidity. Instead of reflexively shooting the unsavory messenger, perhaps we should thank him for the heads up, look at ourselves in the mirrors held by great power and great wealth, and take stock of what we have become as a nation. We can do this, precisely because in spite of acting like a bunch of idiots lately, we are not, and never have been, stupid.

Quick Medicine

By the time the next decade rolls in there will be no paper charts. There will probably still be paper floating around in various capacities, but there will be no one charting on paper. The term “charting” itself may become obsolete, like yonder or popinjay. The term EHR, which is what replaces the paper chart, won’t last either because it doesn’t roll easily off the tongue like say, email instead of letter or missive. EHRs don’t do anything else easily, so chances are EHRs themselves won’t last much longer, relatively speaking. Sooner or later, the national spotlight will shift to something other than health care, and other electronic critters will emerge from the shadows.  What will they be? What should they be? Those could be two very different answers.

What Should Be

Have you noticed how people advocating for EHRs use the word quickly in practically every sentence? Mega EHR allows you to quickly document XYZ, and Super EHR can quickly gather all historical data and display it in a summary dashboard which allows you to quickly assess the status of the patient. You can quickly send prescriptions to pharmacies, quickly order a bunch of tests, and quickly print out (the horror!) education materials. Your staff can quickly schedule patients, quickly answer questions, quickly verify eligibility and quickly drop claims. Your patients can quickly get answers, quickly schedule visits and quickly have their concerns resolved.

Of course, most of these things are aspirational at this point, but the language is indicative of the thought process behind EHR design: hurry up and get it over with. Time is money and quickly disposing of each patient is absolutely imperative in a high functioning health system. You could argue that there is nothing wrong with speeding up, or even eliminating, administrative tasks, and you would be right. But is reviewing historical information on a patient and documenting today’s encounter an administrative task? When reviewing histories is compressed into briefly glancing at a bunch of sparklines like they have for the stock market, it may seem like you are engaging in an administrative task. Buried somewhere deep in the dark chart though, there may be a note you made about Mary’s difficulties to navigate the front porch stairs last year.

Why did you make that old note? It’s not required for billing. It’s not demanded by insurers. What made you type that in? Do you usually make notes about irrelevant things that you fully expect to never see again? When you used paper charts, you had to flip through many pages to gather the information you can now quickly glean from your infographic patient dashboard. And while you were paging back and forth through that chart, chances are you would have stumbled upon that little note that seemed important enough for you to scribble down last year. And maybe you would discover other little notes too.

Is reading a book the same as reading the SparkNotes? Oh, you will pass the test either way, and may even get better scores with the SparkNotes version, but is it the same? Is reading this: “Ultimately, he is unable to bear the psychic consequences of his atrocities”, the same as reading this: “Tomorrow, and tomorrow, and tomorrow, /Creeps in this petty pace from day to day, /To the last syllable of recorded time; /And all our yesterdays have lighted fools /The way to dusty death. Out, out, brief candle! /Life's but a walking shadow, a poor player, /That struts and frets his hour upon the stage, /And then is heard no more. It is a tale /Told by an idiot, full of sound and fury, /Signifying nothing.”? Which version leaves you better equipped to address the story at hand, and the story-teller himself as a whole person? And which version makes you, the reader, feel more like a whole person?

Whatever else the EHR of the future might do, it should quit trying to quantify, summarize, highlight and decontextualize the soul out of the medical record. Disposing of patients quickly should not be our goal. Other than being demeaning and dehumanizing for all involved, seeing patients quickly is the root of all our health care woes. In an environment increasingly hostile to human interaction, EHRs should ferociously fight to create more time for patients to spend with their doctors. EHRs should automate the business of medicine and eventually the science of medicine, while protecting the art of medicine. And by art, I don’t mean compassion and advocacy. I mean the application of professional judgment, without which the science is incomplete and will always be incomplete, regardless of how many genes we can map or how many bots we can implant in ourselves.

Assuming that the business of health care will be marching along the glorious path currently laid out by our betters, the EHR of the future should endeavor to become a silent background processing machine. Natural language processing should be the first and foremost feature to be implemented to perfection. The EHR should parse and extract useful information from doctor-patient interactions to maximize physician reimbursement by maximizing claim values (yep, I just said that), and by scouring all opportunities to obtain incentives and bonuses from the overlords, and automatically applying for all, without user intervention. Not an easy task, but IBM Watson could drop out of medical school and take this on.

The flip side of maximizing revenue is to cut overhead. No practice needs a scheduler. Let patients schedule themselves online or on the phone. Let them check in and let them room themselves (think about those little restaurant gizmos that beep when your table is ready). Let them take their own vitals and answer all those preliminary questions on their own. For the outliers, the frail and the elderly, one medical assistant can cover these tasks for bigger practices. It doesn’t sound much like an EHR because it isn’t.

What else costs money, but has practically nothing to do with medicine? All the school notes, the back to work notes, the disability forms, trade forms and all other forms, authorizations, pre-authorizations, eligibility checks, statements and everything in between, can be delegated to computerized self-service. Get the medical records online and let patients have at it. Make it user friendly like all other trivial consumer facing apps that have absolutely no bearing on enterprise technologies. Make them colorful and fun. Show pictures, animations and ads. Put them on the iPhone. Monetize the heck out of everything, and remove this purely administrative burden from the practice.

And then comes a moment when restraint needs to be religiously exercised. Stay the heck away from the exam room. Let people say whatever they want to say. Let doctors ask whatever they want to ask. Forget about boxes, no matter how useful they look. Forget about structure too, because Watson will be taking care of that. Don’t make documentation easy, because taking notes is not just about documentation. It is mostly about the background thought process that makes one decide what to note and what to discard. Remember, the way you would use different styles of handwriting and text of different sizes or boldness, and how you added critical notes in the margins, or big pointy arrows? Actively taking notes helps you synthesize information, internalize, memorize and understand the narrative (programmers, think back to your college days).

If EHRs want to be helpful, let them be secretaries. Arrange the notes in a way conducive to better information retrieval. Don’t summarize and don’t impose your (or your machine’s) notions of what is or is not important. Collate and bind everything into a patient book. Remember that this is a reference book and the user can read at a 30th grade level. It is not a cookbook and it is certainly not a picture book. Add a table of contents. Use the computer to make it dynamic. Make it easy to flip pages in an electronic context. Make the fonts nice and large, and do learn from beautifully maintained old paper charts. Go out and look at some before they are extinct. You can’t improve that which you don’t know.

What Will Be

Of course none of the above is going to materialize in a meaningful way, except maybe the infantilized consumer facing EHR. Health care is going retail and health care will care about its customers precisely as much as Walmart and Amazon do. And health care will care for its employees as much as Walmart and Amazon do. When providers are all transitioned to having their employer paid for value, EHRs will become very easy to use. A few big buttons, at the bottom of pages prefilled with stereotypes and sprinkled with colored sparklines, should quickly do the job (i.e. Order, Refer, or Deny). There will be nothing for you to document and nothing for the patient to convey because the system already knows everything there is to know. Eventually, it will dispense with the buttons altogether, and your job will be to quickly explain to your customer why the system did what it did. And you will never have to use a computer ever again. Mission quickly accomplished.

Technology for Onesies Twosies

“We’re not really set up to service onesies twosies… Oh, I’d say at least fifty to even begin a conversation… There’s no money there, and support is a nightmare. You know what I mean… Besides, there aren’t many left anyway…”

According to the American Medical Association, there were approximately 685,000 physicians in patient care, post-residency, not employed by the federal government, in 2012. 60% of these physicians practiced in independent private practice, and 84% were working in small to medium size practices. Assuming that the trend to employment of doctors by health systems continued unabated to this day, over half of practicing physicians are still in private practice and the overwhelming majority is working in small to medium practices. Let’s pause, and allow this simple fact to sink in.

When it comes to EHRs and health IT in general, you are the omnipotent consumer. Unfortunately, the best and brightest seem to consume just like the worst and dumbest do. Would you buy 10 magazines for a chance in hell to “win” $100 million? Would you open a bank account if I give you “free” checking? Would you use my credit card if I give you 1 cent back on each purchase? Would you click this shiny button if I let you use my “free” software? And what would you do for a Klondike bar?

Case in point: Meaningful Use is a voluntary program. The maximum incentive per Medicare physician is equivalent to seeing one more patient per week. The maximum penalty for a typical Medicare physician can be recuperated by seeing one more patient per week. The cost of using a Meaningful Use EHR, in both cash and physician time, far exceeds one weekly visit. Can someone please enlighten me on why there is no market (and trust me, there isn’t) for non-government sanctioned technology that is purposely built to serve doctors? Remember, you own more than half the market.

After swallowing Meaningful Use, hook, line and sinker, here comes desert. The goal of Meaningful Use was to collect enough information about your patients, so you, and every Silicon Valley funded techie, can process the health of large populations in bulk. As any United States Postal Office clerk can tell you, bulk processing of things is much cheaper than first class processing of the same, but bulk processing requires specialized machinery beyond the simple collection of items to be processed. The bottom line is that in order to stay competitive you will have to buy more technology. In light of your previous shopping history, we know exactly what’s going to transpire. You will buy whatever junk the government subsidizes. And you will use it in the prescribed manner, while complaining that it is taking the joy out of medicine, the quality out of patient care and the profit out of your practice.

You will be using your EHR to dutifully collect the meaningful dataset each time a patient walks through your door. Your interoperable EHR will then feed the data to a population management software product, which processes the data to yield such insights as the exact size of the diabetic population in your practice, tagged with the exact levels of Hemoglobin A1c results for each item. The artificial intelligence embedded in the population management software then performs some very complex analytic tasks, which are beyond the capacity of the human brain, to highlight the items outside normal parameters (e.g. A1c > 9), and very advanced analytic software may even suggest that these outlier sub-populations need additional management (e.g. behavior modification to eat less candy).

But wait, there is more. Population management machines can actually predict the future of mankind, one man at a time. The superhuman intelligence embedded in these software products can take advantage of massive genomic data and situational data to predict the future health of any given person, which is something that a mere country doctor could never, ever accomplish by his lonesome self. For example, you can be alerted in real time that the 30 year old guy with a recorded BP of 140/100, who is 50 lb overweight, smokes a pack of cigarettes per day, works in a call center 10 hours every day, and whose hobbies consist of watching reality TV and playing video games, will be developing some very expensive diseases in the future, and you’d better do something about that. 

This is truly amazing stuff, but sadly these exquisitely useful population management machines are also exquisitely expensive. The global market for population processing products is projected to reach $40.6 billion within the next three years (probably a gross underestimation), and there is no assurance that you will be included in this booming market, because without government assistance, selling technology to onesies, twosies is like herding cats for no reason. Onesies, twosies is a term of endearment in the industry for small independent practices that find it difficult to part with their money, and where physicians are obsessed with “seeing patients”, instead of schmoozing with disruptive innovators. Luckily, and right on cue, the government is jumping in to lend a helping hand.

For the already tech savvy, but cash poor private practice, CMS is now offering to pay upfront for your technology investments, if you agree to assume risk for the health and happiness of your populations. You would have to band together with other likeminded practices to form an Accountable Care Organization, and CMS will in turn advance you enough cash to pay for population processing infrastructure. You pay CMS back with several years of hard labor to reduce expenditures for your population. If you fail to save CMS money, or if you decide to walk away, you will have to return the entire cash investment to CMS. Your technology vendor is not likely to be encumbered by such medieval arrangements.

For the laggards and procrastinators, starting on January 1st 2015, the Medicare physician fee schedule will include a new CPT code for Chronic Care Management (CCM) that will pay you $42 per month, to provide 20 minutes of non-face-to-face services to people with two or more chronic conditions who agree to pay $8 copays for the privilege. After decades of silent complicity in the destruction of primary care, Medicare is placing a significant amount of money on the table for you, with the understanding that this too requires certified EHRs and a roadmap to population management infrastructure that will enable you to eventually assume risk for your empowered patients.

Disruptive innovation, according to the grand priest of innovation, Prof. Clayton Christensen, “is a technology that brings a much more affordable product or service that is much simpler to use into a market. And so it allows a whole new population of consumers to afford to own and have the skill to use a product or service, whereas historically, the ability to access was limited to people who have a lot of money or a lot of skill”. This definition does not seem to fit the, taxpayer funded, successive layering of complex and increasingly expensive big iron technology products, on an already unaffordable industry sector. A more modern interpretation of Prof. Christensen’s definition seems to be in order.

Let’s define consumers to be health insurance companies, and in their world affordability means profitability. The products are the covered lives and the services are your labor. Now we have a technology that brings much more profitable covered lives and medical services that are much simpler to manage for health insurance companies. And so it allows a whole new breed of insurance plans to profitably enroll covered lives and have the skills to manage physician labor, whereas historically, the ability to do so was limited to insurers with particularly savvy business models and a lot of manipulative skills. Here is your disruptive innovation. The end game of course is to remove actuarial risk from health insurance stakeholders and transfer it all to you.

Theoretically, you, and all other onesies twosies, or even twenties and fifties, who form the (still) independent majority, could stand up and stop the madness. Theoretically.