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.