What the Heck is mHealth?

Wanted: White knight (shiny amour optional) to save us from ourselves and the wretched lifestyles we choose.

Your coffeemaker went dead on you this morning, and while lamenting your drowsiness at work, your friend Denise mentions that she just bought a new coffeemaker at Target and she absolutely loves it. You take your coffee the same way Denise does, black, strong, and all day long, so you decide to buy one for yourself. You are a busy professional and you don’t have time to go to Target, search for a good parking spot, walk to the store, walk around until you find the small appliances, pick it up, stand in line, walk back to the car, struggle to back out from the too narrow parking space, and drive home through congested intersections. It could easily take half an hour out of your already busy day. So you decide to buy it online in the evening. You get home, feed the kids, answer a couple of urgent emails from your boss, and after everybody goes to bed, you settle down to finish those spreadsheets you meant to complete at your office, but ran out of time. In between emails and spreadsheets, you remember your coffeemaker, browse to Amazon.com, search for it, find it, and are getting ready to order when you notice that the ratings are not stellar. It seems that 347 shoppers, just like you, gave it only 3 stars. Surely you can do better than that. So you search for coffeemakers in general, find a whole bunch, sift through ratings after ratings, and learn that people that bought a coffeemaker also bought filters and funny little measuring spoons. An hour later, you settle on some other coffeemaker, throw in a gold filter that never needs replacing, some organic rainforest coffee, and a box of genuine Italian biscotti that the raters say go great with your green coffee, and order the whole bunch from Amazon, which gives you free two days shipping with one click of a button. You feel very efficient and very accomplished. You just spent twice as much time as shopping at Target would have taken, sitting on your chair in the comfort of your home, spent twice as much as you intended, and for the next three months or so, every time you open a browser, some well-meaning retailer will be providing you advice on what else you need to buy to make your coffeemaker happy. You have proven that you are a good and savvy consumer, and now you can advance to the next level, and try your hand at consuming health care.

The first order of business is to place health care at your fingertips so you can shop for it while sitting motionless on a chair, in the comfort of your home. Going to an actual doctor is as inconvenient and as detrimental to your worker productivity as going to an actual store, and probably much worse, because once you enter the doctor’s office, you are denied the freedom of choice that comes from being able to compare ratings and opinions of other savvy shoppers like you, and barred from accessing the benevolent advice freely available on websites. Health care shopping is the ultimate level in this game, so it requires new tools, collectively known as mHealth, or mobile health. Mobile, not because God forbid you may have to move to use them, but because these sophisticated tools do all the moving for you, much better than the old fashioned Amazon.com ever did. mHealth can attach itself to your pocket, your clothes, your wrist, your underwear, your skin, your eyes, and can even nestle comfortably inside your body. mHealth does not need you to summon it into existence like Amazon.com did. mHealth is always there, tirelessly working on your behalf, anticipating every muscle twitch, every thought and every desire you may have, providing you with healthy advice and support in your times of need, even in your sleep. Like a good butler of days gone by, mHealth makes it its business to quietly learn everything there is to know about you, so it can provide you with a level of personalized service, once only available to fabulously wealthy individuals, and now available for free to every convenience seeking pauper.

As of February 10, 2014, the Apple iStore contains 29,504 health & fitness apps, and 23,420 medical apps. Together, these apps are known as mHealth. Most are free, some cost a few cents and some have substantial pricing. Most are standalone, simple things, and a few are part of larger elaborate systems of smart hardware, some wearable, others to be used at certain times only. They range in scope from expert advice on where to buy pesticide free eggplant to FDA approved medical devices for measuring the function of your heart. There is only one thing all mHealth apps have in common: they all collect information about you. Collectively, mHealth knows when you are sleeping and knows when you’re awake. It knows what you are eating, when you eat it, and where you are while you eat it. It knows if you are walking or running or just sitting down. It knows your vital signs, your mood, your diagnosed ailments and all the medications you are taking. It knows who your friends are, what they look like and sometimes what they are eating too. It knows more about you than your spouse, your mother or your children. And since mHealth is a social animal, it is happy to share all that knowledge with the world, so the world can better cater to your specific needs. And the world is eager to reciprocate and share everything it knows about you with your mHealth. From Amazon.com to Target, the IRS, the DMV, MasterCard, the Department of Homeland Security, your alma mater and even your own car, everybody will be joining forces to serve your health in more and better ways.

There is one small problem though, and that’s your secretive relationship with your doctor. For some reason, doctors insist on talking to you alone, behind closed doors, like criminals. They say things, you say things, maybe you all look at things, and nothing gets transmitted to your mHealth. The world and mHealth can’t really help you if you keep secrets from them. The government, acting on behalf of the world at large, is now installing computers in doctors’ offices and mandating disclosure of your secretive conversations. That’s a good first step, but the ill-fitting EHR technology is still unable to communicate with the world, let alone your mHealth. To speed things up a little, the government is paying doctors to make you manually transmit your previously secret information to your mHealth. With one click of a blue button, you can liberate decades of your most private secrets, and send them to roam free through all the mHealth apps out there and combine themselves in most fortuitous ways with data from Amazon, Target, Verizon and all other agents toiling on your behalf.

And if you think this is some sort of utopian wishful thinking, I suggest you read the recent issue brief from the Office of the National Coordinator for Health Information Technology (ONC), about the government’s plans on “Using Health IT to Put the Person at the Center of Their Health and Care by 2020”. It’s only eight pages long, with large fonts and soaring rhetoric that mentions the word physician only once and makes no reference to doctors, because this is all about you, the person and future patient. By 2020, the ONC envisions that “The power of each individual is developed and unleashed to be active in managing their health and partnering in their health care, enabled by information and technology.” You get goosebumps just thinking about the tens of thousands of elderly folks with heart disease, cancer, and dementia, suffering in silence and yearning since the Second World War to have their powers developed and unleashed.

This wonderfully clear ONC manifesto, lays out a roadmap to a “brighter, more inclusive future”, enabled by the “emergence of health IT, including consumer eHealth tools” (a.k.a. mHealth).

• A future where: “Individual self-determination and the public good are both optimized”
• A future where we: “Motivate policymakers, employers, and other stakeholders to establish guidelines and environments that promote and support healthy behavior”
• A future where we: “Soften or erase the boundaries between what occurs inside and outside of the health care system by promoting increased information flow”
• A future where we: “Encourage providers to value patients and their data”
• A future where we: “Build appreciation for and competence in technology-enabled self- and shared management of health and health care, by both providers and individuals”
• A future where we: “Encourage interaction in online communities via social media”
• A future where we: “Facilitate the aggregation of health and health care information for individuals and populations from diverse sources, including non-clinical information if desired”
• A future where we: “Promote technology that shows trends in diverse health status measures, including deviations from normal for the given individual”
• A future where we: “Promote easy-to-use technologies that integrate individuals’ health activities and treatment into the rest of their lives, where and how they already live, work, and play”

This is just a happy roadmap and ONC is not certain if “consumers and providers will fully embrace the resulting cultural shift”, but they are “optimistic that stakeholders will rise to these challenges”. I am too, and Mr. Kurt Vonnegut was already optimistic back in the middle of the previous century. Unfortunately, Mr. Vonnegut died before his power could be developed and unleashed, and thus was spared the joy of watching the stakeholders rise with the shifting cultures, but wherever you are Kurt, here is a rainforest coffee toast to your prescience. Amen.

10 Misfortunes We Shouldn’t Blame Obamacare For

There is a new report out from the Congressional Budget Office (CBO) titled “The Slow Recovery of the Labor Market”, and as its title implies, it predicts a slow recovery from a labor perspective. Among other things, the CBO report is now making headlines in the political game of Obamacare because it forecasts a 2.5 million job reduction by 2024 due to the effects of the health care law. You should read the report itself (it’s not very long and it has lots of pictures), because it is practically impossible to find objective coverage of its contents in today’s media, which is full of ideology driven experts and completely devoid of old school reporters. I don’t know about you, but I for one am growing tired of the incessant drumroll crediting or blaming Obamacare for everything from the price of gas at the pump to the demise of penguins in Argentina, so let’s show some magnanimity and absolve Obamacare from, at least, the following 10 naturally occurring phenomena.

Number 10: The CBO labor forecasts – Starting with the most recent development, we should observe that the CBO report is not stating that Obamacare will create a shortage of jobs or increase unemployment, which will remain high independent of Obamacare. These 2.5 million jobs are projected to be voluntarily forgone by people, or as the White House press secretary put it, “Americans would no longer be trapped in a job just to provide coverage for their families, and would have the opportunity to pursue their dreams”.  And for 2.5 million able bodied folks, those dreams are projected by the CBO to include no work. Instead of having to toil from dawn to dusk in large offices or start small businesses of their own, Americans now have a choice, and we should rejoice in utter disbelief that in a country where one in five children is living in poverty and unemployment is rampant, citizens finally have the liberty to earn no income.

Number 9: Health insurance cancellations – Much ado about nothing was made of millions of insurance cancellations sent in bulk to those who purchased health insurance on the individual market. In case you weren’t aware of it, this type of mass turnover has been occurring in this hapless segment of the market since the beginning of time. Every year, all insurance companies rescinded all policies for all their customers. If your experience is different, then you are definitely an outlier. Besides, it is a well-known fact that individual market policies, as opposed to those issued by benevolent employers, such as Walmart or McDonald's, were pure garbage before Obamacare, as any retired executive, or middle class family can tell you.

Number 8: Health insurance premium hikes – Seriously? We wouldn’t be having Obamacare if insurance premiums wouldn’t have crippled our economy, impoverished the nation and rendered Apple and Google incapable of competing in the global markets. It is true that Obamacare is forcing insurers to pay out a fixed share of revenues to doctors and hospitals, but Obamacare is also delivering millions of fully subsidized customers to private insurers, allowing revenues to grow through volume in addition to the customary growth in unit margin. This should help avoid wanton increases in premiums beyond originally projected ones.

Number 7: Price of Care – Yes, prices for medical services are exceedingly high in the U.S., but Obamacare was obviously not the catalyst for those. The hospitals started this trend many years ago, and private insurers who like any honest enterprise, get to keep a percent of their revenues, had little incentive to curb the hospitals’ enthusiasm. It is true that Obamacare is providing incentives to hospitals to consolidate into price gauging monopolies, but aren’t monopolies the natural outcome of a free market? The cost of health care in the U.S. was almost double its nearest European competitor before Obamacare, and it still is, and Obamacare had absolutely no ill effects, or any other effects, on that sad statistic.

Number 6: Narrow networks – It seems that people signing up for new Obamacare plans are having trouble getting to see their old doctors, because health insurance companies have concluded (based on extensive and nonexistent research) that folks prefer cheap insurance over actual medical care. Thus, all consumer centered benefit designs include less doctors, less hospitals (particularly popular ones), less of what consumers don’t need or want, and more insurance stuff, such as peace of mind. This cost containment strategy has been initiated long before Obamacare was even contemplated (remember the nineties?), and it worked exceedingly well when combined with #8 above. All Obamacare did, was to create the healthy transparency needed for us to observe this highly beneficial trend towards value for our most esteemed citizens, such as AARP and United Healthcare.

Number 5: Shortage of doctors – Ah, the scare tactics of the rabid right are at work again. Supposedly, Obamacare and its millions of uninsured will be flooding doctors and hospitals, squeezing paying customers out of their place in line. Nothing could be farther from the truth. First, as any Obamacare advocate can tell you, we’ve been having a shortage of doctors long before Obamacare kicked in a month ago, so this has nothing to do with the health care law. Second, Obamacare contains many provisions aimed at finding ways to liberate doctors from the practice of medicine, and to liberate medicine from practicing physicians, so consumers can avail themselves of health care uninhibited by ancient guilds. Also, when insurance plans are firing doctors from their networks by the thousands (see #6 above), how can any free-marketer in his right mind suggest that there is a shortage of doctors?

Number 4: The insurance gap – This is the bleak spectrum of folks who are not poor enough, old enough, young enough, or otherwise demographically endowed enough, to enjoy the opportunity of pursuing their dreams of not working while having the peace of mind that comes with an insurance card. Obamacare tried its hardest to liberate these folks, but a conservative Supreme Court and recalcitrant Governors in red States have come together to obstruct the expanded Obamacare subsidies in many States. It looks like the Governors are beginning to soften their stance though, so we should see more Medicaid cards issued soon. Either way, Obamacare did not cause folks to be in this category to start with, and if you must blame someone, blame the Governor or the judicial branch of government.

Number 3: The Website – We’re talking about a website, a minor technical detail that has absolutely nothing to do with the essence of Obamacare. Yes, Healthcare.gov and several other local health insurance exchanges have been a good example of how not to build and deploy software. It was a learning experience for the nation, and there is clear value in that. As any entrepreneur can recite in his sleep, failing early and failing often is the only way to achieve success. And the website seems to have accomplished that, at the modest cost of less than half of what it would cost to build, say, a new Space Shuttle.

Number 2: Redistribution of wealth – Yes, Obamacare is providing subsidized insurance to the poor, and yes, Obamacare is forcing the young and healthy to pay more so that the old and sick can be charged less, and if you look at the chart published by the Brookings Institute, your heart will sing with joy at the sight of two huge positive columns of gains for the very poor, and the tiny loss columns for everybody else. Until you read the full report, that is. Those huge income gains for the poor, you see, include the money paid by the government on their behalf to insurance companies, and as Brookings wisely shifts the terminology, these are gains in “well-being”, not cash in your pocket. We could use similar logic to divvy up what the government pays defense contractors, agribusinesses, all foreign aid, government salaries, and pretty much the entire federal budget, and show a vast increase in “well-being” for the poor. The President’s recent lukewarm inequality rhetoric notwithstanding, rest assured that Obamacare is not even remotely trying to alter the Darwinian redistribution of wealth in use today.

Number 1: Dysfunctional government – Obamacare, although the most hotly debated federal undertaking in recent memory, cannot be blamed for the present impotence of our federal government, no matter what they tell you from the right or left side of the aisle, or the TV.  If President Truman were alive today, he could write volumes on his own “Do Nothing” Congress. Obamacare is actually the one rare incident where a significant law has been passed in the five years following the election of President Obama. It is testimony that Congress can indeed legislate, and it is proof that our government is working as redesigned by an invisible hand. Sure, Obamacare has been the favorite football for the biggest exhibition game on earth right now, but you don’t usually blame the football if your team just doesn’t show up in New Jersey.

To MU or Not to MU 2, that is the Question

Meaningful Use Stage 2 is now on the clock. Three years after the program began in 2011, and a year later than originally planned, the escalator has finally moved up one level. Surprisingly, the usually boisterous and highly hyped health information technology (HIT) media is largely silent on the subject. It’s almost like everybody gave up, or perhaps the entire Meaningful Use exercise is now assumed, and the buzz has shifted to sophisticated analytic apps, preferably mobile, that will utilize all the big data collected by EHRs to perform medical or fiscal miracles. Of course, the best engineered and the sleekest looking Ferrari cannot run without fuel, and since Meaningful Use participation is the fuel for all the cutting edge innovation floating around in the intelligent apps market, it may be useful to take a quick look at the Meaningful Use state of affairs for 2014.

Let’s get some numbers laid out first, so we can have an informed discussion.

• According to CMS, back in 2011, the first year of Meaningful Use, approximately 60,000 physicians attested to Meaningful Use of a certified EHR and 50,000 more attested to buying or upgrading to one. That’s at least 110,000 doctors that purchased a certified EHR in 2011, and probably more.
• By December 2013, 213,000 unique physicians attested to Meaningful Use in the Medicare program, over 20,000 for the first time in 2013, and most likely a bunch more newbies will be added in January and February of 2014. For Medicaid, 100,000 doctors attested to something so far.
• If everybody continues to participate in the program, we are looking at upwards of 350,000 physicians, not counting new ones in 2014, that will be needing an upgrade to a 2014 certified EHR, which is the only allowed EHR edition in 2014, whether one is attesting to Meaningful Use Stage 1 or Stage 2.
• The number of 2014 certified ambulatory EHRs is approximately the same now as the number of certified EHRs was in January 2011. While the supply is the same, the demand should be 3 times higher.

For anyone vaguely recalling the difficulties experienced by many in obtaining a “certified” EHR version in 2011, the three fold jump in demand should immediately become cause of concern. This is most likely why CMS is allowing all Meaningful Users to attest for only 3 months in 2014, regardless of the Stage they are at. Theoretically, one would have until the first week in October 2014 to begin this year’s attestation period. Unfortunately this is not exactly the case for everybody. If 2014 is your first year of Meaningful Use, you must complete your attestation by October 1st to avoid the penalty. You could roll the dice and start your reporting period as late as July 1st, hoping and praying that the reports will be satisfactory, planning to work late on September 30th to get all your stuff ready, and keeping your fingers crossed that there will be no snags with the attestation site that evening. If the stars fail to align, you will be penalized. I am not certain about this, but I wonder if the possibility exists that you will be both penalized and incentivized in the same year.

If this is not your absolutely first year of Meaningful Use, all attestation periods are tied to calendar quarters in 2014, so you can either start on January 1st, April 1st, July 1st, or October 1st. You cannot just run reports until you find a “good” 90 days period. If one of those four periods is not good enough, that’s too bad, you’re out for the year, and since this is a new EHR version, chances are some unexpected “glitches” may occur. In the past, people devised several “workarounds” to improve on Meaningful Use reports prior to attestation. Those workarounds included, retrospective data updates for things like problem lists or demographics, and the perennial favorite of “print to file”, where clinical summaries are sent to a virtual PDF printer to increment the EHR count with minimal deforestation effects. Since attestation periods are fixed now, and since those attesting to Stage 2 are looking at significantly higher thresholds, and some new ones to boot, one should expect a much higher incidence of innovative fixes to workflows.

Another thing to keep in mind is that clinical quality measures (CQM) reported this year, partly for PQRS, may become public. While in the past, the numerator for these measures was irrelevant to attestation success, good performance is very important now, and carelessness with the numbers may very well come back to haunt you in the not too distant future. Fortunately, CMS has increased the pool of CQM sanctioned for reporting, so everybody, including specialists, can pick measures pertinent to their practice. Unfortunately, with the exception of a handful of EHRs, most vendors chose to not certify for all possible measures, so this year, just like in 2011, most physicians will have no choice of CQMs. Keep in mind that the reporting requirements for CQMs in 2014 is the same for all participants (i.e. 9 measures, electronically submitted), regardless of Meaningful Use Stage, except for first year participants, who are exempt from the electronic requirement.

[Note: On 2/1/2014 HIMSS, the EHR vendors association, has posted a remark on the HIStalk blog stating that "CMS is permitting manual attestation on clinical quality measures for meaningful use in 2014, as has been done through 2013, not just for those in their first year". The official CMS website is stating otherwise, but I am not one to dispute the insider information of HIMSS, so expect some changes.]

Speaking of choices, those planning to attest to Stage 2, are allowed to pick 3 measures out of 6 menu choices, two of which are practically impossible to choose, since not many States have the ability to receive electronic data to cancer, or some other registry (other than immunizations), and also because almost all 2014 certified EHRs chose to not certify themselves for these measures. Realistically, there are no menu choices for Stage 2, and we should have probably never expected any, based on recalling that back in 2011 many EHRs were certified for functionality they didn’t really have (e.g. immunizations interfaces in all 50 States).

Another baffling set of numbers comes from this year’s National Ambulatory Medical Care Survey (NAMCS). A joyfully reported 78.4% of physicians in the U.S. have an EHR, and 48.1% have a “basic” one (i.e. an EHR with functionalities that could satisfy basic Meaningful Use requirements), or better. The question that always springs to my mind looking at this graph is what on earth do 30% of doctors have in their practice? Microsoft Office? There is practically nothing you can buy today that does not meet the definition of “basic”, yet the gap between basic EHR and any EHR, shows no signs of narrowing down, which in my mind, makes these survey results questionable at best, but I digress.

The 48.1% of basic EHR users matches very well with the approximately 350,000 physicians that are participating in the Meaningful Use program. The NAMCS also finds that 13.1% of physicians are ready for Meaningful Use Stage 2, which means that practically all physicians that started their Meaningful Use journey in 2011 were using a 2014 certified EHR and were ready to move up the ONC escalator at the time they were surveyed. Considering that the “2013 NAMCS EHR survey was conducted from February through June 2013”, I doubt that very much, seeing that there were no 2014 certified EHRs on the market at that time. Perhaps those optimistic doctors meant that they are confident that they (and their EHR vendors) will be ready when the time comes.

Either way, we are left with over a quarter million doctors who don’t think they are ready for Meaningful Use Stage 2, and perhaps unbeknownst to them, they are also not ready for Meaningful Use Stage 1, which requires this year a brand new, 2014 certified EHR, and another two hundred thousand physicians who think they have an EHR, but really don’t. If 2014 was designed to stress test the $18 billion (so far) Meaningful Use program, odds are the crash will be spectacular. If, on the other hand, the thinking was that as long as the camel is on the move up the escalator, we can happily add bale of straw after bale of straw to its back ad infinitum, we’re in for a bit of a surprise this year.

The Hippocratic Message in a Bottle

I like reading Dr. Kevin Pho’s blog. I read, or at the very least scan, his diverse collection of essays every day. The posts themselves are mostly good, but I like reading the comments section more, and most of all I like the anonymous comments, because those are rare insights into how regular, everyday doctors think. I read Health Affairs and JAMA and NEJM and the New York Times to figure out what “thought leaders” say, and medical associations’ websites for “leadership” messaging. And guess what? The anonymous, and sometimes not so anonymous, opinions of the rank and file are diametrically opposed to official party lines. Of course, most doctors don’t read or comment on blogs, don’t speak at conferences and don’t write opinion pieces for mass media outlets. Over the years, I spoke with many members of the silent majority, not a representative sample by any means, but a good indicator that anonymous commenters are closer to being representative of popular opinion than their much more visible counterparts, most of whom have quit the practice of medicine years ago, if they ever practiced at all.

There is a dark cloud of discouragement, dejection, disheartenment, and all other synonyms of despair, hanging over the medical profession. It’s not that all physicians live in constant gloom and doom, although quite a few do, particularly those still in private practice, but the profession itself seems to be losing its luster. Some doctors seem content to pragmatically adapt to the new and duller definition of their old profession, but in other quarters there is deep seated anger stemming from the perception that this is something purposely inflicted on physicians by a power hungry government, greedy businesses and an ignorant and ingrate populace. No matter how the conversation starts, the question seems to always be whether there is anything that can be done to turn the tide. And no matter what is said and done, the exchange of opinions always devolves (or evolves, depending on your position) to money – cash, payment, reimbursement, fees, compensation for long years of learning and training, and for performing arduous work that is really (or at least should be) beyond monetary valuation. And this, my friend, is the most counterproductive narrative of all. This is where you shoot yourself in the foot, albeit with undeniable gusto. Regardless of its merits, this is a nonstarter.

The hurricane hitting health care today can be traced in its entirety to money. We would not be having this dialogue if medical care was affordable for the average American, and if the sum total of national expenditures on health care would be hovering around 10 to 12 percent of the inadequate measure called gross domestic product (GDP). You can engage in the futile exercise of splitting hairs trying to allocate blame for runaway costs away from doctors, but you would find yourself outgunned, outnumbered, and late to the game. The mass media is chockfull of randomly chosen inflammatory examples of the small fortunes charged by physicians and hospitals for stitching a pinky finger. The shining bright lights make every pharmaceutical hotdog cast a shadow the size of the Keystone XL. Large insurance companies are providing interviews to anyone willing to listen, on their strategy for keeping premiums affordable for the working man by expelling “low value” providers from their “high value” networks.  And Medicare just announced that it will be releasing information on how much money it pays to individual physicians, because the “public has a right to know”. How do you fight that?

The same way George Washington fought the war of independence – you redefine the battlegrounds and meet the enemy at a time and place of your choosing; a time and place where your inferior force is actually an advantage. So first of all, you don’t discuss money, and you certainly don’t go into endless tirades about your accounts receivable and accounts payable over the last 30 years. Why? Because complaining about the frosting on your cake while your audience is starving is not a very endearing or effective method for garnering support and sympathy. There is no way you can convince the nine out of ten Americans who would gladly trade places with you, that your work is hard, your life is hard, and your six figure income is inadequate compensation for lack of joy at the office. There is no way you can explain to a nation that makes on average around $50, 000 a year, that $150,000 is not good enough. And bluntly telling them that they are too stupid and too lazy to do what you do, and that’s why they are deservedly worse off, is not going to get you much applause either.

The second rule of engagement is that you should never confuse your arguments with political partisanship. Why? Because, the moment you do that, you lose half your audience, and it doesn’t really matter which half. If you are ever going to win this battle, you need all the hearts and souls you can get. You don’t discount half the country by calling them irresponsible moochers, and you don’t throw out the other half by labeling them heartless disciples of Ebenezer Scrooge. Your best, and arguably only, weapon in this fight is that both halves still trust your professional voice. You don’t further diminish that trust by descending into the political swamp to meet your enemy. You pick your time and place. You choose to fight on the moral high ground.

You took an oath to help the patient in front of you, to the best of your ability and judgment. Whatever modern enlightened technocrats think about ancient oaths, potions and incantations, there is an implied promise here to conduct one’s professional life in an ethically responsible manner, which is more than can be said about any other secular profession. So what happens when your ability is harnessed by entities whose sole raison d'être is to increase shareholders profits by any means necessary, and your judgment is subordinated to agencies that live and die within political election cycles? Your ability is steadily crippled by diluted training and limited practice, and your judgment is shelved in favor of shiny fly-by-wire instrument panels (medicine is like aviation, remember?), configured by invisible and unaccountable hands. This is what the public needs to know and thoroughly understand.

If you are going to speak up, make public statements, write blogs, start a movement, or just post an anonymous comment somewhere, you should stick to your high ground, your guns and your strategy to inform the public about health care issues that matter to individual people, their children, their parents and anyone else they hold dear. You can write stories, relate experiences, compose elaborate treatises, sponsor studies and do research, and all of these things need to be about the one patient in front of you. When people come to you for advice, they should understand that it’s not necessarily your advice they are getting now. When the frightened ask you what you would do in their place, they need to know that you may not be at liberty to give them an honest response. They need to know that advocating for your patients, may draw disciplinary actions from your handlers, and financial retribution from your masters. They need to know that medical ethics are largely outside your control now, and subject to lobbying and political patronage arrangements. They need to know that the archaic words of Hippocrates are turning into a largely empty exercise before graduation parties begin. But most of all, they need to know that you are asking them for help.

And next time you lament the loss of joy and the diminishing status of your profession, you will have to give Old Hippocrates some credit, because two and a half millennia ago he forewarned all doctors of the fate awaiting them, if his moral prescription was ignored: “If I fulfill this oath and do not violate it, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; if I transgress it and swear falsely, may the opposite of all this be my lot.” What’s your lot look like these days? And what are you planning to do about it?

VIDERI QUAM ESSE

I was reading the popular HIStalk health IT news/opinion site the other day when I ran into a blurb stating that beginning in 2014, a new “North Carolina law requires hospitals with EHRs to connect to the state’s HIE and submit data on services paid for with Medicaid funds”. For the uninitiated, HIE stands for Health Information Exchange, and in this context it refers to a federally funded organization whose mission is to facilitate clinical information exchange in the State. There are similar organizations in most every State, funded back in 2009, alongside Meaningful Use and other shovel ready economic stimulus activities, through the ARRA and its HITECH Act.

The noble goal of HIE organizations everywhere is to improve care for patients by simplifying interoperability between disparate EHR technologies, allowing clinicians timely access to relevant, up-to-date medical information at the point of care. It makes perfect sense that North Carolina would like to “nudge” hospitals into sharing information with community physicians to improve care coordination and hopefully outcomes for its citizens. What doesn’t make any sense at all though, is the narrow requirement for Medicaid information only. Wouldn’t North Carolina want better care coordination for all people? And how does a hospital submit data only for a subset of services (not necessarily a subset of patients)? And why is this limited to submission, and there is no requirement that hospitals avail themselves of HIE data submitted by others? Obviously, I needed a bit more information to satisfy my foolish curiosity….

The first step was to check out the North Carolina HIE. Like many other organizations of its kind, the NC HIE chose to create a clinical data repository to be fed by prospective customers with “prescriptions, vaccinations, allergies, lab and test results, image reports, conditions, diagnoses or health problems and medical visit notes”, and with hospital ADT (admission-transfer-discharge) information as well. So far, like similar HIE organizations across the country, NC HIE is failing to garner active support from local hospitals. In an interview with the Carolina Journal earlier this summer, Mark Bell, CIO of the North Carolina Hospital Association (NCHA), suggested that “[t]ypically, a provider will not be thrilled with the idea of somebody else making money off of their data” which seems to be a “hot button topic”. Indeed, the NC HIE client list is remarkable for the absence of North Carolina’s famous academic centers of excellence and their affiliates. 

Mr. Bell’s hardly novel implication that some HIE organizations are seeking “to aggregate all that data and sell it to anyone who wants to buy that data, or for research, or a number of other uses” does raise the uncomfortable specter of patient privacy. According to its website, the NC HIE is an “opt out” exchange, which means that patients are “automatically” enrolled in the exchange whenever they “visit a participating doctor or hospital”, at no cost to the patient, of course. For inquiring minds, the NC HIE explains that it is only acting “as a “virtual medical record department” to collect and store medical records, and allow authorized providers to review and upload records”, and that “[h]aving a third party manage medical records is common practice”. Right. People may still opt out by calling a certain phone number or by mailing a certain form. As with most HIE organizations that engage in data accumulation, the “opt out” mechanism does not prevent patient information from being sent to the HIE, being stored in the HIE database, being disclosed to public agencies, or being used for other purposes when required or as permitted by Applicable Law. It only prevents disclosure to doctors and hospitals that are actually treating the opting out patient.

With that in mind, let’s go back to the brand new Applicable Law. The original bill contained language stating that effective January 1st 2014 “any hospital, as defined in G.S. 131E-76(c), that has an electronic health record system shall connect to the NC HIE and submit individual patient demographic and clinical data on services paid for with Medicaid funds”. This is a pretty lucrative arrangement for the NC HIE, which stands to gain approximately $5.5 million per year from subscription fees (at $250 per bed per year) alone, and undetermined amounts from interface charges, which as we all know can run into tens of thousands of dollars for each facility. Forcing the rich and famous North Carolina health systems to support the floundering public exchange may have been good enough reason to introduce this legislation, but that’s not the end of the story. The final bill, which is now the law of the land in North Carolina, was amended to include the following: “The NC HIE shall give the Department of Health and Human Services real-time access to data and information contained in the NC HIE”, and goes on to specify that the “Department of Health and Human Services and the NC HIE shall execute an agreement regarding the utilization and sharing of data and information contained in the HIE Network”, in a manner that complies with HIPAA and federal law. Note that the amendment language is not specific to “services paid for with Medicaid funds”.

It looks like the State of North Carolina came up with a rather innovative method for participating in what Mr. Bell from the NCHA terms a “hot button topic”. I am not sure how, or if, the State is planning to enforce this law, and I am not sure if hospitals will take the extra trouble (and expense) needed to segregate and submit to the State only those medical records that contain a Medicaid charge, but one thing is certain: individual patients in North Carolina have absolutely no say in this matter.  And so we take one more step on the road to trusted exchange.

Top 10 Accomplishments of American Health Care

It’s that time of year when the OECD publishes its "Health at a Glance" comparative health indicators, and The Commonwealth Fund follows with an international survey of health care related activities. A cursory review of these documents always ends up with the customary assessment of American health care: much more expensive than all others, wasteful and inefficient. But this is the month of December, and health care workers are people too, so maybe a short moratorium on bad news and criticism may be in order, allowing these folks to pursue a little bit of happiness during the Holiday season. A deeper dive into the vast amounts of data in the OECD report exposes all sorts of measures where the United States health system performs magnificently. Therefore, without further ado, let’s look at the top 10 achievements of American health care.

Number 10: Generic prescription rates in America are highest in the world. In fact the rates are so high, that the OECD didn’t dare show them. The best generics utilizer in the OECD report was Germany at 76% of prescriptions volume in 2011. The U.S. comes in at a whopping 80% in 2011 and 84% in 2012. Not only that, but the U.S. is also #1 in per capita spending on medications, and if 80% are low priced generic drugs, imagine how many more drugs we get to take. This speaks volumes about our new value based health care system.

Number 9: America was once again able to maintain the second lowest number of physicians per capita among developed nations, and well below the OECD average. Obviously, this spells productivity like no other metric can, and it’s most likely due to labor saving innovations, such as Electronic Health Records. With medical school graduation numbers at the bottom of the pack, the future will no doubt bring many more innovations to further increase the efficiency of American doctors.

Number 8: Americans are making big strides in technology use for communicating with their doctors. We beat practically every single developed country at some email metric, which is irrefutable proof that Meaningful Use is working.

Number 7: As in previous years America is holding the line on hospitalizations. Way below the OECD average and practically last in cancer discharges (except Mexico, where they don’t have cancer), our health system figured out much more cost effective ways of treating an increasingly older population, which leads us to #6.

Number 6: No one, and I mean no one, spends less of their health care money on hospitals than the U.S. We are #1. And no one spends more than us on more efficient outpatient care, which includes inpatient physician services when billed separately. It seems that all those inflammatory articles in the media regarding hospital price gouging, are pure nonsense.

Number 5: Not only does America have less hospital beds than most OECD countries, we are not using them very much. With an occupancy rate second to last, it seems that if we closed a third of our hospitals, as some reformers are suggesting, we would be just fine (with room to spare), and we could save oodles of cash. Finding inefficiencies that are easy to fix is a good reason to celebrate.

Number 4: Quality of care for the people that do end up in a hospital is pretty good. On multiple variables of mortality and surgical complications, the U.S. is consistently among top performers. Not absolute best, but a top performer nevertheless. Not to mention that compared to the best performers, your chances of leaving an American hospital with an instrument lodged in your bowels are much lower than in some very high performing countries. For all the alarmists having visions of Jumbo Jets crashing out of the sky daily, killing thousands of innocent patients unbeknownst to anybody else, slow down folks, there are no Jumbo Jets; maybe a Cessna here and there, but definitely no Jumbo Jets.

Number 3: Our children are the best in the whole wide world. The Puritan founders would have been so very proud of them. American kids are dead last when it comes to drunkenness and smoking. Although they are just average when it comes to eating their fruits and vegetables, our 15 year old boys and girls are the most physically active of all other OECD nations. Strangely enough, they are also among the chubbiest, but with all that physical activity, this is bound to resolve itself in the long run. It may be too late for us, but the future looks bright for the young ones.

Number 2: America is the healthiest nation in the world, bar none. Yep, you heard right. Almost 90% of Americans consider themselves healthy, and I have no reason to doubt their self-assessment. Much has been said about other countries, having higher life expectancies. The difference between the U.S. and Japan is over four years of life, but consider this: less than 1 in 3 people in Japan report being healthy. I don’t know about you, but 78 years of healthy life sounds much better to me than 82 years of living with disease.

And the Number 1 accomplishment of American health care is (drumroll please) Obamacare. Yes, Obamacare went viral, probably through the Internet or something like that, because Obamacare is now a global phenomenon affecting every single OECD nation.

A couple of weeks ago Paul Krugman, winner of the 2008 Nobel Prize in Economics, and self-described liberal, let us in on a little secret. Obamacare, it seems, is the only logical explanation for the reduced growth of health care spending in the U.S., and Obamacare began “bending the curve” from the moment it was signed into law in 2010, long before it was formally implemented. Since according to OECD data, all other nations have experienced the same “curve bending” effect since 2010, we must conclude that Obamacare has reached all developed nations instantaneously (the Internet is very fast).

And in some cases (such as the UK, not to mention Greece) Obamacare seems to be working even better than in the U.S. So here you go, once again America saves the world…. Merry Christmas American Health Care!

The Implausible Manifestation of a Doctor Shortage

In a New York Times opinion piece Scott Gottlieb, MD joins forces with Ezekiel Emanuel, MD to inform us all that “No, There Won’t Be a Doctor Shortage”, and just to clarify, Dr. Gottlieb goes on to say in a subsequent Forbes article “That Doesn't Mean You'll Have Access To Them”.  Doctors, it seems, are destined to be like the lights of Hanukkah candles – only for looking at, not for using. As tempting as it may be, let’s not hastily assume that the more fortunate members of society, like the authors of these articles, are brazenly suggesting that maintaining a good supply of doctors for themselves, is as simple as denying everybody else access to physicians. Of course not.

To dispel our concerns that an aging population and expansion of health insurance may somehow require more doctors, Drs. Gottlieb and Emanuel urge us to look at the great State of Massachusetts where universal insurance has been in place for years and no shortages have been observed. According to the Census Bureau, Massachusetts has almost double the national average number of doctors per population, and by the authors own admission, its “experience may differ from other areas”. Looking at Mississippi, for example, would have been a stretch I suppose. Either way, policy makers should be all set, since the only place where doctors seem to be growing on cherry trees is our nation’s capital. Other than that, the New York Times article contains the usual innovative fare, being repeated now in most health care journals over and over again. The future holds marvelous technology advances that will minimize duration, complexity and intensity of treatments and non-physicians of all stripes will be delivering most of this now routine care (one interesting suggestion was that pharmacists should deliver urgent care). The main idea is that instead of “expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers”.

Increasing worker productivity is where America’s exceptionalism truly shines. Labor productivity (i.e. the ratio of output to input) has increased in the U.S. by 254% since WWII (see graph above), and really accelerated in the new millennium. Unfortunately, compensation for this wonderful productivity, took a different path somewhere in the early seventies, hence the gaping divide between America and a handful of very wealthy individuals who benefit financially from productivity gains. The conservative Dr. Gottlieb and the progressive Dr. Emanuel are merely suggesting that this very successful business model should now be applied to the horrendously inefficient health care sector.  If you think about it, it becomes abundantly clear that this suggestion is actually an imperative. If we don’t find a way to integrate medical services in the lower-wages/cheaper-products innovation cycle, all those wonderfully productive workers will be unable to afford the medicines needed to sustain their blessed productivity.

The New York Times opinion piece, and the many others like it, are the theoretical foundation leading experts such as Dr. Gottlieb to conclude that “there’s every reason to believe that technology will continue to make the aging process itself (and the treatment of many diseases) a far less resource intensive endeavor – and ones that require fewer physician inputs for a higher level of “outputs” in terms of improved healthcare”. This is very similar to how restaurant chains, or canned food manufacturers, have a Chef that is shown designing fabulous new dishes, using market fresh ingredients, on TV commercials, but the actual “outputs” in each establishment, or can, require practically no Chef inputs. And this is why health care is strongly encouraged to learn from other industries that mastered the art of maximizing outputs to inputs ratios. Fair enough, but how do we know that we have enough Chefs or doctors to start with? Luckily, Dr. Gottlieb has valuable insights on this question as well. The argument is that “if there was a shortage of physicians, it wouldn’t be so easy for the Obamacare health plans to push around doctors and trim their pay”. The same logic is used very effectively by defense attorneys in rape cases where the victim did not scream or kick hard enough. 

When analyzing things from an economic perspective, shortage of something implies that demand exceeds supply, and demand does not mean need or even want; it means willingness to pay. For example, one could observe that we have no shortage of private trainers, not because people don’t need to work out, or because they wouldn’t want a personal trainer, but because most folks are not willing or able to pay for one. Demand, and subsequent shortage, is also a function of culture. There is no shortage of wholesome and freshly prepared foods today, because our culture has been altered to have different expectations from food. Preemptively changing perceptions and expectations is therefore paramount to preventing shortages. So if back in the 1990s HMOs were “soundly rejected” by the people, according to Dr. Gottlieb, “[w]hat Obamacare, in effect, tells Americans, is that the White House believes many people made the wrong choice when they rejected those HMOs in favor of PPO plans that offer broader access to providers”. Of course we did.

You hear frequently today how fixing health care requires a cultural change; how we must choose wisely and how we should not expect that everything is done to prolong individual lives; how we should become more accepting of death and how we should quit running to the doctor every time we are sick; how we should learn from Rwanda and how we should fear the killing fields of conventional medicine; how we should value fast service and convenience above intrinsic quality. All these things are necessary to bring demand for physician services more in line with productive workers’ ability to pay for medical care, and as worker compensation continues to shrink, we may end up with a surplus of doctors, which in turn will make pushing them around and trimming their pay even easier, as Dr. Gottlieb writes in conclusion: “In the future, there will be enough doctors for you to choose from. Problem is, in many cases, the Obamacare health plans won’t pay for you to see them”. And it won’t need to, because by then, you will be conditioned to not demand to see them.

Everywhere on this planet, physicians’ professional status, autonomy and compensation, are inextricably tied to the same metrics for the patients they serve. It is plausible and perhaps understandable, that physicians who were and still are the highest paid professionals in the land, considered themselves immune to the increased exploitation and marginalization of all other American workers, including highly educated ones. The almost linear relationship between worker compensation and physician compensation, and the mathematical impossibility of becoming rich by tending to a nation of impoverished workers, must have escaped our best and brightest, until now.

The harsh (and unpleasant for some) reality is that unless you can find your way to medically pamper “Internet moguls”, or happen to practice medicine on TV or at the New York Times, you are in the same boat as the McDonald's workers now rioting in the streets, perhaps in a much nicer cabin (for now), but same boat nevertheless. Something to ponder upon…

Update 12/11/2013: For a bit different, but more authoritative perspective, see Prof. Casey B. Mulligan's Economix article today.