Tuesday, May 10, 2011

Health Reform: What’s Hot, What’s Not

When an idea is hot, it’s hot. When it’s not, it’s not.

Whether an idea is hot or not depends on your opinion, and the spin you want to give it. That said, here goes.

What’s Not

• The idea of universal coverage as the main strut of health reform is not so hot now. Conservatives gleefully shout.” Look at Massachusetts!” Costs are up, access is down, premiums are up, waiting lines are long. For Mitt Romney, the Massachusetts experience over the last 4 years, is a downer. Says a May 10 Wall Street Journal editorial, “National Health Preview,” .”The real lesson of Massachusetts is that reform proponents won't tell Americans the truth about what "universal" coverage really means: Runaway costs followed by price controls and bureaucratic rationing.” If you regard Massachusetts as the paradigm of Obamacare and what’s to come, universal coverage is not what’s hot.

• According to the media and the polls, the Paul Ryan (R-Wisconsin) idea of putting Medicare on vouchers or platform supports , is not so hot politically. The very idea of restructuring Medicare by shifting costs to Medicare recipients and putting a lid on expenditures geared to the rate of general inflation rather than the rate of health cost inflation is said to be cold-blooded and inhumane. Never mind that Medicare, as currently practiced, is hurdling towards bankruptcy at an accelerating rate. Besides, the Democrat you know may be better than the Republican you don’t know. The lesson here may be: government entitlements without caveats tend to be more popular than personal responsibility.

What’s Hot

• The idea of a data-driven, computer-guided Holy Grail as the ultimate solution, as a grassroots all purpose universal solvent and ubiquitous catalyst remains hot. And why not? In its stimulus plan, the government promised to devote $27 billion to universal computerization of the health system, Consultants and electronic medical and health record companies have gathered at the monetary trough, and government has declared it will give bonuses to the EHR-haves and punish the EHR-have-nots. Anyway, why can’t we be more like the Europeans, the governments of which finance doctor-based computer systems?

Joel Sherman, MD, a cardiologist who blogs at Medical Privacy, a Patient Oriented Discussion, sees a hot future for patient Medical ID cards plugged into doctors’ EHR systems. These records will be based on a standardized national record format (“Implementation of a Rational System of Medical Care”). KevinMd.com, May 8, 2010)

“The patient entered her private solo physician’s office and handed her medical ID card to the doctor. He put the card in his desktop reader and reviewed her medical history. All of her visits, vaccinations, medications, tests, x-rays etc from all providers were inscribed on the data chip in the card. The card also included insurance and billing information. At the end of the visit, he updated her information on the ID card at his desk and returned the card to the patient. The completed entry on the card was processed centrally and the physician received his payment in a few days, no rejections or delays possible.”

Too rational to be true. Perhaps. But for avid data-mongers, this story is a chip off the old bloc, viz, with computers and enough information we can solve all problems.

• Then there is the idea of the “Hot Spotters, “ as articulated by Utal Gawande, MD, in the January 24, 2011 New Yorker. He cites the experience of Jeffry Brenner, MD, a Camden, New Jersey primary care doctor, who has developed a data-based system for spotting and catering to the needs of the sickest, most expensive patients. It is well-known that 1% of patients generate 30% of costs, but identifying them, lowering their risks, preventing their diseases, and keeping them out of ERs and hospitals is a process yet to be developed.

Brenner’s success reminds me of two similar projects:

- One, Mayor Rudy Guiliani’s successful campaign to lower New York City's crime rate by using computers to study where and when crimes usually occurred, then assigning the police to the trouble spots.

- Two, the Health Lead’s Project Health strategy in Boston, where help desks were situated in hospitals, ERs, and clinics, and student volunteers help poor families find social resources to keep them healthy.

In Camden, Brenner introduced an expanded computer database that lets Camden doctors view laboratory results, radiology reports, emergency-room visits, and discharge summaries for their patients from all the hospitals in town—and could show cost patterns, too. This system will help Camden doctors reduce costs of troubled patients in Camden’s “hot spots.” The lesson here is that physician entreprenuer's may be more effective than government in lowering costs.

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