Thursday, January 21, 2016

Big Health Reform Ideas and What They Portend for Physicians
As I see it, there are three big abstract ideas behind implementing  and improving health reform.
The big ideas are:
One,  FIHR (Fast Health Care Interoperability Resources) -  This is a draft standard, compiled by major health care organizations describing data formats and elements known as “resources” and an Applications Program Initiative (API) for standards for exchanges of health records.   Major health organizations are creating these standards ,  as created by Health Level Seven International  (HC7) organizations.
Two,  PM (Precision Medicine) a medical model proposing customization and standardization of health care with medical decisions, problems, and products tailored to individual patients based on genetic content , and  on molecular and cellular considerations.
Three,  VC (Value Based Care)-  Value of outcomes and not on clinical  Volume or services provided.    Pay-for-Performance is to be based on data and measurements rather than Fee-for-Services.

Consequences of Big Ideas
Again,  as I see it, the consequences of these three big ideas are:
One,  health reform will not go away, and will be continually debated as to what works and doesn’t work, as seen from the perspective of government and payers.  The impact of physicians will be a secondary consideration.
Two,  the health exchanges are having an impact,  the main features of which are covering about 11 million of the 45 million uninsured,  higher costs for insurers,  higher premiums and deductibles for the middle class,  and lower payments for physicians, which is a major reason why 25% of physicians do not accept  health exchange patients, and why consumers are flocking to direct cash primary care physicians, urgicare centers, and surgi-centers to avoid higher premiums and deductible and ObamaCare rules.
Three,  health care is rapidly becoming a consumer business  with drug-store clinics, urgent care centers, and surgi-centers. Consumers are driven by cost considerations and convenience, and get much of their information online,  which is why every physician office needs to have a website presenting what the physician office has to offer.
Four,  integration of EHR and claims data is becoming a high priority among  payers, but  is difficult to pull off because of physician resistance and different EHR  systems which do not communicate with each other.  The demand of doctor documentation continues to grow,  but physicians are reacting by demanding that EHR systems be redesigned, and by pulling out of traditional  3rd parties  to enter cash-only DPC (DirePatient Care), urgentcare centers, and surgi-centers.  Free Market health care is in its infancy, but is growing as physician seek to  or minimize  coding, data entry, and overhead burdens.
Five,   Big Data has huge potential, so say payers, who seek objectivity and evidence that at least 30% of health care monies are wasted on unnecessary procedures for the doctors’ rather than  the patients’ benefit.    This point of view is difficult to nail down  because of patients’ different preferences,  variability of patient  needs,  complexity of patient presentations with multiple co-morbidities,   and the sheer subjectivity  of medicine  with its multiple choices of tests and treatments.
Six,  everybody agrees “transparency” is a wonderful concept on the surface  and we ought to have more of it, except when it comes to the nitty-gritty.    Will people understand when given “open notes,” of what  doctors said?  Will health organization be willing to share their records with competitors?   Will “transparency” violate patient data security, privacy, and confidentiality?   Will “transparency” be an unprecedently  opportunity of malpractice attorneys?
Seven,  online  health care information  for patients may be  a golden opportunity for patient engagement.   Given more patient information on the Internet,  especially via social media apps, doctors will be able to engage in shared decision making with fuller patient understanding .    Online engagement will allow virtual patient visits  for patients unable to conventionally visit or afford direct physical contact with doctors.   Doctors can monitor patients at a distance to record their progress?  And patients can monitor and diagnose their own health problems and present at  doctors’ offices with histories and symptoms recorded and documented.   
Coming Events
These events  are all coming, and in most respects they are a good things.   Who can quibble  with medicine as another   marketplace, consumers as kings, digital records as clear evidence of one’s history,   algorithms as supplements to clinical judgment,  and doctors as onlookers of how you’re doing once you leave the office or the hospital?
Nobody, I suppose.  But as the poet T.S. Elliot said in this famous poem, the Hollow Men
Between the idea
And the reality
Between the motion
And the act
Falls the shadow
The shadow has many dimensions : What do these things mean for physicians?  Are they hollow promises?  Will data replace or supplement clinical  judgment?   Will technology reduce costs, which it has failed to do so far?  Will  technology information compromise privacy, confidentially, and  freedom of choice of doctors and health plans? and dehumanize medicine   At this point, there are more questions than answers.






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