Monday, January 25, 2016

The Making of a Health Reform Nuclear Reactor
c=speed of light
Albert Einstein, Theory of Relativity, 1905

Like most health reform investigators, I am always in search of metaphors.   In this case, the metaphor is  e=n/c2, an analogue of Einstein’s e-mc2.
e= energy
n =nucleus  
c= speed of reform

e is the energy of the American democracy, characterized by entrepreneurial dynamism and robust economic growth, both waiting to be unleashed.
n is the nucleus of the American nation,  and its freedoms, guaranteed by  the Constitution and the Bill of Rights, and relatively free of  government coercions .
c is the speed of health reform, which has been halved by the weight of government regulations  and market resistance.
In effect, the health reform law has split the nation’s nucleus into two halves - one commandeered  by centralized  government, the other countermanded  by decentralized market forces.
In both halves of the nation's nucleus, experiments being conducted, but results of the two  has yet to fuse.
On the federal  half of the nucleus,  experiments include:   Individual and employer  mandates,  Centers of Medicare and Medicaid Innovations with  accountable care organizations,  medical homes,  value care and population health ,  precision medicine, bundles of care based on episodes and  continuums of care,   multiple government –health systems-hospitals-physicians collaborations ,   government health exchanges, exchange co-ops. 
On the market half of the nucleus, these experiments include -  Free market care,  regional integrated health organizations,   retail clinics, urgicare centers,  surgicenters and other diagnostic and treatment centers,   focused factories, and numerous other  consumer-oriented and empowering  entities .
Lack of Critical Mass
What the two halves lack is  strong enough particles  to bombard the nucleus  to achieve critical mass to sustain a health reform   chain reaction, which in the government’s case is sufficient  new health exchange members to make going forward feasible  , and in the market’s case  adequate political support to make their brand of reform  possible.
Critical mass is essential to make a nucleus chain reaction possible,   but a nuclear  reactor is needed to control the energy release, whether that is uncontrolled government spending or free-market excesses.
Needed: A Nuclear Reactor
What is needed is some sort of nuclear pile to dampen the speed of reaction in one case and to accelerate   it in the other case.    
Most nucleus experts agree that modulating and monitoring   force must be some sort of computer-interpretative device or group of devices  that is simple and useful  and collaborative  and acceptable enough to bring the two sides together in a workable mass. 
That group of devices may  the  Free Health Interoperative Resources (FHIR) movement and the Argonaut Project  that brings together organizations  with common standards with relevant metadata that is collected on the front-lines of care from clinician -friendly electronic health records that are useful,  relevant , non-intrusive,  and produce results of value (see David Shaywitz, MD, PhD, “The Last Best Chances to Achieve Interoperability,” The Health Care Blog,  January 2015, and Richard Rhodes,  The Making of the Atomic Bomb, 1986, Simon and Schuster.

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