Variations of the Health Care Theme

Variation is an integral part of the human condition,
That’s what makes inevitably for regional variation.

Variation is a big part of Darwinian evolution.
That’s why human uniformity defies solution.

Variation is an esential part of democratic society.
That’s how it assures freedom- through more variety.

Variation is without doubt the spice of life.
That’s when it becomes a source of strife.

Variation, say experts, should be absolute zero.
That’s where a collectivist can become a hero.

Variation, say the ruling elite, should be minimized,
That’s whose political terms may be shorter than realized.

Health Reform: A Vast Law with Half-Vast Consequences

As insurers adapt to the new world of reform, their actions will reverberate throughout the economy in unexpected ways; given the vast reach of the law, it seems certain there will be more than a little consequences.

J.K. Iglehart, “Defining Medical Expenses – An Early Skirmish over Insurance Reforms, “ New England Journal of Medicine, September 9. 2010

The operative phrase in the above quote is “vast reach of the law.” The key word is “vast.”

Use of the word vast brings to mind two personal experiences.

One was when my father warned me, “Son, don’t launch vast projects with half-vast ideas,” a slightly off-color but telling pun.

Two was a 1973 book I read by Dean Acheson, the former Secretary of State. It bore the title This Vast External Realm. Acheson was writing about how difficult it was for a President to control external events.

The Accountable Care Act is a case in point.

The vast reform law, which vastly covers every American in this vast continental nation, though debated for a year, was passed at the last minute under half-baked and rushed circumstances.

Here is how Peter Suderman describes its passage in the October issue of Reason in “The Revolt Against Obamacare.”

“Much of the language that passed into law was never intended to be final. It was more like beta software. Most of the important elements were the authors had intended to include were there, but not always in the final intended form. And the code was still crawling with bugs, particularly on the level of implementation at the states.”

“But the Democrats had heard the call of history. Passing any bill- even a creaky, obviously flawed beta version – was better, party leaders decided, than declaring defeat so tantalizing close to the finish line.”

So the bug-infested bill passed on March 23, 2010. The consequences, which may be unfounded, nevertheless are there for all to see.

• Disapproval by the American public by 56% to 40%.

• The Tea Party sentiment, calling for Repeal and Replacement,to counter Big Government.

• A revolt by the States, who say they cannot “afford” the “Affordable Care Act,” the individual mandate of which may be unconstitutional.

• Fear that ACA's promises may be empty, i.e., it will allow you to keep your plan, will bring down your premium costs, will cost taxpayers less than $1 trillion, won’t cut Medicare benefits in spite of $500 billion in cuts, and won't limit access to doctors, many of whom say they cease seeing Medicare and Medicaid patients under the conditions of reform.

• Growing unease among business leaders, who are uncertain they can shoulder the administration burdens and costs of reform.

• Multiple surveys among physicians indicating they feel reform will increase expenses, create hassles, and decrease quality.

• A palpable anxiety among health agents, brokers, and small insurance companies that they will be the first victims of health reform, even though they feel themselves indispensible in writing policies for individuals and small groups.

I am not saying the Affordable Care Act is “good” or “bad.” I am saying its final passage was rushed, and the difficulties of its implementation, and its unfullfillable promises were not thought through or anticipated.

The Doctor Autonomy Dilemma: Who Decides?

In recent political debates, the autonomous physician has been portrayed as a problem to be solved, an out-of-control actor motivated by greed – and a major cause of rising health –care costs. Insurance companies and the federal government have sought to control physician behavior with the dual aim of decreasing costs and improving care. In their view, individual and regional disparities in rates of medical testing, hospitalization, and surgical procedures are ipso-facto demonstrations of physician autonomy run amok.

Saul Greenfield, MD, director of pediatric urology at the Women and Children’s Hospital of Buffalo, “In Defense of Physician Autonomy,” Wall Street Journal, September 9, 2010

The practice of medicine, and who pays for it, is a highly personal, emotionally charged, politically volatile element of current policy debates.

Who should pay? The government, the employer, the patient. That is the first question.

Who should decide for what to pay? The government, the employer, the patient, or the physician. That is the second question.

What criteria should be used to establish for what to pay? That is a third question.

Should government make the decision – using statistical criteria developed by comparative effectiveness research, outcomes, and regional disparities? That is a fourth question.

Should employers, and their surrogates, health plans, using federal criteria as well as their own, decide? That is fifth question.

The sixth and last question is: Should autonomous physicians, in concert with their patients, decide? Physicians and patients are, after all, closest to the scene of the illness and know most intimately the stakes involved.

The answers to these questions comes down to yet another question: How does one control runaway spending in an aging population in a democracy in which politicians promise affordability and protection against the dire consequences of illness?

One can rely on government rationing, usually presented as “cuts” in “waste,”"savings," or "increased efficiency." One can rely on market forces promoting “competition.” One can rely on consumers spending their own money, thereby incenting them to be selective on what they will pay for.

Or finally, one can place your bets on controlling costs by dictating physician behavior. In the final accounting, most politicians believe the physician’s pen, or increasingly, his or her computer keys, determines the cost. To control behavior, one uses anonymous statistical data, based on large population studies, to assure uniform, standardized behavior to control physician autonomy.

Doctor Greenfield, who I quoted in the opening of this essay, summarizes the irony of it all with this telling sentence, “Physician autonomy is a major defense against those who comfortably sit in remote offices and make calculations based on concerns other than an individual patient’s welfare.”

Remote bureaucrats, of either the public or private stripe, will never be able to gauge the hopes, feelings, and consequences of their remote judgments when a patient and a doctor meet in the exam room to decide what is best for the patient. The outcome of this meeting hinges on those imperishable elements of a democracy called individual freedoms of choice and action and clinical judgment.

“Patient-Centered Care” and What Patients Want

Today , September 13, Doctor Donald Berwick, the new head of CMS and President Obama’s controversial recess appointee, gives a much awaited maiden speech before a Medicare and Medicaid audience.

A lot is riding on his presentation. He must convince Americans that the Affordable Care Act, now often referred to as “Obamacare,” is a good thing.

If you look at the latest polls, so far the Obama administration’s efforts to sell the new health reform law have failed. The latest polls indicate Americans against/for Obama’s health plan are: USA/Gallup +17%, Rasmussen Reports +22%, CNN/Opinion Research +16%, CBS/NBC +13%, and Pew/National Journal +12%. In other words, an average of 16% more Americans oppose the plan than favor it. In public polling, this is considered a huge margin.

And in political campaigns to date, Democrats running for November re-election are either shunning, running away from health reform. or bragging about opposing the health reform law.

Enter Doctor Berwick. He has long been a champion of “patient-centered care.” According to an abstract of a 2009 article ,” What 'Patient-Centered' Should Mean: Confessions Of An Extremist,” he wrote for Health Affairs,

“ ‘Patient-centeredness’ is a dimension of health care quality in its own right, not just because of its connection with other desired aims, like safety and effectiveness. Its proper incorporation into new health care designs will involve some radical, unfamiliar, and disruptive shifts in control and power, out of the hands of those who give care and into the hands of those who receive it. Such a consumerist view of the quality of care, itself, has important differences from the more classical, professionally dominated definitions of 'quality.' New designs, like the so-called medical home, should incorporate that change.”

The key phrase, which I have italicized, is "radical, unfamiliar, and disruptive shifts in control and power, out of those who give care and into the hands of those who receive it."

In Berwick’s past actions since the 1991 founding the Healthcare Improvement Institute, based in Boston, and serving it as its CEO through 2010, this phrase has come to mean improving hospital safety, avoiding unnecessary deaths, looking at care from the patient’s point of view, and ridding the system of health care waste, i.e. procedures and tests with no proof of benefits. These are admirable goals.

What rankles critics is his insistence upon “shifts in power and control, “ in most cases means shifts from current market-based practices to government-based regulations, and away from physicians and hospitals. To many, Doctor Berwick is a liberal, even a socialist, idealogue.


As a Time Magazine piece today says,

“Interest in his remarks will be high because Berwick is perhaps the single most powerful person in American health care, overseeing a 2011 budget of $759 billion — larger than the Pentagon's — and a bureaucracy that includes 4,500 employees providing health coverage for some 100 million Americans. As part of the new Affordable Care Act, Berwick will begin the process of cutting some $500 billion from Medicare — largely by eliminating subsidies for the private insurance program known as Medicare Advantage — and lay the groundwork for adding 16 million Americans to the Medicaid rolls.”

For me, “patient-centered care” boils down to what patients want and fear from government control. This is what I hear on the streets and from fellow physicians.

• Patients want relief from pain, which is why so many hip and knee replacements are being done. Patients fear government will limit joint replacements.

• Patients want good vision. They fear government will ration cataract surgeries, perhaps restricting them to one eye.

• Patients want protection from higher costs and medical bankruptcies, which so far government has not provided. Quite the reverse is occurring.

' Patients want something to happen now, rather than waiting until 2014 and thereafter.

• Patients want quick access to doctors, who will be in short supply when 78 million baby boomers become eligible for Medicare starting in 2011 and 16 million Medicaid recipients become insured in 2014.

• Patients want hope for cures, particularly of cancer, which may involve treatment with expensive cancer drugs which they fear will not be authorized or paid for by government.

• Patients want their medical care to be safe, an area of expertise or Dr. Berwick and perhaps his biggest selling point.

• Patients want their doctors to be on time and for medical care to be convenient and accessible 24/7, which is why retail clinics and urgent care clinics are popular, and why emergency rooms are crowded.

• Patients fear government bureaucrats, not their doctors, will be making clinical decisions on what can and cannot be done. Thia directly contradicts Berwick's philosophy.

• Patients fear what they want and what they will get will be radically different.

Health Reform: Don’t Forget the Details

Sometimes, as we ponder the total impact of the Affordable Care Act (ACA), we forget the details.

We forget details like the ACA impacts every American in one way or another – more coverage for 32 million Americans( it extends insurance from 83% to 95% of the population); more costs of up to 9% in 2010 for the remaining 278 million (assuming the 2010 census count is 310 million); more expenses, taxes, and penalties of $150 billion or so for large and small businesses); more taxes for U.S. tax payers (in the neighborhood of $900 billion to $1 trillion over the next years(depending on who is doing the estimates).

We forget details like the individual mandate's constitutionality, the state of Florida is challenging tghe mandate right now in court. On behalf of 20 state attorney generals the mandate has lodged a suit against the mandate, without which Obamacare might collapse.

We forget details like the ACA is 2074 pages long, contains 400,000 words, and is longer or wordier than the Declaration of Independence (1337 words), the U.S. Constitution (4,543 words), War and Peace (1400 words), the Torah (80,000 words).

We forget the ACA document weighs in at 19 pounds, stands 9 inches tall, and costs $2.24 million per word.

Because of the ACA’s size, we forget it is easy to get lost in the details, like a little detail calling for every business to file a 1099 tax form identifying any vendor, supplier, or contracts to whom they pay $600 or more per year for goods or merchandise – food, bottled water, gasoline, labor, office and building supplies, travel, Internet or phone services – including sending copies of the form to vendors, suppliers, and contractors –and printing details of the every $600 transaction in the annual report.

We forget this new $600 filing requirement poses a huge bureaucratic burden, applied to 38 million businesses, including hundreds of thousands of medical practices, 26 million sole proprietorships, and 2 million farms.

We forget this $600 detail is particularly tough on independent doctor-owned solo or small practices, which may earn as little as $120,000 per year with average educational debts of $24,000 a year, which doesn’t leave much after household, resident , taxes, and children’s education expenses.

We forget what this $600 provision is intended to raise $17 billion over 10 years to help pay for the cost of the Affordable Care Act. The $17 billion will come, it is said, from closing of tax loopholes, but will require millions more to help the IRS enforce compliance.

We forget that the Senate next week will vote for repeal of the $600 provision because of waves of protest from the business community which supplies most of the nation’s jobs.

We forget the White House is very nervous about repeal of this $600 reporting provision, which is attached as an amendment to the $50 billion bill to help small business.

The Obama administration fears that repeal could set a precedent for rolling back other unpopular features of the law.

They also fear repeal may block passage of Obama’s symbolic small business bill, designed to aid small business by cutting taxes and rewarding investment.

It is unclear whether Democrats and Republicans can reach agreements on repealing the provision and on finding a way to offset the loss of money.

We forget that unforgettable massive amounts of money and forgettable massive documents foster forgetfulness of devilish details.

Details! Details! So many details! Forget them at your own risk.

Please don’t forget the health reform details, They may drive the Obama political train off the rails. They may cost you as an individual aplenty. Few of you will know in precise dollars how many, until you weigh the details on our own scales.

The Next Big Thing for Doctors – Lower Fees Mandated by Health Reform Law : The Next Big Clinical Innovation - Automated Patient-Entered Histories

Next: The Future Just Happened

Title of book by Michael Lewis, 2001

As a consultant to the Physician Foundation, a not-for-profit 501 C-3 Organization representing physicians in state medical societies, as a sometime futurist, and as someone who has written extensively about innovation in Innovation-Driven Health Care(Jones and Bartlett, 2007) and in 1475 blogs in Medinnovationblog, I have been asked: What is the next big thing for doctors, and how should they react to it?

The next big thing for physicians will be Medicare fee cuts in the neighborhood of 50% by 2020 as mandated by the Affordable Care Act, and the next big clinical innovative response for doctors will be encouraging patients enter their own data, their own chief complaint, and their own medical histories before seeing the doctor to compensate for fee reductions.

Ceding a Traditional Physician Function to Survive Economically

Doctors will have to cede a traditional function – taking a history – to patients to become more efficient to survive. Payers - including Medicare, Medicaid, and private health plans- will demand standardization and restructuring of the medical history to achieve consistency in medical records. Patient-entered information may be disruptive. Doctors will have to change practice flow patterns to adjust to reality of lower pay. The need for greater productivity will drive this change.

Patient- entered data, which is already happening, has positive aspects. It empowers patients by making them an integral and formal part of the diagnostic process. Patient-entered interviews, conducted by means of simple clinical “yes” or “no” algorithms, have these benefits – 4 to 8 minutes saved for each patient encounter, useful information for differential diagnosis, an increase of 5 or 6 more patients seen each day, the feeling by patients that they are partners in the diagnostic process, protection against misunderstandings leading to malpractice suits, greater coding revenues because of comprehensive documentation, and generation on the spot of a clinical document that can be used for referral letters, for claims processing, and for an electronic document that can be taken home by the patient on the day of the visit (see chapter 4, page 41, in Innovation-Driven Health Care).

Inevitable Trends

These trends make patients-entered data and histories is inevitable.

• Doctor and hospital fees will be systematically reduced to save Medicare, and structured electronic records will be required for payment. Reducing these fees is a fundamental part of the new health reform law as well as the government emphasis and financial incentives to install electronic records.

• Information technologies – i.e., the Internet, wireless devices, IPads, home computers, the social media, the whole electronic kit and caboodle – will make it practical for patients to automatically and seamlessly enter their data into doctors’ office computers.


• All doctors, primary care doctors and specialists alike, share in common an absolute need for a patient narrative history and certain data – identification numbers, chief complaint, age, sex, other demographics, family history, medications, allergies, symptoms, vital signs.

• The rest of society and other industrial sectors already have technologies in place that are making consumers do the work of obtaining or buying a service. These technologies lower the cost of doing business, replace the more expensive human interface, and make collection of revenues standardized, organized, systematic purposeful, and consistent.

• The underlying rationale behind all of these things are consistency and standardization, less hiring of fickle expensive human beings, and automation of business functions.

Look Around You

If you doubt what I am saying, look around you.

• Check into an airport, and a computer screen – without a human interface – will confront you.

• Check out at the supermarket, and you will have a choice of going through a clerk or a entering your selections on a computer.

• Call almost any business or government agency, and you will be marched through a voice-activated, computer-driven menu.

• Go to a bank for money, and you will likely get the cash through an ATM.

• Pay your bills and check your bank balance online.

• Prepare your annual tax return, and you will be more likely to do it through Turbo-Tax or its equivalent.

• Look for ways to lower legal fees, and you may well go to Legalzoom.com.
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Medical Practice Will Become Like Rest of World in Spite of Complexity

For the rest if the world, automated consumer entry information is an old story, but for medicine, because of the intensely personal nature of medical services, the need for privacy and fear of its loss, confidentiality issues, sacrifice of the human touch, resistance of physicians to traditional ways of doing things, i.e., taking the history face to face, automated patient entry is taking place at a slower pace, and the very complexity of the medical-social enterprise, assures a much slower pace.

Bob Wachter, MD, a West Coast academic and the moving force behind the hospitalist movement, explained the complexity well in a September 9 edition of The Health Care Blog, “With all due respect to the Pentagon, humankind has not invented a more complex organization than the modern academic medical center. The combination of high tech and high touch, the Byzantine regulations, the toxic medico-legal environment, the extraordinary pace of change…. Well, you get the idea.”

The medical environment may be even more complicated outside the academic medical center in the fragmented world of multiple specialists, different entry points into the system, and escalating health plans requirements for payment.

Complex or not, clinical innovation in the form of standardization and structuring of medical records, so that payments can be justified and outcomes tracked, is coming – and coming fast.

One need look no further than the health reform law and the federal government spending of $27 billion over the next ten years to subsidize, incentivize, and promote “meaningful” electronic health records. This starts in earnest in 2011.

Standardizing Care Delivery – The Next Big Thing

Standardizing delivery of care -- identifying “best practices,” and insisting physicians follow guidelines – theoretically could save money while improving quality. It is the basis for Obamacare. For government management experts, the allure of standardization, and the seductive comfort of quantitative metrics (however meaningless and off-target) and rigid guidelines (however unwieldy and irrelevant) is too powerful to resist.

In my opinion, the next big data trend in health care will be structured patient data entry during e-visits and meeting with the doctor in the exam room. These structured e-visits can be entered seamlessly into an office-based computer or into an electronic medical record.

Why Nots

Why not let the computer take the history and record the review of systems from patients? All of this can be done and is being done using simple “yes” or “no” algorithms based on the patient’s chief complaint, gender, and age (see instantmedicalhistory.com). And it can be done by the patient in ten minutes or less from a home computer or a laptop in the reception room.

Why not let patients document why they are seeing the doctor? Why not let patients enter their own data, complaints, and histories using simple software? Why not permit patients to tell their own stories on their own time, rather than the doctor’s time? Why not place a computer in the reception room to serve an ATM-like function, viz. letting health consumers enter their own data? After all, no one knows their history and their demographic and other data better than the patient.

For the last decade and one half, Doctors Allen Wenner, a South Carolina family physician and John Bachman, head of primary care at Mayo in Rochester, working collaboratively have used the computer to gather patient histories using a software tool known as the Instant Medical History( instantmedicalhistory.com.) Thousands of other doctors around the country have done so as well.(Bachman, J., The Patient-Computer Interview, Mayo Clinic Proceedings, 78, 67-78. 2004)

Wenner and Bachman ask. Why not let patients enter the exam room with their stories spelled out in a computer interview? Why not program the history so that it appears as a narrative? Why not make it easy for physicians to simply add their findings with a few simple computer key strokes? Why not let patients leave the office with their documented histories and findings in hand? And why not let this comprehensive document serve multiple purposes – a medical record, a billing document, the source of referral letters?

Costs of Patient Information Entry

What is the cost of patient-documented histories? Roughly $50 a month for software. The gain? Four to 8 minutes of time saved per patient. In addition, it saves money by making most dictation unnecessary, and the patient-generated record generates even more revenue per patient encounter by consistently serving as a basis for claims initiation and enhanced coding. Further, the patient immediately has a clear record of what transpired, thereby minimizing confusion or misunderstandings that might lead to malpractice suits. Through comprehensive documentation , made possible through patient input, codes often up one level. Patients and third parties will be pleased doctors have moved up the electronic documentation curve by structuring the history and physical.

Caveats

As with anything in this turbulent world of Sturm and Drang and rapid and accelerating change, the devil is in the details. For patients to enter information requires that physicians have a compatible computer system or electronic health record that will accept the data. It requires physicians and patients have comfort, confidence, and competence with computers. It requires that patient privacy be protected and sensitive parts of the record be kept confidential. It requires acceptance of the brave new world the Internet has created. It requires acceptance of the naive idea that for every complex problem, there is a simple solution. It requires flexibility, viz, rejection of the thought that patient-entered data will apply to all patient visits - follow-ups, prescription refills, phone and e-mail enquiries.

Conclusion

The two next big things for physicians will be systematic reduction of fees proposed by the new health reform law , The Affordable Care Act, and the need for some sort of systematic response resulting in lower costs of practicing through greater practice efficiency and productivity. One such response may be structured patient-entry of their own data and history using clinical algorithms . History taking and data entry now requires significant physician and physician staff time and may be inconsistentwith resultant claims rejections with delays in payment.