Sunday, July 17, 2016

Is Data the Health Reform Answer?
“In God we trust. All others use data” is the mantra of health care managers and CMS officials who administer ObamaCare rules.
Data - The Foundation for Health Law Policies
Data is the foundation for policies such as outcome management,   pay-for-performance,  evidence-based medicine, and the new kid on the Medical Management Block  MACRA (Medicare Access and CHIP Reauthorization Act of 2015).  The latter is based on data collected in ACOs (Accountable Care Organizations), which are experiencing health care delivery pains because of hospital and physician opposition and disillusionment.
Attractiveness of Data
Data management has an attractive ring to it.   It is neutral. It is objective.   It is collectable at the site of care.    It is capable of being standardized.   And theoretically it can be implemented across the health care landscape, among physicians of every ilk and specialty.
Is Data Relevant: On What Does It Depend?
But like any other human-directed endeavor, data depends on its relevance.  It is germane to the problems being addressed, e.g., the cost and quality of care.   Is it affordable?  Does it protect patients?   It has variables,  like the nature of questions being asked to get the data, the truthfulness of patients.   It depends on costs of data collection.  It depends of its usefulness as a communication tool.   It depends on how the data is interpreted and applied,  and if it is of any benefit  to patients and physicians  or administrators. 
EHRs as Data-Gathering Tool
It is essential for the government to recognize that two-thirds of physicians  do not find electronic health records,  the chief collection tool of government, useful.   I  won’t go into the reasons why.  Suffice it to say,  the majority of clinicians find EHRs to be a waste of time and money because of their poor design and expense of feeding the data-eating monster.
I am beingtoo dramatic.    But let me say this. Among most private physicians,  especially those in small practices,  EHRs offer gloom for improvement.
A Private Physician’s Lament
To show what I mean,  consider these words of Niran Al-Agba, MD,  a physician in private practice in Washington state (“Dear Mr. Slavitt, Please Come Visit My Office,  The Health Reform Blog,   July 11, 2016.    Andrew Slavitt is the administrator of CMS.
“Andy, if you want to fix primary care you must do some field research.  Come spend one day, or even a week at my office or another small primary care physicians’ office.  You need to see what we do on a daily basis and actually understand the view from a small practice perspective. This knowledge deficit is at the core of CMS’s problem.  You cannot repair what you do not comprehend.”
“Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while still providing high quality, then you are ready to tackle Focusing on Primary Care for Better Health.  The bottom line:  you must pay us more for what we are doing if you want to increase our overhead expenses.  Tasking us with additional administrative burden in order to earn extra money is not actually paying us any more for our work.  We would be working harder, not smarter.  Do you understand that?”
First and foremost, the largest stumbling block for reducing expenditures of a small practice is addressing the certified EHR. Why do you need all this data?  Your days at McKinsey & Company have hooked you on its necessity to make management decisions, but your background is in healthcare insurance and expenses is a far cry from the provision of primary health care or value-based care.”
“The EHR mandate has damaged our profession as a whole.  It has been destructive to the physician-patient relationship as well. Technology has not improved safety, efficiency, or patient satisfaction and has only served to increase physician dissatisfaction.  Physicians are overwhelmed, hopeless, and trying to get out of the practice of medicine altogether.  You do not belong between me (the physician) and my patient – move out of the way.  Please.”
“If you want me to collect mountains of data, then prove it actually increases quality, reduces cost, and decreases our workload before I get on board.  There is very little margin to work with in my office, and if I make a wrong decision, my practice (and many others) will be dead in the water.   Find technology that is useful to both physician and patient while being affordable at the same time.  Stop adding complicated algorithms and programs to increase reimbursement while expanding our administrative burdens.”
“Second, value will materialize if you pay us more for what we do.  Higher reimbursement allows us to slow down and talk longer with each individual patient.  Make our lifestyle something to which others want to aspire and you will find more primary care physicians wanting to work in smaller areas.  Primary care physicians, actually ALL physicians, deserve better.”
“Have you not realized small practices provide urgent and emergency care, acute and chronic care, plus everything in between?  Care coordination, we already do it!  Winging it when there is NO specialist to refer to at all, we already do! It is value, pure and simple.  You cannot get anything more out of us.  There is nothing more to give.  If primary care is rendered obsolete because we could not keep up with your overwhelming demands, access will be in jeopardy.  Access will be worse than it is right now.  What will you do then?”
“As to your Collaborative Care Model, supporting mental and behavioral health through a team-based, coordinated system involving a psychiatric consultant, behavioral health manager, and the primary care physician sounds like a dream come true.  My county with a population of 260,000 has NO psychiatrist.  Not one.  Many states all over are experiencing the same provider shortages.  Can you grow psychiatrists somewhere at an accelerated rate, like that clone army in Star Wars, and drop them randomly by plane throughout the United States?  That would be a good start.  They could be raised to believe indentured servitude is their destiny.  I think it could work if you put that on your task list.”
“CMS employees have not spent one day inside a small primary care practice.  It is necessary at this point in time that they do.  You talk about encouraging innovations to connect people with primary care.  Here is the thing Andy, primary care physicians do not need innovations to connect people.  We use phones, interact face-to-face with our patients, and chart to document the entire process.  If we were not good at connecting with people, we would not be successful primary care physicians.”


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