Thursday, September 15, 2016

Big Brother Is Watching, Documenting, Dictating, and  Paying You
Big Brother is watching you.
George Orwell,  1984
He who pays the piper calls the tune

           Times are changing
            In the good old days, after World War II, physicians got much of what they wanted.  They had access to more resources and unprecedented economic growth.  The public wanted more health care, more physicians, and more hospitals. Physicians were respected,  were deferred to,  and received the money they wanted.   The medical world was theirs for the taking.

             But then came Medicare in 1965, rising costs,  diagnostic related groups,  managed care,  the HMO Act of 1973, medical technology advances,   computer driven CT and MRI scans, renal dialysis, organ transplants, and joint replacements, and open heart procedures,  stents, and the relentless rise of government and  corporate surrogates such as insurers,  hospitals, integrated health organizations,  big pharma, and the so-called medical industrial complex.

           Along with this rise came shifting sources of power and influence.   Physicians were no longer that only game in town.   They had to set aside time, energy, and personal resources to form organizations and to devote their time to activities they did not find personally satisfying to keep their place in power spectrum.

         Power became diffuse.   Government, because it was paying for more and more care, began to dictate the terms of patient engagement – what procedures  could be done and what price.    Physicians had to negotiate with insurers to remain in their networks.

         Government become more watchful, meddlesome, and intrusive, and with new computer technologies, they had the power to impose their will.   Government  decided tat power could be exercised in the form of electronic records  which could be installed in every doctor’s office and could be used to document  everything entailed in the diagnostic and therapeutic activity.   Furthermore,  it could used to determine what was of “value” to the patient,  what was the proper optimal quality/outcome equation,  what separated the good doctors from the bad doctors,   what they should be paid,  and how this magical electronic technology could be used to centralize power,  to homogenize and standardize physician behavior, and achieve continuous quality improvement and total quality control.

             But government failed to recognize that  there is no magical way to influence physicians and to bring them to heel, that quality is an elusive concept,  that individual physicians and patients cannot be reduced to data points,  that physicians and patients alike cherish privacy and confidentiality ,  that data on populations may not apply to individuals,  and that somebody must decide what to do and how to diagnose and treat individual patients.

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