EMR Stimulus Follow-up

A recent webinar by the Information Technology and Innovation Foundation (ITIF) and IBM addressed some of the concerns I voiced in my previous post on stimulus spending on EMRs.

The strategy of the EMR and larger IT portion of the stimulus bill was informed in large part by a report created by the two organizations. This report outlined the job creation potential and downstream benefits of IT infrastructure subsidies. Logistically, the process will go something like this:

Governmental agency publish guidelines -->
Hospitals and physicians purchase and implement EMR systems according to guidelines, possibly with the help of govermental loans -->
Time is allowed to prove adherence to guidelines and possibly effectiveness -->
Hospitals and physicians are reimbursed for EMR system

Therefore, the argument that EMR spending will not generate immediate jobs is actually false, provided that the ONC publishes guidelines in a timely manner and loans are set up to foot the bill. Since analysts are now telling us that the job market is likely to stay slumpy through the end of this year, I wouldn't be surprised to see EMR jobs begin to flow before that time.

Strategically, the stimulus bill states these following goals for funding EMRs:

1. Create a Office of the National Coordinator (ONC) that oversees the "[development of] HIT infrastucture to improve quality, reduce costs, and protect privacy" ($2B). Dr. David Blumenthal, director of the Institute for Health Policy at Mass Gen and a Professor of Medicine at Harvard, was recently appointed to head the ONC.
2. 90% adoption of Electronic Health Records for physicians, 70% for hospitals ($17.2B).
3. Health information exchanges to support information sharing ($300M).
4. Comparative effectiveness research to "reduce inappropriate and unnecessary care." This "would not be used by the government to mandate use of clinical guidelines for payment, coverage, or treatment" ($1.1B).

In my previous post, I stated two major concerns. First, without a focus on overall organization and information exchange, a wide EMR implementation will just be a big expensive undertaking without any of its potential cost-reducting and care-improving benefits. Second, the needs of physicians who work in private groups or rural areas need to be addressed (and guidelines created) differently than those of hospitals. The stimulus goals address the first issue by creating the ONC and including information exchange as part of its reimbursement guidelines (presumably, as these have yet to be developed and published). The research goal is like icing on the cake; it shows that lawmakers have the long-run in mind. But my second concern is still not adequately addressed. Will guidlines be different for individual group practices and rural physicians? Will different products be recommended (or new product development encouraged) for these groups versus hospitals and larget networks? How is the heavy burden of the upfront cost for small group providers going to be tided over to ensure their survival? I expect more answers will come forth in the actual content of the guidelines.

Where do health care bloggers fit in?

I subscribe to a good number of health care blogs. There are subtle nuances -- some slant towards markets while others towards policy; some focus on details of running a hospital or specific health issues, while others on big-pictures such as health care reform or cost structures; some are individual thinkers contributing their observations while others are multi-blogger efforts backed by well-known organizations. This speaks to the great interest that exists among the blogging community in health care issues, as well as just how big and diverse the "health care" umbrella is.

Call me narcissistic, but I can't help but wonder about the downstream impact that blogging (a.k.a. my words and time) has on the health care field. In fields that survive on innovation such as entreprenuership and philanthropy, blogs are a quick and en mass way of exchanging ideas. These ideas, half-baked as they might be, build on each other and drive the field forward. But health care sits at a unique intersection -- between private markets and public policy, between inherited hierarchies and incentives-based structures, between old world traditions and a new eye for efficiency and evidence-driven action. So where do the words that float around in the health care blogsphere go? Do old guard movers and shakers in Washington spend time listening to not their constituents and consumers of the health care system, but thinkers who have educated opinions about change? How much, or where, does idea-exchange drive health care like in entreprenuership?

What motives commitment to social justice - two working hypotheses

*This is not strictly a health care related post, but I think it's still fitting to add it to the discussion.

Last week, I was having dinner with a friend whom I met as a junior in high school. We ended up at the same college, meeting up once or twice a quarter to fill each other in on what was engrossing us in our lives at the moment. As our college years progressed in parallel, she had found her passion in human rights work, while I became fascinated by health care policy. Although we met sparingly at best, our connection hinged heavily on a sense of purpose that we both found in social justice.

So over dinner, interwoven with news on relationships, family, and future plans, we talked about where our passions have taken us (her continuing her research on the history of the international human rights movement, me exploring the possibility of applying business sector experience to reforming the health care system). As we talked, I discovered that for the first time since I've begun to seriously pursuing a path in public service, someone else put into words something that had been bothering me from the beginning about my own philosophy on why I was choosing this path.

Many stories you hear about young people going into volunteerism and public service come from one mold -- the person had either personally lived or witnessed first-hand some form of injustice (domestic abuse, governmental corruption, health care disparities, environmental destruction), and their empathy for the victims have driven them to action. Consider the kid from an inner city who grows up to be an education reformer because he wanted to give other kids like him a better shot, or the doctor who opens a free clinic in a remote village who had seen one too many patient there suffer due to a lack of medical care. In college, I worked closely with our Haas Center on Public Service, a unique resource dedicated to integrating service with a university education, and that many of us students committed to social change happily call our second home. Even walking around the place and meeting people in passing gives you a sense that you were among folks who, like you, felt that there was a sense of purpose higher than pursuing personal gain.

However, a part of me always felt out of place, like I was some kind of fraud or poser. Time and again, I saw students throwing themselves into mentoring programs for kids in the next town over, which has much lower levels of income, education, and resources (as often is the case with an elite university and its neighboring community), or fighting for prisoners' rights to health care and fair treatment, or helping in legal clinics that provided services to immigrants who were being wronged by the justice system, or one of literally hundreds of issues and organizations the worked directly with needy communities. My issue, justice in the form of equal health care access, is no newcomer among public service fields. What I felt set me apart was my approach to the issue and my inner motivation. Most of my peers were part of a grassroots army, people who served by doing, by being on the ground delivering goods and services. However, as my friend pointed out over dinner, something about us makes it difficult to overlook the frustrations and flaws that we see in people and systems when we're entrenched in grassroots work. We become impatient with the chronic lack of funding, staff shortages, bureaucracy and redtape (especially in larger, more established nonprofits), and a tendency to place ideals ahead of impact. Worst of all, we become impatient with the people that we're trying to help.

Volunteering at the ED in a local hospital, I've seen poor or homeless patients come in complaining of chronic pain in order to get meds to feed their addiction. Frustrated, the doctors would either coax them to leave or give in to their demands in order to free up time and beds. As an intern in a community clinic, I became disillusioned with the power struggles and cultural clashes between organization leaders and the ground staff. As an intern at a small health outreach nonprofit, I again felt frustrated with its "business-as-usual" culture that relied more on tradition than constant questioning of their impact.

Consciously, I know that people who work for nonprofit are no saints; they're just normal people who are just as prone (if not more due to the challenge of nonprofit work) to stress, frustration, disillusion, being satisfied with the status quo, and bad habits. In fact, the unbending idealism that enables nonprofit staff to fight an uphill battle day after day is often a cause of their blindness to impact and feeling territorial about their ideas. Also, not everyone in the nonprofit sector are motivated by noble ideals and altruism; they still need to balance the very human needs of earning money, supporting their families, and deriving satisfaction from their jobs (which is, on the average, higher for service-oriented professions). On the end of the populations being served, I'm well aware that many people that end up in safety nets aren't in their situation by choice. But all this knowledge still doesn't help with being able to better accept people's flaws and facing an innate sense of frustration everyday.

So what keeps people like my friend and I fighting for the causes we've devoted ourselves to? We're too perfectionist, perhaps even too self-righteous, to accept the flaws in the people and organizations we're trying to help. We have trouble relating with people who make bad choices about their lives, however involuntary and situation-conditioned these choices may be. But perhaps this makes us the ultimate idealists -- despite a lack of personal relation with the people that don't share our cognitive styles and even those we're trying to help, we just can't accept the alternative of leaving the field altogether. We're driven not by a sense of personal compulsion, but an indignation with the idea of injustice. The same stubborness that fuels our perfectionism also makes us seek justice that is imperative to our view of what is right, no matter how elusive and improbable. For my friend, her face automatically twists with frustration when she talks about how intolerable it is for humans to suffer torture and a lack of political voice. For me, I feel similarly about the fact that people are sicker because the health care system is biased against their skin color, language abilities, and income level. We also tend to focus on the up-stream causes of injustice, such that instead of delivering services to those who were already victims of human rights violations or a biased health care system, we find it more effective to correct the system in the first place. Simply put, we sense things are simply not right, and we are driven to do what we deem most effective to right the world.

This, to the traditional public servant, may sound blasphemous. He might argued that if service towards other human beings isn't driven by compassion, it is vulnerable to attack by self-righteousness, blindness to the actual needs of the people whom we're supposedly helping, and a tendency to cloister oneself off in one's high-flying ideals. At the same time, service motivated only by personal identification with a vulnerable population has its own downfalls -- you become less responsive to the needs of peoples with whom you identify less (what makes people like you more deserving of help that those who are unlike you?), your actions are dictated more by personal affinity (which is prone to all sorts of biases due the limitedness of one person's experience) rather than a cold focus on achieving impact, and you lose sight more easily of the system-level influences that caused the suffering you're trying to alleviate.

In the end, the (somewhat of a cop-out) conclusion is that a true commitment to social justice is made up of both personal and idealistic motivations. Without staying grounded to the actual people who suffer due to injustice, you lose touch with the humanity you both share as well as their reality, which is the ultimate benchmark of your effectiveness (if doing what you believe is right isn't actually improving their lives, then you've failed). But without a healthy distance from their perils, you can become trapped in anger or blind to gaps in your own thinking, leading to burnout and a habituation to ineffective processes.

Equal opportunity vs. absolute equality -- Looking at the psychology of American health care reform

America is all about equality -- it's written into the fiber of our being that "all men [and women] are created equal" and are entitled to "life, liberty, and the pursuit of happiness." It is therefore not surprising that equality has remained an unquestioned principle through many a round of health care policy debates. Interestingly, the rhetoric of equality has also been wielded by both conservatives and liberals, by those for universal public health insurance as well as those for privatized, market-driven coverage -- essentially all parties across the spectrum. How is it that such a commonly accepted value can be used with equal effectiveness by opposing arguments?

Perhaps we ought to stop and think about what each side means by "equality." There are those who are interested in creating a publicly funded universal insurance program similar to the Oregon Health Plan, in which services were defined by their degree of necessity and strictly rationed based on patients' medical needs. These people are likely concerned about equality in the sense that everyone obtains the same services in terms of type, quality, and quantity. On the other side of the debate, pundits argue that it is precisely in unrestricted access to whatever medical services people desire or require that the principle of equality will be upheld. Of course, open access necessarily doesn't necessarily mean that everyone will get the latest CT scans, cancer therapies, or boob jobs. The hidden limiting factor here is money; we have an openly accessible system where those with money can buy whatever care they want, while the poor are often barred from even a basic level of service. In the end, we as Americans may actually care less about having the equal level of care than the theoretical equal opportunity to get the level of care we want or need.

But most of us lie somewhere in between. On the one hand, we feel that we've earned our money fair and square. No government should be able to take it away from us to subsidize someone else's care, and gosh darn it, we should be able to get that perfect pair of breasts if we so wished! But we also intrinsically see something wrong with having our health and happiness depend almost entirely on how much green we have in our pockets. In fact, in these troubled economic times, we fear more than ever how one job loss can leave us depending on state-run Medicaid for health insurance. Ai, there lies the rub. You've heard the big scary word before: rationing. Whether you like it or not, baby boomers aren't getting any younger, new diseases are being discovered and therapies being developed for them everyday, medical school is getting more expensive, driving our future doctors to sub-sub-specialize instead of go into primary care, and physicians are being incentivized to provide high quantity, not high quality, care. All of this means there will be more demand for health care services, which further drives up the prices of these services in a techno-philic system that already pays a premium for the latest-and-greatest.

Like it or not, our health care system has long passed the point where people were able to receive as much care as they wanted for a reasonable price, which means rationing has been going on longer than we might perceive. Currently, our system implicitly rations health care based on wealth; depending on your income, you can have pretty much as much of whatever kind of care as you'd like, with almost no upward limits. We don't like to think about this as rationing -- we think of it as the American way, in which there are no glass ceilings to the level of wealth you can achieve, and therefore the level of care you can buy with that wealth. Although most of us live modestly, we would nevertheless like to believe that ordinary people like us, with enough hard work and a sprinkle of luck, can be the one to have it all (see this idea parallelled in this Newsweek article on why we don't hate the rich).


Does our concept of equality (equal opportunity or absolute equality), and thus our idea of what an equal distribution of health care looks like, really come down to what the middle class identifies with the most? In good times, we have the luxury of optimism, to aspire to "having it all," and we don't want that optimism curtailed. But when a downturn like the current one hits, and we begin to prepare for worse-case scenarios that threaten our reality, we believe that we are honest, hard working people who deserve a sturdy safety net (it's why the stimulus bill provides additional funding to bring people into Medicaid). This is the conflict that we're caught in as we try to rectify the inequalities in our health care system; we're torn between the two seemingly opposing cornerstones of our being -- impossible optimism and dogged pragmatism. The ultimate solution looks, again, to be two-tiered. One (say, a government funded basic insurance package) must appease our desire to be guarded against catastrophes outside of our control, while the other (the private market) maintains the hope for unlimited growth and progress. Beneath the surface, however, there is a unifying factor, a redemptive quality - both ideas stem from a deep belief that our efforts can make a difference, that we should be protected against external ills to the extent that they no longer impair our potential for self-made progress. This belief has driven us both towards innovation as well as stagnated debates, towards unparalleled quality of care as well as disparities that rivel those in third world countries. It's what makes health care reform so uniquely difficult.

Baseline EMR?

In previous posts, I've written about two very separate ideas -

1) A universal health insurance model in which everyone is guaranteed a baseline level of coverage, while those with added medical needs or monetary ability can purchase more insurance on the private market.

2) The need for not only widespread use of EMRs, but the importance of EMR systems being able to communicate with each other.

What if we combined these two ideas in the movement to spread the use of digital medical records? We would create a two-tiered system in which the baseline is an EMR system that is low-cost and has basic functionalities, perhaps even something that is opensource (similar to the OpenMRS used by community-based health providers and nonprofit groups such as Partners in Health). This baseline offering is cheap to purchase, easy to customize and use, and addresses the basic needs of a provider practice. At the same time, the market already provides a variety of more comprehensive (and costly) EMR solutions that larger provider systems would favor to cover the level of complexity in their organization. This second tier market wouldn't change, but the problem of compatibility needs to be address. These more complex solutions should be built to encompass the basic capabilities of the baseline product, so that a basic level of communication is possible across all health care providers.

Part of the $20 billion in the stimulus package slotted to go towards EMRs can be used to help physicians in rural areas and small group practices implement the baseline EMR package. Using funds this way is both cost effective and high impact, as it addresses the needs of those providers that are easily left out of larger, more complex systems. Their smaller size also means that they may not need the level of complex detail that are built into EMRs current supplied by the private market (as a health IT consultant, I've gotten to see how needlessly complicated these systems can get). A two-tiered EMR market would ensure that all provider organizations can find a product most suited to their size and financial ability, and it would improve the likelihood of intersystem communication.

EMRs in the stimulus bill

The much-debated stimulus bill that will be juggled between the Senate and the House this week includes some impressive provisions that could potentially have huge impacts on American health care. First, $20 billion have been provisioned for incorporating digitized medical records (or EMRs, electronic medical records) into doctors' offices. This should be applauded as packing a much-needed punch behind words that have been touted since the Bush administration. But even advocates and experts in the health IT field are cautious, as they well should be. Our health care system became the way it is due to a series of haphazard legislation, incremental compromises between interest groups, and a focus on treating disease rather than preserving holistic wellness. EMR systems are an essential part of elimited the poor quality and high cost of health care because they reduce framentation of care in our current system. The problem is not that we lack the technology, the cost-cutting incentives, or now even the funding. The stimulus money will hopefully lay some important ground work to putting into place technological infrastructure that will bring health care up to the standard of other industries. The problem, as usual, is that we lack planning. We don't have an organized approach for how the money we're spending today on EMRs will lead to increased coordination of care and communication between providers, patients, and payers in the years to come. Obama and his health care team will do this country and the future of health care a huge favor by using the stimulus as an opportunity to reshape health care IT. The money should be earmarked for organizations that are willing to share, instead of silo, their technology and expertise. The stimulus plan should also favor organizations that stand to gain the most cost reduction and quality improvement, namely larger, more complex systems, from having EMRs. Smaller group practices and individual providers in rural areas should definitely not be left out, but it is not cost-effective to fund individual EMR implementations for these providers. Instead, they may be allowed user privileges in larger EMR systems nearby, where they may already be allowed referring physician access. Obama has proven how he can use vision to inspire action; with the stimulus bill, he should using the tools at his disposal to drive synchronized action towards a more transparent and coordinated health IT system.

Choosing ethical consistency over reform outcomes?

This morning, Tom Daschole abruptly announced his withdrawl from consideration as head of the Department of Health and Human Services, amidst intense scrutiny over his over $120,000 backlogged taxes, employment by (and possible political endorsement of) a lobbying company that has health care clients, and borderline lobbying activities that are potentially problematic for an Obama administration that promised to clean up Washington. (Click to see the CNN and New York Times news articles, as well as the Time news analysis.)

As a politics and health care enthusiast, I found myself unable to shake this news. On the one hand, I find myself outraged and defeated by the news of yet another Obama nominee with a less-than-spectacular financial track record. On the other, Daschle's experience in public and private health care sectors, unique position of leadership in both, and familiarity with the political and informational landscape of America's health care system made him a clear choice. It's no wonder that Obama had no back-up and is now scrambling to come up with another name. (Tangent alert: It's easy to fixate quickly on his involvement in both the policy and business of health care, to assume that he "sold out" his public service and political insider experience for personal gain. However, given my current position in a large consulting firm, it's clear that I not only disagree with this position, but wholeheartedly believe that successful health care reform must address the perspectives of all stakeholders, public and private, provider and payer, advocate and pundit, etc.. Otherwise, we're doomed to repeat the failure of Hilary Clinton's health care reform in the 90's, and really just about every other effor to change the status quo since the beginning of the centure. End of tangent.)

The question is - is this a case of the perfect getting in the way of the good (even with his imperfect record, Daschle has the seemingly magical combination of knowledge and experience across sectors to lead the rescuing effort of our failing health care system), or does Daschle's oversight constitute an ethical violation serious enough to trump whatever good he might have been able to do as head of DHHS (and thus he was wise to withdraw voluntarily)? The former paints the debate into a matter of pragmatism, while the latter makes it into one of ethics and public trust. Or maybe these views are not as clearly dycotomized as I'm making it out to be. Are we seriously to believe that Daschle overlooked the driving serivces and private consulting fees he received as part of his income? Are we to accept the fact that he never disclosed his tax problems to the Obama administration, even after being nominated? Can we still stand behind his efforts to create a National Health Board and trust in his upholding the public interest, knowing that he participated in lobbying-esque activities while not technically registered as a lobbyist? The answers seem to suggest that without ethical consistency (the kind that is visible to the public anyway, but that's my cynical side speaking), a political leader loses the intangible capital of trust that eventually drives through change.

Which, if you think about it, is not a very difficult concept to grasp for us ordinary people...

Baby babble (aka my first real counter with big bad insurance)

Yesterday I went in for a follow-up optometry appointment. Usually these are the most basic of basic medical encounters - you pop onto the doctor's exam chair, he ask you read a few lines of letters and numbers, tweaks with some lens combinations, and pops out a prescription for your glasses or contacts. Easy as that. I've had myopia (i.e. nearsightedness) for as long as I can remember, so these appointments have become entirely routine. As a recent grad with my first full time job, I thought that there couldn't be an easier way to try out my brand spanking new health coverage than this. I picked out a doctor out from the website that was linked to my company's internal portal, found myself pleasantly surprised that I was able to view and even compare information such as the MDs' credentials, comparative ratings, and patient population types. This, I made note, is what empowering the patient looks like.

The first time, I go in to see Dr. Soss on a Saturday morning. Upon entering, I'm greeted by his receptionist, Eileen, who seems more like an amiable librarian in the children's section than someone who deals with billing and insurance papers. Dr. Soss has a commanding, larger than life air about him, which is backed up and explained by the various plagues on his walls dictating his various memerships and leadership positions in local and national optometrist organizations. Personally, I prefer my doctors old fashioned - stethescope around the neck, kind eyes and a ready smile, and more of a listener than a talker. But I felt reassured by his commitment to his profession. The appointment goes as I expect; Dr. Soss even goes on to recommend an eye exam in addition to the normal lens exam, which I agree to. Out of professional concern, Dr. Soss suggests that I provide him information about my previous contact lens prescription so he has as much information as possible before he finalizes my prescription in a follow-up appointment. Again, as both a patient and someone who has thought a heck of a lot about the doctorly ethos, I was impressed by his diligence. After we finish, the librarian receptionist finds my insurance information in her computer, charges me the co-pay (we have a slight tie-up with my flexible spending account, but she provides me the papers to get reimbursed), and I leave with the understanding that I'll need to come back for another appointment.

Yesterday, another bright Saturday morning, I walk into the same office and am greeted by the same receptionist. But something was different; she tells me in a concerned tone that I'm no longer in her system. At first, I suspected that there must have been some mixup; what with it being the beginning of a coverage year of all, sometimes names might get lost in the system. I ask her to check again, but all she pulls up was someone with the same last name and first initial. It turned out that she had mistakenly billed this person for my last appointment, and that I was never in this system to begin with. She calls the insurance company with the vision plan, but then has to hand the phone to me as the agent tells me, after rattling off a professionally rehearsed greeting, that not only I, but my employer, are nowhere to be found in the database. I'm confused; I had clearly gotten Dr. Soss's information from my company's website, how could they not be an in-network provider? At this point, Dr. Soss emerges with his previous patient and gets an understanding of the situation. Apparently he is only a medical, but not a general optometry, provider within my plan's network (which, of course, my company's spiffy website failed to inform me of). Being of no help, he further tells me that since my appointment was already on the books, I'd either have to complete it or accept the $50 no-show penalty charge. Meanwhile, I have had no luck getting in touch with my medical insurance. Even though Eileen promises to help me with any paperwork the insurance might require for reimbursement, I had no idea what percentage, if any, my insurance would cover for non-reported out-of-network providers. I'm stuck trying to decide between taking the penalty but getting no service for it or going through with the appointment and risk having to pay for it out-of-pocket.

At this point, I'm very frustrated -- I studied this stuff for three years! I know how health insurance works! I can tell you the difference between HMO, PPO, FFS, and P4P, as well as the different incentives that they invoke, in a heartbeat! But when it came down to it, why don't I know how reimbursements and preferred networks work, and what I need to do to get it? I also found myself casting doubting glances at my doctor - was he trying to pressure me into paying him for the appointment without concern whether it would be paid for or not?

These thoughts are not the ranting complaints of an eager beaver who thinks a great deal but doesn't know how the world works (well, they kind of are, but I promise you I do have a point). If someone who is educated, knowledgeable in the theoretical workings of health insurance, and has a great deal of respect and understanding for health providers could, in one small incident, be made confused and doubting, what is it like for someone who sees health insurance as a black box, or a self-employed small business owner, or a cancer patient? Lack of knowledge and wondering, all the while desiring the relief of suffering, whether they can pay for improved health can make any patient anxious, interferring with the way they seek care and trust their provider.

Putting on my consulting hat, the next question is - so what is the solution? On the technology front, it's clear that even self-serve web-based tools designed to empower the patient to make more informed decisions can sometimes be confusing or even counter-productive if it provides erroneous or incomplete information. As an IT consultant at a large hospital, I see firsthand how out of hand and complex huge medical systems - whether it's EMRs (electronic medical records), electronic prescription signing, or insurance records - can get. As with any honest look at reality, we have no magic bullet solutions (see my previous post on health care IT - magic bullet or recipe for disaster?). As much of a cop-out answer as this is, we need to be both open-minded and cautious about adopting health care technology. The momentum forward for bring the health care industry up to the technological standards of pretty much every other privatized industry is an absolute imperative, but we can't do it blindly. There needs to be adequate research and planning before we shower money on EMR implementations and web-izing patient-provider information exchange (again, see my thoughts on health care IT and Obama's stimulus free-rider health care reforms).

Of course, this encounter was more than just a breakdown of technology. It microscopically reflects the fragmentation of our health care system. As a patient, my primary concern is my own best interest -- finding a provider whom I'll feel comfortable talking to about very personal experiences, who is willing to take the time to partner with me in my care, and whose expert opinions I can trust. Worrying about whether this provider will take my insurance, or worse yet, might slam me with charges for services that I had little control over due to my relative lack of expertise, should be the last thing on my mind. (The health care industry by nature is imbued with this imbalance of information, which endows the physician with the peculiar role of providing both supply and demand of medical services.) Envision walking into any doctor's office (primary care, specialist, eye care, midwife, dentist, acupuncturist, whatever), presenting proof of a single source of insurance (nationally funded with standardized levels of coverage, but operated by private insurance companies to ensure competition and efficient delivery), and knowing exactly what services will or will not be covered because you've checked the comprehensive federal website. You're able to clearly ask your doctor for certain services you know will be covered and have an actual informed converation. You walk away being satisfied with the results of your converation, knowing that you'll be able to use a web-based system to communicate to your doctor or his/her staff, manage your personal information, and access your test results. Most of all, you also feel assured that you won't encounter surprises in the mail or the next time you walk in the door. Oh, a girl can dream...

Epilogue

Things have a way of working out, even if it's in a twisted way. I called my health insurance to verify whether my optometrist was a vision provider and got an assurance that he is, even though Dr. Soss stressed over and over that he was tired of dealing with my insurer and only remained in their system for medical patients. For better or for worse, I'm just going to leave the bickering to my doctor and insurance company, file my reimbursement papers, and thank my lucky stars that I'm a healthy twenty-something who escaped relatively unscathed from the provider-patient-insurance entanglement (for now, anyway).

Thoughts on a burgeoning (or fatigued) space

Every morning, as I wave my badge in front of the security clearance device by our office front door, I can't help taking an extra glance at the printed sign next to it labeled "Information Technology." Normally this wouldn't raise any eyebrows, except for one notable fact - I work for a major academic hospital.

These are new waters for me - for much of my undergraduate career, the thought that my first real job would have anything to do with the word "technology" never crossed my mind. The one CS class I took my senior year made me both terribly sleep-deprived and absolutely miserable. This was made even more certain by my firm belief that I was ultimately headed for medical school. I was going to be a doctor who healed patients with drugs and touch and words, and even though I knew I wanted to take time off before returning to school to explore the health field, that time was neatly limited in my mind to no more than two years, doing something within the counventional boundaries of the field (junior researcher, policy intern, academic assistant, etc.).

So it's with a bit of wonder that I ended up here, in health care IT. In the title, I referred to this space as both burgeoning and fatigued. In one sense, IT is the new buzzword in health care. Digital medical records, patient-oriented interfaces that allow them to email physicians, have visits online, check test results, and access online medical information databases (e.g. WebMD, a new and very spiffy tool called Medpedia) are the hottest things. As a field that has long included diverse players ranging from ethicists to engineers, health care is soaking up ideas such as crowdsourcing and social networking.

On the other, the oragnization and planning behind some of the ideas is still quite poor. As a health care system, we have no vision for how to digitize our provider networks so that communication flow leads to improved outcomes and lower costs. Pharmaceutical companies are taking advantage of this gap between providers and patients to directly advertise costly and not necessarily more beneficial products.

Moreover, if you step back, IT is no new sheriff that just rode into town to save the day. EMRs have been around for a good two decades (Epic Corporation, which produces one of the most popular EMR systems, was founded in 1979). The VA hospital system has digitized health data since the 80's, and their VistA system became the largest in the country by 2001.

The point is, the movement for digitizing health information is not as new as the recent spotlight would suggest. It's been a (painfully slowly) growing process. Obstacles abound at multiplate levels when hospitals or physician groups are trying to decide whether to take the plunge into a digitized system -- internal politics, upfront cost of implementation, uncertainty outcome of better care or lowered cost, lack of convincing research, etc. The $19 billion provisioned in Obama's recovery package should help with the financial aspect, but it depends on the logistics of how and to whom this money will be dispursed. We need to see this money as a chance to radically shake up health IT, both in terms of widespread digitization and strategic change.

Introduction

Why health care? Why change?

Let's face it. Our health care system is sick -- 1 IN 6 Americans has NO HEALTH INSURANCE. 1 IN 3 is OBESE. 7 OUT OF 1000 NEWBORN BABIES DIE in infancy. We have a health care system that costs us 16% OF OUR GDP (expected to rise to 20% by 2016), the most expensive in the world, yet it's ranked 37th by the WHO, behind countries like Chile and Costa Rica, and right before Slovenia. And we are the only nation in the developed world WITHOUT UNIVERSAL HEALTH COVERAGE.

We’re ready for change, but we can't decide what we want. We look to Canada and its universal health care system, but wince at the notion of having to queue up for services. We think getting free government services, like the British NHS, is a nice idea, but we’d hate to have our choices limited in what kind of care we get. Our health care system reflects the principles that this country has always celebrated -- individual freedom, personal choice, diversity, and equal opportunity. In short, here in America, we think that we should all have the chance to get whatever we want, however much we want, whenever we want it.

While we’re freely consuming health care services, our health care system is bursting at the seams. With the graying of the Baby Boom generation, many believe that Medicare is set to go bankrupt before another generation reaps its benefits. Medicaid now pays for the majority of long-term care costs in the country. Meanwhile, the average worker contributed $3,300 to his or her employer-provided health insurance. Together, public insurance programs pay for over 60% of all health care costs, while the rest comes either out of our pockets or our payroll.

America does do one thing very well – providing us with however much of whatever we want, whenever, granted we (or our health insurance, if we have it) can pay for it. Our hospitals have the best newborn- and elderly intensive care technologies in the world. We have specialists for every disease and body part imaginable. Our doctors can transplant anything from hearts to livers to skin. We're constantly investing R&D on new drugs and unexplained diseases processes. And as America ages, we now have more diseases that we manage than fight. These "magic" interventions would most likely be only dreamed of anywhere else.

But for the one in six uninsured Americans and the many more under-insured, however, reality is very different. They are most likely racial/ethnic minorities and immigrants working in low-wage jobs, who are already dealing with other challenges. Uninsured patients wait until the last possible minute to seek care for illnesses ranging from bad colds to cancer and serious infectious diseases. Care is not given in doctor’s offices or hospital visits, but in the emergency room, often with poor outcomes and at high costs.

This blog was inspired by a class of Stanford undergraduates studying comparative international health policy in the winter of 2008. It’s organized by relevant topics in health care and policy (seen as “labels” to the right), along with some thoughts and questions to get started. While these tend to be the most recurrent themes in health care policy debates, please let me know other topics that you think I’ve neglected, as well as if you'd like to be a co-author of this blog. Most importantly, this blog is meant to be a forum for all of our comments, entries, resources, and ideas.

CHANGE BEGINS WITH CONVERSATION. So let’s talk.

vision

I'd been meaning to publish this post for a while. It was inspired by election day (yep, definitely a while). I tried to move beyond the sense of hope and imminent change that much of the country was wrapped up in, and begin to pulling the bits of pieces of thoughts I've had over the past several years on how the American health care system can best move forward. It's quite a change from the research-heavy type of writing I've done in the academic sphere of Stanford, where your every word must be backed up by 5 peer-reviewed papers or else it doesn't count. So pardon the oozing optimism, my lack of citations, and please bear with me.

Tuesday, Nov. 4, 2008

As I watched this new era unfold and thought about my part I was to play in it, I felt that it’s appropriate that I should begin putting down thoughts of a coherent vision for the future of health care, both in the US and internationally. Overall, the keywords are integration and multidiscipline. We need to realize that the future of medicine doesn’t only lie in more advanced drugs, devices, and procedures, but also in maximizing the efficient utilization and equality of access to existing medicines. This paradigm shift will reduce costs in the developed world as well as bring about more impact in developing regions. Innovation does not only need to occur in the sciences, but also in health care management and policy.

Unique in that it’s driven by a strong sense of ethical purpose, the health care industry also needs to realize that it’s part of the business sector. The tough job is to balance its moral obligations to patients with adopting more cost-cutting and quality-raising business processes. The beauty, however, is that if incorporated correctly, these two commitments are complimentary. This mindset will shift current perverse incentives of overspending, patient appeasement, and isolationist physician practices towards evidence-based, low-cost practices that improve patient outcomes.

On the other end, patients need to be both given greater access to accurate information as well as learn to compromise, so that they have more tools at their disposal to cooperate with their physicians. These changes require both a change in psychology as well as information infrastructure. For better or for worse, the latter has already begun to take shape – direct advertising of drugs to consumers, the burgeoning health 2.0 movement (websites like WebMD and CDC). There is no isolating patients who want information from those who are more than willing to provide it, so there had better have a planned approach to developing these infrastructures and monitoring their quality. The former, however, might be more difficult to bring about. Traditionally, physicians have been the benevolent patriarch, dispensing tokens of pure truth to their patients who then follow it to the word. Armed with direct access to information and choice, however, patients have begun a backlash of sorts; they now demand certain procedures or brand-name drugs even when the effectiveness has not been proven. And physicians often have no choice but to appease patients for fear of losing business, which then gives patients a bad taste of the health care industry only tending the bottom line, making them even more likely to be on the defensive and demanding unreasonable care. This speaks to an underlying imbalance and inaccuracy of information, of patients and physicians being out of touch with each other and failing to realize that they are working towards a common goal. Physicians need to be taught how to deal with their patients’ demands and insecurities, and patients need to learn to trust their doctors again. With the recession rolling in, perhaps here’s a sliver of a silver lining – as a new sense of economic insecurity sets in, perhaps both patients and physicians can be more easily persuaded to back cost-saving measures that might curtail some of out society’s appetite for the newest and most expensive technologies.

Of course, there is the perennial problem of health insurance coverage. Studies that establish the negative consequences of having no or inadequate health coverage are numerous and indisputable, as well as research that shows how factors such as race and ethnicity compound these consequences, so I won’t spend time on this here. The bottom line is that universal health coverage should absolutely be a goal that policy makers strive for. Obama and McCain both have important elements of what I believe to be the correct solution. McCain’s idea that empowering individuals to make their own coverage decisions derives from both the Republican ideal of self-determination and an economics model of free market competition. Both have proven to be effective in other situations to improve quality of the product, which is in this case not only more efficient health insurance plans, but also improved medicine. Patients will only pay for the best insurance packages, which in turn cut costs and increase their competitive edge by paying only for the most effective medical practices. But he falters on at least two important points. First, he underestimates how heavily health insurance is essentially being subsidized by employers. By taking away the tax benefit of employer-based insurance, McCain would be uprooting a bothersome but deeply entrenched wisdom tooth without the precaution of anesthesia or stitches. There would only be pain and chaos. His proposed credit would not only be inadequate to cover health plans for those who will lose their employer-sponsored insurance, it also won’t do a single thing for the working poor who most need the coverage. It’s been shown that when the poor receive cash, they will choose to spend it on necessary goods such as food and clothing; health insurance will be the last thing on their minds. Secondly, even if he were to give families enough money to buy insurance from the market, he would never pass a mandate. But without such, the majority of this cash return will only get lost in the general economy.

Obama is willing to pass a mandate, but even he only goes as far as proposing it for children, along with raising the income limit for SCHIP to enroll more kids, to avoid tanking his candidacy (because, after all, who would take away health insurance for kids, right? Oh wait…George W. Bush). But to me, the most insightful one of his proposals is the creation of a government-financed basic insurance package. Obama might still be fuzzy about the details of this plan, and in the end it might be too much for a conservative America to swallow, but I’ve long suspected that when absolute equality can’t be achieved, at least we can strive for guaranteeing a basic level of care for all. Let’s face it, for all the talk of equality we have here in America, what we believe in is not absolute equality, but equal opportunity. We don’t think everyone should be allocated the same amount of resources; instead, we think that people should be given the same chances to achieve their dreams, and be rewarded differentially based on how hard they chase after their dreams. And gosh darn it, we should certainly be able to use our hard-earned money to buy superior health care. By nature, we balk at a Canada- or EU-style pseudo-socialist health system that is heavily subsidized and/or entirely run by the government and offers no special treatment based on economic status. Instead of ignoring this fundamentally American trait, we might want to acknowledge it, and more importantly, focus on the fact that it stems from the belief that one has the fundamental right to pursue one’s dreams. There are several precursors to this pursuit such as education, public safety, and health. (Interestingly, the former two are largely recognized as responsibilities of the government without anyone raising a whimper, but talk of a publicly financed health care system would put most Americans on edge.) Right now, we have a baseline of service -- emergency care. Yet when a patient walks into an ER with advanced stage breast cancer or diabetes-related complications, they are many times more likely to have poor outcomes, and are tens of thousands of dollars more expensive than they would be if these conditions were caught early and managed properly. This means that they would need access to regular primary care. They need to have health insurance. Hence, it makes sense, both from a cost savings and a health outcomes perspective, for all people to have a basic level of health insurance that ensures them access to yearly check-ups, prenatal care, mammograms, prostate exams, dental work, etc.

The next question is – how does this happen? Nearly half of all ER care is uncompensated by either public or private funding. Therefore, hospitals need to shift this cost to their paying patients, driving up health care costs and making health insurance more expensive for all. This relationship potentially produces a cycle in which more people are squeezed out of the insurance market due to high costs, which makes them more likely to end up in the ER for care. If an entity was willing to step in and ensure better primary care for those who seek care in an ER, it would stop this cycle, drive down the overall price of insurance, and ensure a healthier, more productive society. Sounds like some good incentives for a large public body (if only Obama can use his silver tongue to convince the middle class that spreading the cost will ultimately be worth the sacrifice).

Now we’re getting down to the nitty gritty – what’s the best mechanism? How do we combine the ideas of encouraging individual choice, establishing a mandate to ensure coverage, and fostering health competition in both the insurance and medical care markets? Some point to the Massachusetts system as a model of a potential solution. This system, the initial success of which was recently validated by a JAMA study, operates on a pay-or-play model – employers are either required to offer their employees affordable insurance options or pay into a common pool that is used to alleviate the burden of uncompensated ER care. But they forget that Massachusetts was operating with a huge surplus that was supporting the cash pool. Also, no pool would be large enough to cover ER services for the 46 million uninsured in the US today. Again, the solution lies in early and regular care, not supporting the existing safety net that’s bursting at the seams. Rather, a solution that would incorporate all these principles would be a health insurance voucher. This can be offered, as Obama suggests, as one of the options offered by one’s employer, and it can also be obtained directly by those who are unemployed, self-employed, or for some reason don’t have employer-based options. Note that this only affects how health care is financed, not how it’s operated. The way that care is delivered will change very little; there will still be large non-profit hospitals, private physician groups, and plenty of specialist care. It also doesn’t drive out private insurance companies; those wealthy or sickly enough, of whom there are plenty in America, can still choose to purchase additional coverage on top of this basic package or skip it altogether. This solution simply guarantees that the money allocated will be spent only on health care, and it also encourages competition – in the insurance market for the most cost-effective plans (they’ll have to compete with the government option), in physician services for the most high quality, evidence-based practices (patients gets a much wider choice of physicians and hospitals), and in the PMP market for low-cost generics (they must compete for government business). These principles are similar to how Medicare effectively integrated hospitals in the 60’s by refusing to pay racially segregated hospitals, as well as how it leverages its position as the biggest buyer of pharmaceuticals to set prices.

A new frontier

Last winter, I announced that I was going to work for a large consulting firm instead of applying to medical school, attending public health school, or working at a non-profit, as were more consistent with my apparent interests and experiences as an undergrad. When people heard this, those who didn't know me said "Good for you, you'll be making oodles of money!" Those who know me asked "Why are you selling out?" But people who really know me understood that this was a perfectly logical step in my quest to better understand the complexities that come as a consequence of the inevitable intersection of health care and business.

It's been 5 weeks since I took on my new identity as consultant-in-training. Albeit, most of it was spent in training, but so far I've learned two main lessons: 1) When it comes to technology, clinical medicine is dismally behind most other industries (including ones in the health care field, such as pharma and ) in virtually all traditional business functionalities. For example, most hospitals have little technology that is efficient and integrated across departments that would allow them to track accurately real-time clinical data such as bed occupancy and surgical supplies. 2) The up side is that for this reason, there are plenty of opportunities to apply some simple business principles to achieve high impact on the medical process, reduce costs, and ultimately improve quality.

A NYTimes article today titled "Simulating Age 85, With Lessons on Offering Care" perfectly embodied several of what Daniel Pink discusses in his A Whole New Mind are right-brain,
R-directed" qualities." (The book was a gift from Oprah to us, Stanford graduates of 2008.) The article describes programs that can be provided to staff at nursing home facilities, medical students, businesses, and other professionals that come into contact with senior citizens. These programs literally put their participants into the shoes of over-85-year-olds (e.g. putting corn kernels into their shoes to simulate the pain experienced during walking due to fat loss) to create for them a personal experience from where their work for the elderly will stem.

First, this is a perfect illustration of how the medical and corporate worlds are incorporating "empathy" into their work. Pink foresees that in a future "R-directed" world, more services and products will have their development and delivery center around empathy. This is true not just in professions that traditionally value empathy such as health care, non-profits, and education, but also in businesses that have always thrived by competition. Today's article provides a clear example of this shift.

Empathy is connected to two other principles Pink describes -- "story" and "design." In a way, humanistic design, which Pink argues will be what gives companies an edge in over-crowded and outsourced industries, cannot be done without understanding the personal experience and stories of its consumers. These connections are also touched upon in this article.

From NYTimes, "Doctor and Patient, Now at Odds," July 29, 2008:

"...Doctors, facing declining reimbursements and higher costs, have only minutes to spend with each patient. News reports about medical errors and drug industry influence have increased patients’ distrust. And the rise of direct-to-consumer drug advertising and medical Web sites have taught patients to research their own medical issues and made them more skeptical and inquisitive."

A quick, concise look into some of the things that are wrong with our system today, an unplanned mesh of old-world medical paternalism, free market forces, the internet, and the beginning of a patient-centered movement.

Sir Michael Marmot on health inequalities

Sir Michael Marmot, a prominent British social medicine scholar, health policy adviser, and principle researcher in the Whitehall studies in the UK, made the following points in his talk this evening on health disparities:

1) The gradient effect of health disparity: poor health does not just strike the poor below a certain threshold of income or education, but applies across a gradient. Anyone who is not at the "top" of society has some degree of degraded health proportional to how far they are from that "top." This was clearly demonstrated in the original Whitehall study of British civil servants, in which universal health care access made income level the only meaningful variable. The study showed that even a small difference in income correlated with poorer health, both physiological and psychological. This, in effect, makes health disparities everyone's problem.

2) On linking research on the gradient effect of health disparities to policy-making: the gradient effect of health disparities poses a challenge for policy-makers. It can generally be assumed that the government, not the private market, will ultimately need to step in to correct health inequities. However, the lack of clear benchmarks makes it difficult to use this research to identify priorities for allocation of funding and health care resources. In fact, Sir Marmot proposed that it is almost impossible for a country (such as the U.S.) that begins with a health care system in which groups of people are targeted for special treatment (elderly - Medicare; poor - Medicaid) to switch to a universal system. Such a system needs to be mindfully designed beforehand. This, of course, returns to the old theme of how cultural values shape the design and evolution of the health care system. A fragmented, targeted system assumes that public care is inferior to private care, that one person should not be responsible for the health care of another, and that government programs are only for those who are weaker or sicker than the rest. In a universal system, there is a general sense of entitlement, and thus ownership of and satisfaction with, the public system; it is something that everyone pays into and reaps the benefits of. Thus, the health system between Canada and the U.S., for example, are not just structurally different, but really reflect two very different value systems.

3) How can we meaningfully measure the effects of race? In the U.S., a country so uniquely obsessed with race and color, many studies includes race in a way that is not informative, while others do not explore in enough depth the silent effects of conscious or subconscious discrimination on minorities' health status. This is evident in the fact that within any socioeconomic stratification, people of color generally have poorer health indicators than their white counterparts. At the same time, traditional measures of socioeconomic status such as income and education level have just as clear an effect on the health of minorities, seen in the difference that these factors make in the health status among people of the same color or ethnicity. These suggest that race plays a uniquely subtle but undeniable role in health disparities, which presents complex challenges to researchers in terms of measurement.

"It didn't fit their business plan"

The NYTimes published an article (see article) today on an expensive drug, Cerezyme, used to treat a rare genetic disease, and the issue of dosing as drugs become more and more expensive. It brings up several interesting topics.

When it comes to technology use, it is evident that those with enough wealth in our culture, and increasingly, the globalizing and westernizing world, readily soak up the newest and most expensive technologies, perceiving them to be more effective than the old. However, the system of research and development (R&D) of new pharmaceuticals and procedures in the U.S., where much of the world's foremost medical research is produced, does not guarantee that this is always true. The series of clinical trials that a new drug must go through need only show that it is 1) safe, 2) chemically distinct, and 3) effective against a placebo trial. There is no requirement that it needs to be more effective than the best existing treatment. The article also mentions that the clinical trial for Cerezyme was based on only 12 people, again showing that FDA approval and rounds of clinical trials may lend a false sense of "betterness" to newer drugs. With this said, there are certainly advantages to having a variety of equally effective treatments for each disease -- patients who might not respond well to one treatment might find another that works better, and some new drugs may be able to achieve the same effectiveness with fewer or milder side effects. In general, however, the intense comodification of the pharmaceutical development process and the huge profits that go into the industry (supply-side), combined with consumers' sense of safety with newer drugs (demand-side), tend to skew companies' priorities towards the bottom line and result in an overproduction of expensive new drugs that may not be any more effective.

Meanwhile, the burden of skyrocketing costs fall on both public and private insurance systems, as well as on those individuals who are uninsured, ineligible for insurance, or inadequately insured. Ultimately, it is individual patient and physician choice that drive this overuse, so educating the public and doctors on appropriate drug prescribing might be beneficial. (But it seems that the pharmaceutical industry is one step ahead in recognizing this loophole in their profit-making process -- enter the massive amounts of direct consumer advertising to ensure that patients continue demanding the industry's products, and the legions of physician-salespeople hired by drug companies to "educate" their peers on the benefits of new drugs to ensure that they continue prescribing, perhaps even in higher doses than necessary, as indicated by the article.)

Sicko, Michael Moore's latest documentary on health care

http://www.imdb.com/title/tt0386032/plotsummary

Documentary look at health care in the United States as provided by profit-oriented health maintenance organizations (HMOs) compared to free, universal care in Canada, the U.K., and France. Moore contrasts U.S. media reports on Canadian care with the experiences of Canadians in hospitals and clinics there. He interviews patients and doctors in the U.K. about cost, quality, and salaries. He examines why Nixon promoted HMOs in 1971, and why the Clintons' reform effort failed in the 1990s. He talks to U.S. ex-pats in Paris about French services, and he takes three 9/11 clean-up volunteers, who developed respiratory problems, to Cuba for care. He asks of Americans, "Who are we?"

Individual responsibility vs. Governmental obligation

A fundamental issue that divides liberals and conservatives in this country, as well as the global public health community, is the question of what expectations we should place on individuals to be responsible for their own health (either through insurance or behavior), and what obligations the government has to ensure a basic level of health for its people. Going even deeper into its core, this issue also involves a discussion about a capitalistic vs. socialistic point of view -- the emphasis on free market and competition in capitalistic ideology deems it inevitable that some people will be left out in the cold, while pure socialism is more concerned with providing equal services to all, with the caveat that those with the desire and means to purchase enhanced products are not able to do so. In the U.S., we obviously have a heavily capitalistic leaning, with a market absence of the social solidarity that exists in many European health systems. Yet we can safely argue that our health care system has evolved beyond the era of social Darwinism in recognition that it is both ethically and practically unacceptable to systematically preclude the poor and disadvantaged from health care. The thorny issue, then, perhaps lies in the balance. How do we, conservatives and liberals, compromise to ensure that people have an incentive to contribute towards society in return for health care benefits, to take care of their own health in order to avoid doctors' visits, whilst still providing a basic level of care for those who are disadvantaged due to factors out of their control, such as cycles of poverty and poor education? How can public health causes promote both self-care (exercise, healthy eating, safe-sex education) and provide services to keep people safe and healthy (needle exchange programs, condom distribution)?

Cost & financing

Should the bulk of the financial burden be on individuals, employers, and/or the government?

Insurance coverage: issues of equity and access

Should we all have the opportunity to whatever care we want, or should we be expected to give up the right to certain services in the interest of saving costs for the whole system?