Number 10: Generic prescription rates in America are highest in the world. In fact the rates are so high, that the OECD didn’t dare show them. The best generics utilizer in the OECD report was Germany at 76% of prescriptions volume in 2011. The U.S. comes in at a whopping 80% in 2011 and 84% in 2012. Not only that, but the U.S. is also #1 in per capita spending on medications, and if 80% are low priced generic drugs, imagine how many more drugs we get to take. This speaks volumes about our new value based health care system.
Number 9: America was once again able to maintain the second lowest number of physicians per capita among developed nations, and well below the OECD average. Obviously, this spells productivity like no other metric can, and it’s most likely due to labor saving innovations, such as Electronic Health Records. With medical school graduation numbers at the bottom of the pack, the future will no doubt bring many more innovations to further increase the efficiency of American doctors.
Number 8: Americans are making big strides in technology use for communicating with their doctors. We beat practically every single developed country at some email metric, which is irrefutable proof that Meaningful Use is working.
Number 7: As in previous years America is holding the line on hospitalizations. Way below the OECD average and practically last in cancer discharges (except Mexico, where they don’t have cancer), our health system figured out much more cost effective ways of treating an increasingly older population, which leads us to #6.
Number 6: No one, and I mean no one, spends less of their health care money on hospitals than the U.S. We are #1. And no one spends more than us on more efficient outpatient care, which includes inpatient physician services when billed separately. It seems that all those inflammatory articles in the media regarding hospital price gouging, are pure nonsense.
Number 5: Not only does America have less hospital beds than most OECD countries, we are not using them very much. With an occupancy rate second to last, it seems that if we closed a third of our hospitals, as some reformers are suggesting, we would be just fine (with room to spare), and we could save oodles of cash. Finding inefficiencies that are easy to fix is a good reason to celebrate.
Number 4: Quality of care for the people that do end up in a hospital is pretty good. On multiple variables of mortality and surgical complications, the U.S. is consistently among top performers. Not absolute best, but a top performer nevertheless. Not to mention that compared to the best performers, your chances of leaving an American hospital with an instrument lodged in your bowels are much lower than in some very high performing countries. For all the alarmists having visions of Jumbo Jets crashing out of the sky daily, killing thousands of innocent patients unbeknownst to anybody else, slow down folks, there are no Jumbo Jets; maybe a Cessna here and there, but definitely no Jumbo Jets.
Number 3: Our children are the best in the whole wide world. The Puritan founders would have been so very proud of them. American kids are dead last when it comes to drunkenness and smoking. Although they are just average when it comes to eating their fruits and vegetables, our 15 year old boys and girls are the most physically active of all other OECD nations. Strangely enough, they are also among the chubbiest, but with all that physical activity, this is bound to resolve itself in the long run. It may be too late for us, but the future looks bright for the young ones.
Number 2: America is the healthiest nation in the world, bar none. Yep, you heard right. Almost 90% of Americans consider themselves healthy, and I have no reason to doubt their self-assessment. Much has been said about other countries, having higher life expectancies. The difference between the U.S. and Japan is over four years of life, but consider this: less than 1 in 3 people in Japan report being healthy. I don’t know about you, but 78 years of healthy life sounds much better to me than 82 years of living with disease.
And the Number 1 accomplishment of American health care is (drumroll please) Obamacare. Yes, Obamacare went viral, probably through the Internet or something like that, because Obamacare is now a global phenomenon affecting every single OECD nation.
To dispel our concerns that an aging population and expansion of health insurance may somehow require more doctors, Drs. Gottlieb and Emanuel urge us to look at the great State of Massachusetts where universal insurance has been in place for years and no shortages have been observed. According to the Census Bureau, Massachusetts has almost double the national average number of doctors per population, and by the authors own admission, its “experience may differ from other areas”. Looking at Mississippi, for example, would have been a stretch I suppose. Either way, policy makers should be all set, since the only place where doctors seem to be growing on cherry trees is our nation’s capital. Other than that, the New York Times article contains the usual innovative fare, being repeated now in most health care journals over and over again. The future holds marvelous technology advances that will minimize duration, complexity and intensity of treatments and non-physicians of all stripes will be delivering most of this now routine care (one interesting suggestion was that pharmacists should deliver urgent care). The main idea is that instead of “expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other health care workers”.
Increasing worker productivity is where America’s exceptionalism truly shines. Labor productivity (i.e. the ratio of output to input) has increased in the U.S. by 254% since WWII (see graph above), and really accelerated in the new millennium. Unfortunately, compensation for this wonderful productivity, took a different path somewhere in the early seventies, hence the gaping divide between America and a handful of very wealthy individuals who benefit financially from productivity gains. The conservative Dr. Gottlieb and the progressive Dr. Emanuel are merely suggesting that this very successful business model should now be applied to the horrendously inefficient health care sector. If you think about it, it becomes abundantly clear that this suggestion is actually an imperative. If we don’t find a way to integrate medical services in the lower-wages/cheaper-products innovation cycle, all those wonderfully productive workers will be unable to afford the medicines needed to sustain their blessed productivity.
The New York Times opinion piece, and the many others like it, are the theoretical foundation leading experts such as Dr. Gottlieb to conclude that “there’s every reason to believe that technology will continue to make the aging process itself (and the treatment of many diseases) a far less resource intensive endeavor – and ones that require fewer physician inputs for a higher level of “outputs” in terms of improved healthcare”. This is very similar to how restaurant chains, or canned food manufacturers, have a Chef that is shown designing fabulous new dishes, using market fresh ingredients, on TV commercials, but the actual “outputs” in each establishment, or can, require practically no Chef inputs. And this is why health care is strongly encouraged to learn from other industries that mastered the art of maximizing outputs to inputs ratios. Fair enough, but how do we know that we have enough Chefs or doctors to start with? Luckily, Dr. Gottlieb has valuable insights on this question as well. The argument is that “if there was a shortage of physicians, it wouldn’t be so easy for the Obamacare health plans to push around doctors and trim their pay”. The same logic is used very effectively by defense attorneys in rape cases where the victim did not scream or kick hard enough.
When analyzing things from an economic perspective, shortage of something implies that demand exceeds supply, and demand does not mean need or even want; it means willingness to pay. For example, one could observe that we have no shortage of private trainers, not because people don’t need to work out, or because they wouldn’t want a personal trainer, but because most folks are not willing or able to pay for one. Demand, and subsequent shortage, is also a function of culture. There is no shortage of wholesome and freshly prepared foods today, because our culture has been altered to have different expectations from food. Preemptively changing perceptions and expectations is therefore paramount to preventing shortages. So if back in the 1990s HMOs were “soundly rejected” by the people, according to Dr. Gottlieb, “[w]hat Obamacare, in effect, tells Americans, is that the White House believes many people made the wrong choice when they rejected those HMOs in favor of PPO plans that offer broader access to providers”. Of course we did.
You hear frequently today how fixing health care requires a cultural change; how we must choose wisely and how we should not expect that everything is done to prolong individual lives; how we should become more accepting of death and how we should quit running to the doctor every time we are sick; how we should learn from Rwanda and how we should fear the killing fields of conventional medicine; how we should value fast service and convenience above intrinsic quality. All these things are necessary to bring demand for physician services more in line with productive workers’ ability to pay for medical care, and as worker compensation continues to shrink, we may end up with a surplus of doctors, which in turn will make pushing them around and trimming their pay even easier, as Dr. Gottlieb writes in conclusion: “In the future, there will be enough doctors for you to choose from. Problem is, in many cases, the Obamacare health plans won’t pay for you to see them”. And it won’t need to, because by then, you will be conditioned to not demand to see them.
Everywhere on this planet, physicians’ professional status, autonomy and compensation, are inextricably tied to the same metrics for the patients they serve. It is plausible and perhaps understandable, that physicians who were and still are the highest paid professionals in the land, considered themselves immune to the increased exploitation and marginalization of all other American workers, including highly educated ones. The almost linear relationship between worker compensation and physician compensation, and the mathematical impossibility of becoming rich by tending to a nation of impoverished workers, must have escaped our best and brightest, until now.
The harsh (and unpleasant for some) reality is that unless you can find your way to medically pamper “Internet moguls”, or happen to practice medicine on TV or at the New York Times, you are in the same boat as the McDonald's workers now rioting in the streets, perhaps in a much nicer cabin (for now), but same boat nevertheless. Something to ponder upon…
Update 12/11/2013: For a bit different, but more authoritative perspective, see Prof. Casey B. Mulligan's Economix article today.
Over the last century, science and technology changed hospitals from places of suffering, grief and death, to places of hope and new beginnings; from dreary Spartan wards for the dying, to plush private suites for the soon to be healthy; from whispered footsteps in the twilight, to shiny instruments of mechanical shops; from final moaning and groaning, to humming of machines and laughing soundtracks of sitcoms punctuated by shrill alarms and flashing lights. Dying in a hospital is now considered a failure of sorts, a preventable and costly mistake. There is no place for God in a modern hospital, and there is no place for special emissaries or angels. And when God vacates the premises, big business comes in to take His place. Today’s technology driven medicine is shaped by young and invincible entrepreneurs, in search of fame and fortune. Masters of their own fate, bursting with self-quantified health, brilliantly educated in the intricacies of computerized logic, armed with stacks of data points, and carefully clad in black turtlenecks, hoodies, tee shirts and designer jeans, these modern knights of the business round table are engaging in the timeless quest of vanquishing death, or at the very least making it less expensive for the rest of us.
So where does all this leave primary care? Primary care is now considered routine care; routine, like changing oil on an automobile. Sticking a needle in your arm so you never, ever die from a plague is no longer a miracle, just like switching the lights on, or flushing the toilet is no longer deserving of thought. Miracles only happen in hospitals now, and not very often either. Primary care doctors are increasingly banned from hospitals, and asked to stick with routine care and leave the complex stuff to their betters. And primary care doctors agreed to this arrangement, mostly voluntarily, and explained (mostly to themselves) that routine care nowadays is pretty complex on its own, and arguably even more complex than the narrowly specialized interventions occurring in hospital settings. Maybe so, but routine complexity is what technology entrepreneurs eat for breakfast. Terminology is important.
When health care reformers say that primary care is foundational to reform, they mean routine care. They mean vaccines given on schedule, screenings done on time, lifestyles assessed and documented, educational materials handed out, and referrals coordinated to completion. They mean managing populations, stratifying risk, conducting outreach, dotting every BP and crossing every A1c. Welcome to Lake Wobegon primary care where all patients come in correctly diagnosed and ready to be tracked. These things can be automated with the right technology and properly trained teams of workers, supervised by medical professionals providing spot checks and quality assurance. High tech and high deductibles will combine forces to turn routine primary care into the first medical service to become a retail product, with its Med Emporium, Osler 5th Avenue, and eventually, Hello Kitty Diabetes toolkits sold at Amazon.com. The question is no longer how to stop the train; the question is where primary care goes from here.
Let It Go!
When primary care physicians became overworked and underpaid, something had to give. Inpatient care, arguably the high end portion of practicing at the top of one’s medical license, was snatched away by hospitals oblivious to their mission statement, and a good portion of complex care had to be offloaded to secondary care, just so primary care can keep up with demand for routine care. Primary care became literally broken, and with it, the entire system downstream was broken too. In a fool’s errand type of strategy, routine primary care now includes tasks aimed at gluing primary care together again (e.g. transitions of care management, exchange of clinical information across facilities). Furthermore, routine care is being expanded to include things previously in the purview of public health (e.g. health literacy, physical activity, safe sex), stuff that grandma used to do for us (e.g. eat your string beans, keep your hands out of the cookie jar) and new retail oriented things (e.g. online shopping, consumer experience, values and preferences).Today, in a plot twist worthy of Beckett himself, tech entrepreneurs in concert with non-physician workers are vying for the business at the low end of primary care. The new routine care will be catalogued, standardized, sterilized, automated, delegated, computerized, transformed and reformed. If you hang on to it, it will drag you down to wherever it’s going. Let it go! Let it go to your “team” (read, staff), or (gasp) let it go to Med Emporium.
Insurers, who could not be made to understand the importance of continuous, comprehensive primary care, seem perfectly willing to support the low skilled, electronic strings and duct tape of the new and expanded routine care. If you have an entrepreneurial gene in your DNA, hire staff, promote your office manager to Chief Quality/Compliance Officer, your receptionist to Care Coordination Manger, the triage nurse to Director of Resource Allocation, and delegate the bejeebers out of your daily work. Become the CEO, and get a secretary (a.k.a. scribe), so you never have to click another box, or type another embarrassingly misspelled sentence. Double your patient population, and let your NPs see the f/u for diaper rash, sports physicals, strains and sprains, the new wave of statin seekers, and everything that your Director of Resource Allocation deems routine. Grab the fluctuating 25% or so of patients that are most complex and be their Comprehensivist. Hospitals are routinely inventing specialties, from hospitalists to intensivists to nocturnists, to further fragment continuity of care and increase profits. It’s time to learn from the experts.
Instead of waiting for the System’s other shoe to drop (on your head), proclaim yourself a specialist in the absolutely last remaining piece of what was once primary care. Grab it and hold onto it like dear life, because it will be nibbled on from below and from above incessantly. You will have to compete with the low prices of Med Emporium on one hand and with the natural expansionist tendencies of hospitals on the other. You will have to find a way to get paid for your new specialty services, and just like every other entrepreneur, you will have to take risk; the more complex the patients are, the bigger the risk and the larger the rewards. Fortunately, the new health care law encourages precisely this type of advanced payment models. Go for it! Spend a leisurely hour with each patient needing comprehensive care, while your routine side of the business is humming along on its own. With proper planning, you can collect the customary and usual fees for your greatly expanded panel, plus the special fees for Comprehensive care, plus any shared savings you can generate from keeping these select folks out of hospitals and emergency rooms. You’ll have to do a bit of marketing and engage in some creative contract negotiations (get a lawyer), but the sky may very well be the limit.
Don’t Let Go!
What if you have no entrepreneurial markers in your DNA? What if the previous few paragraphs made you sick, depressed or really angry? Fortunately, Obamacare is on your side. For all the docs who argued that health insurance destroyed the doctor-patient relationship because it inserted itself in the payment process, and for all those who argued that insurance should not pay for routine oil changes, this is your lucky day, because it doesn’t anymore. With the exception of the very poor and the very old, people will now need to pay for primary care out of their own pocket. That’s what high deductibles mean. A good portion of these people will become savvy shoppers and choose the technology enabled do-it-yourself method, or go to Med Emporium on an as-needed basis, but there will be more than enough patients (perhaps in higher income brackets), seeking quality over cheapness. The same folks that buy artisan bread and free range eggs from local farmers will bring their family to you, if you promise to provide hand-made wholesome and holistic primary care.Direct primary care, whether concierge, or ideal or micro, or contracted by employers and even forward thinking insurers, will most likely explode in size during the next decade. There is a huge continuum of service definitions here, and you should be able to find your comfort zone. You can go back to being a country doctor in the midst of a bustling metropolis, and care for multiple generations at home, in clinic, at the hospital, nursing home and eventually hospice. You can dial back a little bit, or a lot, and contract with midsize employers to provide outpatient primary care. You can be a high-tech, electronic-everything doctor, or an old fashioned one, or perhaps a unique combination of both. Here too, the sky seems to be the limit.
So what’s next for primary care? It seems that for physicians, the door is closing on the treadmill now known as primary care practice, but countless windows are being opened simultaneously. You just have to look up and find yours. Whether you choose to stay in the system, step half way in and half way out, or do it your way all the way, there will always be a need for good doctors. Whether you choose to run the patient mills at Med Emporium, or run your own exquisite Osler 5th Avenue, or start the Hello Kitty Diabetes Company, or care for people slowly and thoroughly, one at a time, from start to finish, primary care may just be the best place to be in right now. You should be thankful this week, because the best is yet to come…
Building on H.R. 2810, the “Medicare Patient Access and Quality Improvement Act of 2013” approved by the House Committee on Energy and Commerce, the new proposal to fix the SGR comes from the House Ways & Means and Senate Finance Committees with support from both Democrat and Republican members, hence the bipartisan and bicameral labels. It is currently in draft form and it is open for public comment until November 12, 2013. This is a short document, and you should read it before it’s transformed into a 1000 page cleverly titled Act. The idea behind the proposal is very simple, and it is widely used in other service industries, where patrons pay a base price for the service, and discretionary bonuses, gratuity, or tips, are available to service providers based on quality of service. There is a small difference though, since the proposal is supposed to be budget neutral (i.e. a zero sum game). Thus, a sufficient number of physicians will need to be penalized to balance the bonuses awarded to better performers.
Below is a simplified summary of the eight point proposal to repeal the SGR, and replace the straight fee for service payment system with quality adjusted risk-based contracting:
- The Medicare physician fee schedule will be (sort of) frozen for the next 10 years. After 2023, the fee schedule will be adjusted upwards by 2% annually if you take risk for your patients through an advanced alternative payment model (APM), or just 1% annually if you don’t.
- The heart of the proposal consists of bundling the multitude of incentives and penalties currently enacted by CMS, into one Value-Based Performance (VBP) Payment Program, beginning in 2017. It’s not that you won’t have to report quality measures or be a meaningful user, you will have to do those things and more, but there will be a single aggregate score to trigger incentives/penalties, calculated as follows:
- Quality Measures reporting – exactly what you think this is – Weight 30%
- Resource Use – similar to the CMS Value Based Modifier initiative, with an added requirement for claims self-reporting (subject to payment reduction) – Weight 30%
- Clinical Practice Improvement Activities – basically patient centered medical home (PCMH) or patient centered specialty practice (PCSP) certification – Weight 15%
- EHR Meaningful Use – it seems that all that is needed here is the use of a certified EHR – Weight 25%
- Practices that have very few Medicare patients are exempt and practices that have significant revenues in at-risk contracts (see below) are excluded from the VBP program. This is a budget-neutral item, meaning that high performer bonuses are directly proportional to the number of penalized poor performers. The pool available for bonuses starts at 8% of the total physician payments in 2017 and increases in subsequent years.
- Since the stated goal of this permanent SGR fix is to eliminate fee for service, an additional 5% bonus will be made available to those who have significant revenues tied to at-risk contracts. The thresholds begin at 50% and go up to 75% revenue. Both Medicare and commercial payer revenues can be counted for this purpose. It is interesting that the thresholds are for revenue, not patients, and it is also interesting that private payers can be counted, although it is not clear if the bonus is 5 percent of Medicare payments, or 5 percent of all payments. A seemingly simpler alternative to obtaining the 5% bonus is to have a “significant share” of revenue in a patient-centered medical home (PCMH) model that has been “certified as maintaining or improving quality without increasing costs”. This will require some explanation in the final bill because PCMH is usually not tied to revenue shares, and because I am not aware of anybody with the ability to certify that a certain PCMH model will increase quality, but not costs.
- For those practicing in a PCMH, or a comparable specialty model (e.g. PCSP), special care coordination codes will be created. The description here sounds very similar to the new Transitional Care Management CPT Codes following hospital discharge. Note that payment for these codes is also budget neutral within the physician fee schedule, so for each care coordination code paid out, someone or something else will be paid less.
- Along with ending fee for service, the proposal will also improve the fee for service schedule, by thoroughly evaluating and “identifying and revaluing misvalued services” to facilitate “smooth downward payment adjustments” The yearly downward target is 1% per year, and if not enough misvalued services are identified, the entire fee schedule will be revised downward by the missing amount. If more than 1% reduction is found, the funds will remain in the budget neutral pool to offset bonuses and other changes.
- The proposal will also ensure that physicians practice medicine correctly. Mechanisms will be put in place to make sure doctors consult appropriate clinical decision tools before ordering “advanced imaging and electrocardiogram services” (no idea why electrocardiogram of all things is specified here). The “tools” will report back to the Secretary of Health and Human Services that such consultation occurred prior to ordering. “Payment would not be made for the advanced imaging or electrocardiogram service if consultation with appropriate use criteria did not occur.” Physicians found to order too many of these services will be required to obtain prior authorization in the future. If things go well, other services will also become subject to appropriate use surveillance.
- To support all these activities, qualified entities that are receiving Medicare and Medicaid data for public reporting, will be authorized to sell analyses and reports to physicians, as well as commercial insurance companies and employers too.
- Transparency will be facilitated by publishing physician payment and various performance metrics measured through the program, so the public can search for physicians by name and get all the data they need to select providers.
Bottom Line
Although right now this is just a proposal, it is very likely that sometime around January 15, 2014, this, or something very similar to it, will become the law of the land. For small independent private practice, the increase in bureaucratic burden will be significant and the reach of insurers into your everyday work will become palpable. Noncompliance with the new regulations means that your topline will remain flat for the next 10 years, minus any penalties, rejected claims and downward adjustments, which may or may not be significant depending on your specialty. Initially, this may only affect the Medicare portion of your practice, but it will not remain that way for long.If you want to continue practicing medicine and remain independent, you have three basic choices: 1) Join a larger entity, such as an accountable care organization, and accept risk for most of your patients in a managed care environment; 2) Adapt to the new paradigm by getting yourself a certified EHR, obtaining PCMH recognition, and learning how to practice under increased supervision; and 3) Stop accepting insurance and switch to a direct pay model. Since the program is slated to begin in 2017, you have 3 years to make an informed decision.
If you are a staunch conservative who believes that free markets should solve health care, or that poor people should work harder and have more skin in the game, or that governments should stick to building armies, you don’t need to read this post, unless of course you enjoy being aggravated by clueless liberals.If you are one of the talking heads posing as a progressive, while repeating the empty slogans of Obamacare (e.g. no one can be denied care any longer, children under the age of 26 can stay on parents’ plans, not perfect but a good a first step, etc.), you should probably not read this either, because you are far beyond the point where independent thinking is an option. If you are none of the above, and have a few minutes between updates on the completely irrelevant status of the Obamacare website, you may want to read on.
Obamacare Strengthens Medicaid
Medicaid is the public health insurance plan for the poor. Medicaid’s continued existence is an affront to human decency. Unlike Medicare, Medicaid is administered by the States. Subject to certain minimums, the States get to decide what medical services are covered, which medications are on formulary, how much money hospitals and doctors are paid, and who is eligible for Medicaid in the State. Some States have the gall to run lottery systems for choosing the lucky poor that are covered by Medicaid, while others have first-come-first-served brief enrollment windows. States are at liberty to decide that they will not cover certain conditions and certain medications, or other therapies, not because these are medically unsound, but just because they can. People on Medicaid have a Medicaid insurance card to let every hospital and every doctor know that they are poor, and that services will be reimbursed with peanuts, if at all. Obviously, many physicians do not accept Medicaid.Having poor people segregated in a defective insurance plan, separate and hardly equal, should be no more acceptable than any other form of segregation. Medicaid needs to be dismantled and all beneficiaries along with all the funds, including States responsibilities, should be funneled into Medicare, the Federally administered insurance plan, for those who cannot, or will not, purchase private insurance. Instead, Obamacare pours billions of dollars into keeping Medicaid alive on one hand, and privatizing its operations on the other (e.g. managed care, health exchange vouchers, etc.), with a net result of transferring a few more Medicaid cents from health care delivery to private corporations.
Obamacare Voucherizes Health Insurance
The Obamacare health insurance exchange is a marketplace where individuals and small businesses can shop for insurance plans that meet new minimum standards. The plans are sold by private insurance companies, and a formal exchange is needed because Obamacare will pay the private insurance companies a portion of the premiums. The Federal subsidy, or voucher, amount is calculated based on means testing. Those who are poor (but not poor enough for Medicaid) will receive a larger voucher than those who are better off financially. This is in effect a progressively defined contribution. Let’s illustrate this with an example. Say the Jones family, which is not completely destitute, received a $2,000 premium discount. Mrs. Jones goes and uses her brand new insurance to have a mammogram which according to the law carries no cost sharing. Say they find something that should be biopsied. This procedure is subject to the Jones family deductible. If the Joneses have the cash to pay for everything until the out-of-pocket maximum is met, Mrs. Jones will get the treatments she needs. If they don’t have the money, the story will have a different ending. So the benefits are not predefined, but the contribution is. This is the definition of a voucher.Obviously, if this is good enough for the federal marketplace, it should be good enough for the employer sponsored group market as well. Private exchanges, where employees get a fixed voucher contribution, are already operational and will most likely flourish in the future. I haven’t heard of any pay increases for workers sent to private exchanges to “shop” for a plan that best fits their “needs”. Eventually, as the contributions fail to keep up with costs of care, all health insurance will become just catastrophic insurance. And as middle class wages keep going down the drain, catastrophic insurance premiums will inch up, because those who cannot afford routine care will be experiencing lots of catastrophes. If you want to talk about death spirals, this is a perfect time to do so.
Obamacare Creates a Tiered Medical System
Much has been said about the transparency of the health insurance marketplace, where for the first time people can get clear information about health plan choices and make apples to apples comparisons. Well, it’s not really the first time, but it helps that plans are labeled by actuarial value, and it helps that there are navigators helping folks make sense of a very complex transaction. However, while you can get information on the costs of insurance, there is no information about the product itself. Health insurance is basically a financial arrangement for paying for health care. Health care is the actual product being bought. Unless we believe that health care is a commodity, then in order to evaluate the product, we need to know who is delivering care. I’m not sure if shoppers on the marketplace are aware of the fact that the financing instruments they are purchasing on the exchange will only work with increasingly narrower networks of health care providers.This is similar to buying a new television set, hooking it up and finding out that it can only receive and display channels 501 through 550. You may get lucky and these are the channels you watched anyway, or maybe these are very good channels, but then again you may not be so lucky. Now, there is nothing inherently wrong with selling TV sets that have limited channels, if people want to buy them, but there is plenty wrong with purposely hiding this particular information from buyers. And there is plenty wrong with a government advertising free and discounted TVs that have bigger screens and better picture than your dinky old TV, without telling you that you may not be able to watch premium channels on many of them.
Of course, if this little marketing maneuver works on the federal exchange, it will quickly spread to the private group exchanges, and soon we will have clinics and hospitals for the well-heeled and larger institutions for the shoeless. It’s anybody’s guess where the better doctors will be found. No, not really. Narrow networks are designed by insurance companies to put pressure on physicians and hospital to lower their charges, either for the sheer privilege of being in-network, or for the additional promise of filling out all seats, with plenty stand-by customers, just in case. This is strictly about money, and has nothing to do with excellence or quality. Exclusive networks of high quality delivery systems are usually more expensive (see Kaiser plans in California).
So basically Obamacare is taking another step towards privatization of health care financing, and the inequitable distribution of resources inherent to private markets. Some conservatives became concerned that if Obamacare does not work as expected, the progressives will have a field day instituting single payer in its place. I wouldn’t worry too much, because Obamacare is great for those who extract profits from health care, and they won’t let it fail. Besides, progressives have lost their way long ago, and single payer is not in the cards for the foreseeable future. If it were, the Obamacare bureaucracy nightmare would have been replaced by folding Medicaid into Medicare, and the insurance marketplace would consist of Medicare, and its defined benefits, as the only game in town for all.
So if your beliefs are on the conservative side, you should support Obamacare. You may have to wait a few years, but it’s going where you think it should go, where the Heritage Foundation wanted it to go. If you happen to be a liberal, and feel compelled to support an embattled President, just because he is better than the alternative, remember DOMA, GLBA and PRWORA. Were you cheering for Bill back then too?
So Obamacare has some seriously faulty and unusable software that they want us to use, and it peddles a whole bunch of new products that we are supposed to buy with government subsidies, or face a penalty. The products themselves have very complex specifications, many of which are not evident before the buyer pays and attempts to actually use the product. Does this remind you of anything?
The Promise
Meaningful Use – Ultimately, the goal is to reduce the cost of health care. The reason the costs are so high is that providers are not willing or able to provide proper care because they are not using intelligent technology to augment the care process. So the Federal government will create a set of requirements for EHR technology that will ensure that care provided through these certified instruments is evidence based, measurable and cost effective, which should increase the health of populations and decrease per capita costs. And the Federal government will of course subsidize the purchase of private products in a vibrant technology marketplace. The program was said to be entirely voluntary, with only a small financial penalty for non-compliance.Obamacare – Ultimately, the goal is to reduce the cost of health care. The reason the costs are so high is that people don’t receive proper care because they don’t have good insurance. If everybody buys health insurance, the risks will be equitably spread out, and so will the expenditures. Furthermore, the program was designed with all sorts of quality checks and balances (e.g. free preventive care, provider payment reform) so people will be healthier, and this should greatly reduce aggregate costs of care. And the Federal government is going to impose certain regulations on insurance products sold in the marketplace, and subsidize the purchase of these products from a variety of competing private businesses, because free market competition fosters innovation, quality and low consumer prices. The program was said to be mandatory, but only carries a small financial penalty for non-compliance.
The Purchase
Meaningful Use – The Federal government is maintaining a website listing all certified technology products, and information regarding certifiable features for each product. Initially the website was a usability nightmare, impossible to navigate, with incomplete information and practically no ability to compare products. Today, the website is much nicer and provides much better searchable information on thousands of certified and partially certified technology products. Providers who purchase a proper mix of listed products are eligible for subsidies based on their particular business circumstances. Although providers must purchase products directly from private sellers, and not through the Federal website, obtaining subsidies (or incentives) requires registration and attestation on another Federal website (operated by CMS), which has gone from bundle of horrific bugs to fairly usable and streamlined software over a period of two years.Obamacare – The Federal government just launched a website listing all approved insurance products, and information regarding compliance with regulatory components, such as premiums, copay, coinsurance, deductibles and out of pocket maximums. The website is chronically broken and is malfunctioning daily, but this website is infinitely more complex than the technology websites because it combines all three functionalities involved in the purchase of an insurance product: listing of approved products, actual purchase from many private sellers, and verification of eligibility for subsidy. Also, the number of shoppers is larger by several orders of magnitude. Nevertheless, this is just a website, and it is reasonable to expect that in a couple of months, or couple of years, it will function smoothly.
The Product
Meaningful Use – Even before they actually purchased anything, providers complained about inadequacy, irrelevance, overpricing, lack of transparency and government interference. After purchasing certified products, many discovered that products did not work as advertised and hidden costs blamed on regulations kept popping up behind every corner. Providers complained about having to switch from products that were not Meaningful Use compliant to those that are, and having to pay inordinate amounts of money for features they had no use for (e.g. why should a dermatologist have to pay for an immunization interface). Predictably, as providers began using their new technology products, two major problems surfaced at very short notice: the designers gave no thought to usability of user interfaces, and interoperability between products was practically impossible, in spite of it being a certifiable feature.Obamacare – The Marketplace insurance products are set to be activated in about two months at the earliest, but even before anybody actually used any of these new plans, people are complaining about government dictating what type of coverage one should have, how much risk people can safely assume, the unexpected high prices and inability to browse and compare apples to apples. People are irate about having to switch from non-Obamacare plans to the new plans, which may be a lot more expensive, and they complain about having to pay for things they have no use for (e.g. why should a 32 year old guy have to purchase insurance for pregnancy). Predictably, as people begin using their new insurance plans, two major problems will surface at very short notice (particularly since early adopters will be poorer and sicker than most).
- The first problem lies in the financial design of exchange plans, which were built to have deceptively affordable premiums, with very high deductibles and out of pocked limits. Yes, the government will help the poorest of the poor, and yes, those who had some sort of insurance prior to Obamacare, most likely had the same out of pocket problem, but let’s face it, most people who are shopping on the exchange can’t possibly come up with thousands of dollars before the insurance even kicks in. True, preventive screenings come with first dollar coverage, but the free screening does not in and of itself prevent anything, and any treatments for what was found during screenings will cost money people don’t have. An insurance executive, I greatly respect, referred to this emerging group of citizens which will soon include most of us, as the “functionally uninsured”. Obamacare is not addressing this problem in any way, and may even exacerbate it by making these hollow insurance products part and parcel of the law of the land.
- The second problem is the narrow networks. Good luck finding out which doctors and which hospitals are included in your affordable Bronze, Silver, Gold or Platinum plan. This is not just about “keeping your doctor”. This is about access to care, and frankly, it is about access to quality care. The model is spreading quickly and quietly all over the country. In my home town, no serious insurer would dare offer a plan that excluded the local academic health system. Until now. Not only did Anthem (one of the largest insurers in the state) drop BJC HealthCare from all its exchange plans, but to my utter dismay, while researching this blog post, I discovered that BJC HealthCare is being dropped from all individual Anthem plans, on & off the exchange, including the one I have. Just like that, on the QT. Strangely enough, narrowing the network by dropping the presumably expensive academic center, made Anthem more expensive than its one and only competitor on the exchange. Greed is good. Government sponsored greed is better.
The Results
Meaningful Use – Following a slow and rocky start, providers began purchasing certified technology products and attesting to their usage in increasingly larger numbers. The government continued to run a huge marketing campaign to sustain and accelerate adoption. It worked. The agencies in charge of this program began releasing numbers on a monthly basis showing how many providers attested and how much money the government paid out in incentives, as indicators of great success. Health care costs did not decrease, and quality of care did not improve, but we are told that these are coming any day now. As time went by, many providers discovered that their certified products are useless at best or about to go under, and hence a second wave of spending is injecting more money into the health IT industry. As technology improves, and the program is further tightened up, it is expected that the flow of cash from health care services to technology companies will become perpetual to the tune of many billions of dollars each year.Obamacare – Following a slow and rocky start, people who are seeing their existing, and way too cheap, insurance products withdrawn by insurers and/or employers, will be purchasing subsidized products in increasingly large numbers. The government will expand its aggressive marketing campaign to sustain and accelerate adoption. The agencies in charge of this program will begin releasing numbers on a monthly basis showing how many people purchased products on the exchange and how much money the government paid out in subsidies, as indicators of great success. Health insurance costs will not decrease, and quality of care will not improve, but we will be told that we need to give the program time to work and improvements are due any day now. As time goes by, people will discover that their insurance is useless, because all the good doctors and hospitals are out of the “rubble only” networks, and the plan doesn’t really pay for anything until you’re half dead and destitute. Following a public outcry, the government will kill off some of the smallest plans, and people will be asked to buy new and improved products from a shrinking number of mega insurers, which of course will be more expensive because they’re so much better. The already perpetual flow of cash from individuals, and taxpayers in general, to health insurance companies, will grow nicely over the next few decades.
Back in 2008 when this whole thing started with talk about a public option, I said that I would happily pay more for health insurance to ensure that everybody gets quality health care regardless of ability to pay. Five years later, it looks like I will indeed be paying double for health insurance, while ensuring that everybody gets low quality health care regardless of ability to pay, except of course the recession-proof Political-Industrial Complex and its financiers.
But Obamacare, which is now the “law of the land”, has a few more pieces in it, pertaining to its affordability and patient protection goals, and those pieces where never up for public debate. Some of these pieces have to do with the definition of health insurance itself: Do people know what an Accountable Care Organization (ACO) is? Do they understand the concept of narrow networks built into the majority of new insurance products? How about high deductibles which seem to be the only game in town, rendering almost all the newly insured to be functionally uninsured? Other pieces have to do with care delivery itself: Who will provide medical care? Who will decide which medical care should be provided? How will care be provided and administered? In the inner sanctum of health policy experts, all these questions, and many more, are answered by a prerecorded message: We are transforming health care from a wasteful, volume based, provider centric, sick care system to a health care system that is value based, patient centered, and fosters the health of populations. What’s not to like? If however, we insist on nitpicking, then perhaps we would like to better understand who does “we” refer to, and what does “value” mean, and maybe some information on how to get sick care, in the unlikely event that fostering the health of populations does not prevent us from falling off a ladder while cleaning the gutters.
Every definition of patient centered care concludes with the observation that such care must conform to patient values and cultural preferences. This is good, because it means we decide what care we want to get. Gone are the days where insurers could interfere with our wishes, and doctors would force us to do things just because they can. Now they have to ask us first, in Farsi or Vietnamese if we so desire, and be respectful about it too: Ms. Patient, would you prefer to take this very expensive brand name capsule once a day, or would you rather take this cheap uncoated pill that will dissolve in your esophagus almost immediately, three times every day? Our call. And if we choose to not take either the capsule or the pills, that’s our prerogative as well. But that’s not all. This goes much further than choice of pills or even diagnostic tests. In a recent NEJM article, two Harvard researchers tell us that “[w]hile some patients may seek greater odds of survival, others may seek a faster return to work or lower out-of-pocket costs. These options are at the core of “patient-centered” care.” [quotation marks in the original] So if, say, you have a tumor on your brain, you may choose to have surgeries and long convalescence times, or you may choose to stay productive until you die while staring at the computer on your desk, or you may choose to pay the rent and purchase food for your children for a few more months. It’s all up to you.
If your cultural preferences are biased towards staying alive and if you have above average values that can easily get you over the high deductible hump, you may want to choose option one. If you have publicly provided or heavily subsidized values, you may still choose to stay alive, although that would entail extreme selfishness on your part, and it may collide with your cultural preference to feed your kids for as long as you possibly can. If it’s not you with a tumor, but your child, the exercise of values and cultural preferences gets a bit more complicated, because children in most cases have negative values which should be balanced with projected future values, and if your cultural preferences lead you to have many children, the value calculation will need to be distributed across all of them. As you can see, with great freedom of choice, come great responsibilities, and this is at the core of patient centered care.
But patient centered care is not only about putting patients in charge of all their medical decisions. It’s also about transforming the system itself to preemptively account for patients’ values and cultural preferences. Care coordination during transitions of care is an excellent example of customer centered service, based on evolving cultural preferences. Informed by their personal cultural preferences, health care transformers know fully well that modern Americans move around the country every few years, from high-powered job to better-compensated job, or just for fun, so having a continuous relationship with one doctor is pretty much impossible. Furthermore, medicine is very complex nowadays, so you can’t expect primary care doctors to keep up with empowered consumers picking and choosing hospitals and specialists all day long, according to their values and cultural preferences. You can’t expect busy primary care doctors to do much of anything really, so the transformers are building all sorts of smart computer systems to automatically track and coordinate the billions and trillions of care transitions from sea to shining sea. This is beautiful indeed, but there’s one small problem.
A Pew survey conducted in 2008 found that 37% of Americans spend their lives in the same town they were born, 57% always lived in the same State and only 15% lived in more than 3 States over their lifetime. According to the U.S. Census Bureau approximately 7 million Americans, or a little over 2%, moved across States in 2012. By comparison, during the heydays of Marcus Welby, 3.4% of Americans moved across State lines, and those numbers have been steadily declining since the glorious sixties. Similar to our health care transformers, those who move around today are more likely to be younger and/or college educated. Another Pew survey finds that the vast majority of Americans prefer living where the pace of life is slow, not fast, and where neighbors know each other well. Only 23% would like to live in the city, with all others indicating a preference for small towns, suburbs and rural areas. Considering these mobility numbers and the clearly expressed values and cultural preferences of the nation, you may be tempted to conclude that maintaining a long term relationship with a doctor is both desirable to most Americans, and also perfectly feasible in a country where most folks die in close proximity to where they were born, but then again, you would be missing the point.
Confused? Not sure how to apply/solicit values and cultural preferences when considering/providing medical care? No worries. We will discuss these things next time. For now, be aware that proper utilization of a transformed system requires that patients are turned on (activated), and that physicians are reeducated.
Somewhere around the turn of the 19th century, give or take a few decades, we figured out how to make things cost less in aggregate, and we have been applying the same principles to an ever increasing array of things that went from being luxuries reserved for Kings and magnates, to being household items taken for granted by every pauper. And we’re not done yet, not by a longshot, but our cost reducing tools have changed from the chemical fumes and big iron of the early 19th century to the clean and minuscule silicon chip. Computers will make health care cost less in aggregate. We just need to figure out how.
Fortunately, the cost of making people is pretty much zero, because people are a renewable resource. Unfortunately, we have very little ability at this point in time to enforce some sort of quality control on an entirely spontaneous production system, so we are stuck for now with high variability in our inputs. Health care is the part that deals with maintenance for all these non-standard people, and hence the high aggregate costs. Exacerbating the problem is that in a fragmented system, those who provide health maintenance services and products are on an innovation spree of their own, with new and expensive products coming to market every day. We could tinker with controlling prices of health maintenance providers, like other developed countries are doing, but frankly that’s just a band aid on the fundamental problem of aggregate costs of health care, which are growing by leaps and bounds all over the world.
To reduce maintenance costs, we need to reduce the need for expensive services, and we need to devise service paradigms that are cheaper to deliver. Since the factory floor is the entire planet, or at least the entire nation, the former requires incredible amounts of computable data, and the latter requires ability to control all aspects of service delivery under one roof. And this in a nutshell is health care reform, not to be confused with health insurance reform and its poster goal of providing “coverage” for the poor and the sick through exchanges, subsidies and expansions. The vertical and horizontal consolidation of health maintenance services has been going on for quite some time, but is now accelerating to the point where there is hardly a day when health corporations merging and buying each other are not in the news. The servicing of these consolidated entities and all other cost reduction tasks fall to Health IT. Just like master craftsmen in the 18th century did not lead the transformation of their respective industries, and just like more recently butchers, bakers and candlestick makers did not build Amazon.com, clinicians will not be leading health care reform. Those who make, and program the machines, always did and will do so now. Health IT will dictate how health maintenance is provided in the future.
So what’s Health IT up to? Health IT is lagging behind IT in other industries, because until now Health IT did not recognize its own strength. Like young superheroes in blockbuster movies, Health IT is blowing things up randomly, while trying to understand how it should apply these newfound powers. But Health IT is not a single minded monolithic being. There are factions, competing ideologies, politicking, and lots and lots of money flowing in, both from customers and more recently venture capital. Generally speaking though, Health IT, as the leader of transformation, has two immediate jobs to do.
Surveillance
This is absolutely necessary if we are going to reduce the need for expensive maintenance services, and a two prong approach is emerging. First, if we have enough information, we can stop people from using their bodies (and minds) in ways that are known to lead to disease, and we can have people engage in early and continuous self-maintenance. Here you find all the little health and fitness tracking apps and gizmos, supported by an emerging common wisdom that the medical profession should play its part in nudging people to hook themselves up to these devices, because it’s about staying healthy and a doctor’s job should be to keep people healthy, not to treat sickness. Who needs yucky sickness anyway? Sure, for a while, we will have to contend with legacy people that are already sick, or on a path to sickness, so for them we have slightly different tracking apps that will help minimize the damage (and costs), one way or another, depending on a variety of factors. These are the feeders, or data suppliers, and in this category we also have involuntary data collectors, such as social media data collectors, shopping/leisure data collectors, financial data collectors, communications data collectors, and even electronic medical records collectors.Second, we have the large (and not so large) aggregators of big data, which are now sprouting like mushrooms after the rain. These applications go by the name of population management or analytics software, and here is where the magic occurs. By combining all data streams, these software programs can identify need for preemptive maintenance. For example, did you know that people that like minivans tend to be obese? If we can combine car purchasing data with food store data and maybe entertainment data, we can red flag people for wellness interventions. And just so we don’t waste our precious resources, we can add health risk assessment data to eliminate those who are not amenable to intervention (why throw good money at lost causes?). No, this is not an Orwellian futuristic state, because nothing is more important than health, and being healthy is the wish of every person in their right mind. As the revolutionary generation used to say, “Give me health, or give me death!” We can finally make this yearning a reality.
Consolidation
But all this big data collection and analysis cannot really work because most people are too stupid to voluntarily see the brightness of a healthy future. So we need to enforce prevention of escalating maintenance costs for the public good, and as always, compliance in a free society, can only be enforced by someone that is bigger, stronger and better armed. If a mom and pop doc tells you to buy and use a Nike+ FuelBand and in your infinite pedestrian idiocy, you decide not to spend money on that, you can always avoid the doctor by simply going to a different one next time your diabetes “flares up”. But, if all doctors in town work for the same outfit, and every single one of them is aware of your obstinacy, because it’s in your permanent medical record, you’re out of luck. And just buying the thing and tossing it in a kitchen drawer won’t work either, because the doctor-employing outfit will be expecting your data from Nike soon enough.Consolidation of the entire continuum of health maintenance services is therefore a must, and since we are now talking about huge businesses, Health IT must come up with enterprise software, which is a far cry from little consumer apps, and even from medium size population management applications. Here we are running into the most hotly debated Health IT issue – large integrated software systems vs. little interoperable apps. The common wisdom (have you noticed how all wisdom is now common?) argues that the big iron enterprise systems are expensive, horrible for users and not given to selfless data sharing (interoperability). Yeah, they are, so what? Have you by any chance seen the horrendous software used by bank employees? Not the cute web/mobile apps for bank customers, but the grey 1950s model used inside the bank, that freezes and crashes and has more boxes and screens than anything I’ve ever seen in Health IT. Does anybody give a damn that the “financial advisor” hates the computer? Nope. And when we have our health equivalents of Citi Bank, JP Morgan and Bank of America, nobody will care about physician dissatisfaction or productivity or burnout or any other feelings reserved for upper management.
How about interoperability, the battle cry of small apps builders wishing to get into the game? There’ll be plenty of interoperability, but not the kind people think they need. Enterprise Health IT will open the gates for all the little data feeders to come in, and all the population management analyzers to come and do their thing, but nothing of substance will ever get out. A corporation cannot honestly provide efficient health maintenance to people floating around specialists and hospitals whenever they want to, and Health IT will be erecting the electronic portion of the barriers to changing health maintenance providers. Yes, we will have Health IT ATMs where we can get a little information when stranded in a strange city, but when was the last time you walked into a Chase bank and cashed a B of A check? And when was the last time your Fidelity financial advisor was able to peruse your various accounts at your current bank and all banks you used in the past, to better advise you on saving for retirement? Come to think of it, when was the last time you switched banks? And how much transactional history was interoperated between your old bank and your new bank?
Ergo
Health IT is hot and Health IT will be leading the revolution and Health IT will transform itself and health care. The big (and rather comfortable) enterprise Health IT will just get stronger and bigger to better support industry consolidation. The little data feeder and analytics Health IT will service the big Health IT. It is very possible that some of these new consumer apps will gain huge market share and become big Health IT (just big, not enterprise), and most likely this is why venture capital is investing. Take home lesson for little Health IT: you can’t beat them, so the best strategy is to join them. And if you think something is missing from this (too) long dissertation, like patient empowerment for example, think again.
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