Next Things First

Reform: Finally, Some Discussion of the Real Issues by Rob Coppedge

In light of all the distraction recently generated by discussions of health care IT (and even, cue the smoke machines, Health 2.0), I was very pleased to find Senator Tom Coburn, MD, and Regina Herzlinger’s piece in the Huffington Post.

In a week that for many of us has been dominated by reading the “wouldn’t-it-be-cool-ifs” of messenger bag-carrying technology evangelists, it was refreshing to see a call for a much needed national debate around the *real issues* facing the health care system.

With little fanfare, Congressional leaders may be near to agreeing on the most sweeping expansion of government in a generation – the de-facto takeover of the health insurance market by the government. Congressional Democrats are already icing the champagne. When the President’s “Medicare for all” plan is coupled with the budget, which contains a “down payment” of $634 billion over the next decade for health care, government-run health care may be inevitable.

All sides in this debate acknowledge that the U.S. has long needed easier access to health insurance. This need has gained urgency for the many Americans who are fearful of losing their employer-sponsored insurance in the midst of a recession. Unfortunately, the President’s plan will not only endanger the U.S. economy, but millions of patients as well.

They make clear that the issue here is cost containment. Or, perhaps better, that solving the “access” issue without controlling costs may be politically expedient but is a recipe for disaster.

The fundamental problem is that the President and congressional leaders lack realistic plans to control the health care costs that are already crippling U.S. global competitiveness. As a percentage of GDP, our businesses spend roughly 70 percent more on health care than competitors in other developed nations, yet we hardly receive 70 percent more in real value.

We talk a lot about cost containment – and in the world of health care venture capital, some of the most exciting investment opportunities address just this set of issues. But translating these decidedly market-focused ideas into terms that are politically palatable is difficult. Denying reimbursement for treatments, no matter their relative value or efficacy, has interest groups rushing to mount the barricades. However, as Coburn and Herzlinger point out, there is a risk of even greater hazard if we don’t engage the cost containment challenge now:

In the end, the Democrats’ health care reform will require drastic rationing… Consider Canadian patients, who may wait a year or longer to get radiation therapy. Or ask one of the nearly 1.8 million Britons who are waiting to get into a hospital or have an outpatient procedure. Or talk to the German breast cancer patients who are 52 percent more likely to die from the disease than Americans.

Concerns about rationing and patient outcomes are not demagoguery. How else can a government control costs in the real world? Many experts, including the Congressional Budget Office, dismiss as wishful thinking the Democrats’ claims of achieving efficiencies through bureaucrats’ dazzling implementation of information technology and other technocratic tools.

And this is where the real world collides with the health care technology bandwagon. It goes without saying that health care lags behind in the implementation of back office and administrative information technology. And certainly this is due in some part to all the factors that are debated regularly in the blogosphere. However, it is also due to the basic fact that there has been little ROI for physicians implementing these technologies.

I worry that we are just further confusing the issue. As my colleague Alan Buffington points out:

Isn’t it interesting that no matter how many times they are corrected, politicians and media folk refuse to distinguish between health care and health insurance.  Failing to make this distinction is what causes the problems discussed in the article.

If you watch the blogs, Twitter or CNN, you will have proof that the problem Alan points out is deep and widespread. The problem with health care is that it is “hard” – complex, path dependent, interlocking, huge, with substantial ethical and moral considerations. For most people (especially politicians),  this is way too much.

Posted by RobC



Electronic Medical Records: Some Insightful Journalism by charlottegee
February 8, 2009, 1:56 pm
Filed under: electronic medical records | Tags:

Even if politicans don’t seem to get it, at least CNN shows a thoughtful mastery of the issues (insert sarcastic emoticon here) …

From CNN’s Campbell Brown, Feb. 6, 2009:

President Obama wants to modernize your medical records. It’s part of his stimulus plan. Up next, this influx of technology could lead to an invasion of your privacy. We’re going to show you how.

And then later, the mother of this California octuplets says she’s being singled out. You won’t believe what else she says when we come back.


BROWN: President Obama’s economic stimulus plan includes $20 billion to improve health care technology.


BARACK OBAMA, PRESIDENT OF THE UNITED STATES: This plan will put people to work, modernizing our health care system. That doesn’t just save us billions of dollars, it saves countless lives.


BROWN: The plan is for every American to have his or her own electronic medical record in the next five years. No more of those paper folders your doctor probably uses right now. And it sounds like a great idea, but there could be a pretty disturbing downside and senior medical correspondent Elizabeth Cohen is here to explain exactly what that downside is.

And Elizabeth, first, I mean, talk us through why the big push to make our medical records electronic and then the privacy concerns because, in fact, you’ve uncovered some real holes here.

ELIZABETH COHEN, CNN SENIOR MEDICAL CORRESPONDENT: Oh, yes, and gaping holes that actually had to do with my records which made it especially scary. But here’s the argument.

Basically people are saying, come on, doctors, you got to move into the 21st century. I mean, who uses paper records anymore. Well, most doctors do. It’s hugely inefficient and also using paper records instead of digital records can lead to medical mistakes that can kill you.

So, President Obama says, look, we’re going to do electronic medical records but I’m going to appoint a chief privacy officer and have all sorts of safeguards to make sure that only the people who are supposed to look at your records are looking at your records. And so, some folks are saying, that sounds good, but really will there be enough safeguards to keep these records private?

BROWN: And Elizabeth, you mentioned your own records. I know you are on your health insurance company’s Web site and you discovered something pretty shocking.

COHEN: Right. I was just on this Web site looking around and I thought all of a sudden I was like oh, my goodness. This is a list of every doctor’s appointment I have had in the past 18 months plus, all the doctor’s appointments and lab tests for my husband and for my four children. I had no idea they were there, but here they are.

These are actually my medical records that I stumbled on to, online. For example, right there, that’s my annual mammogram that I had. Then there was my daughter’s pediatrician’s appointments. All of them.

Then there was my billing for my cholesterol test that I had at my annual physical. And Campbell, the really scary thing here is that if I had seen a psychiatrist during this period of time, it would have been on there, too. Right there online, every time I saw him and his name. Continue reading

A Physician’s Reaction to the New York Times’ EMR Story (From Howard Luks) by charlottegee

The NY Times ran another piece* on the potential benefits of an EMR platform. I’m not sure who was *behind the story*… but I disagree with a number of the statements and premises of their article.

I have blogged about this topic often enough … here, here and here.

I am not against technology. As a doctor, I am against  *shouldering the burden* and *paying a fortune* for technology that will probably not enable my patients, will not materially affect my business, and as currently designed will not reform health care or the practice of medicine. EMRs, as currently available today, are in their infancy. They are, for the most part, very poorly engineered, very expensive, and do not allow me to share patient data with hospitals, RHIOs, etc.

(image from California Physician)

(image from California Physician)

Physician innovators should have taken the lead on EMRs … but we didn’t. We should have been involved at all levels of the platform’s build-out, but we weren’t.

Who benefits MOST from an EMR, and the sharing of knowledge, tests and procedural data … ? *Nope* … it’s not the patient … but the managed care industry!!! *If* technology such as an EMR platform decreases the number of duplicated procedures, the managed care industry’s profits rise. *If* they need fewer FTEs to handle electronic claims, their profits rise.

Do you think they will decrease their premiums if their costs go down???? Nope. Look at the airline industry. Gas/fuel are at four-year lows … yet we are still paying a fuel surcharge!

So, if the MCOs are going to benefit the most …WHY SHOULD THE DOCS, many of whom are already operating on a very fine margin, SHOULDER THE ECONOMIC BURDEN of purchasing, rolling out and maintaining an EMR system that most relevant research shows they probably will not like in the first place????

“This requires the usual leap of faith that knowledge will yield good things — better care, doing things smarter and, yes, saving money in the long run.”*

Leap of faith??? I’m not jumping out of a plane and relying on a parachute opening. Design a platform I like, align the interests/economic burden of those who prosper from the IT expenditure, make it economically feasible, make the systems inter-operable, the data actionable and computable and I will be the first one to sign up.

“We have to restructure our medical culture,” he said. “We have to promote a culture that believes in the evidence and is trained in analyzing the evidence. It’s the only long-run answer to the challenges we face in health care — evidence-based medicine.”*

This has nothing to do with evidence-based medicine (EBM). Whenever possible, I have been practicing EBM for years. The problem is that we do not have enough evidence. Without interoperability, currently available EMR platforms will not lead to a plethora of EBM data.

There has to be a better way … another reason why the Obama administration needs to fund the health care venture capital sector to allow for disruptive innovation in a space clearly in need of a new way of thinking.

In addition, this clearly points to the need for physician thought leaders to be actively involved in the innovation process.

Submitted by Howard J Luks, MD