Wednesday, November 18, 2015

Breaking Barriers

If you are literally starving to death, you can't expect a restaurant to feed you.  If you are homeless and the forecast calls for sub-zero temperatures, you can't expect a hotel to put you up.  But if you think you are having an emergency health problem, by law you can go to a (Medicare-participating) hospital emergency room to get evaluated and at least stabilized, even if you can't pay.  

Similarly, I've heard many calls for a single payor health care system, but I've never, not once, heard anyone advocate that the government should pay for all our food or our housing.

For some reason, we think about health care differently, even from other life-sustaining needs like food and shelter.

I like reading predictions about how healthcare is soon to be radically disrupted as much as anyone -- Oliver Wyman's The Patient to Consumer Revolution and  David Chase's new piece in Forbes are two of the latest -- but I worry that many of these ideas are like putting nicer lipstick on the pig.  

Yes, innovations like digital health, Big Data, and mHealth hold great promise, but even they eventually run into what most people might view as two of the foundations of our health care system but which I fear may actually be hitherto impenetrable barriers to change: "the practice of medicine" and "the business of insurance."  My calling them barriers should come as no surprise to readers of my previous posts.

Let me get to each of these in turn.

Having physician-run state medicine boards oversee who can practice medicine is usually positioned as a benefit to patients, supposedly ensuring that we get care only from qualified professionals.  Some (all right, I) have argued that, whatever their intent, the temptation for such self-policing bodies to end up enabling a cartel is hard to resist.  

Here's two examples of the problem:

  • Let's say I have a rare condition, and it turns out that the best physician to help me with it is in California.  Or Germany, or India.  Fortunately, modern technology allows me to consult with them via video, and increasingly would allow them to perform tests and even procedures on me from where they are.  Unfortunately, under our current approach, unless they are licensed in the state I'm in, they can't help me.
  • As health care accumulates Big Data and the AI programs to sift through it, someday soon such a program will figure out someone's obscure diagnosis and perhaps propose a novel treatment, one that isn't (yet) supported by clinical research or even medical theory.  We may not be able to understand how the program concluded it was the right diagnosis and treatment, but that doesn't mean it won't be.  But, of course, such a program can't practice medicine.   

State-based licensing is an artifact of an earlier, more geographically restricted day.  The medical boards trumpet the new telemedicine compact to show they they are making progress about crossing state borders, but it falls woefully short of what technology allows.  We're starting to have more options, and we'll increasingly want even more of them.

As I've written before, the more we learn about the body and how to keep it healthy, the more it may be that physicians may not be the best people to treat us in all cases.  I'm not talking about physician substitutes like nurse practitioners but, say, geneticists, robotics experts, or microbiologists.  If we subject all the coming advances to our existing ideas about who can "practice medicine," we will be missing out.

And no one that I know of is seriously thinking about how to "license" the inevitable AI-based experts.  That human-centric point-of-view is natural, but will not survive the 21st century.  

To be sure, proof of competence for our health care providers is to be desired, but state licensing is not the only, or the best, way to accomplish this.  Board certification exams, for example, don't vary by state.  Whatever proof we demand should be more universally comparable, more empirically/performance based, and more transparent.  There's no reason that resulting "license" has to be geographically limited, or even limited to our traditional types of providers.

As for the "business of insurance," here are quotes from two dissatisfied customers in a recent The New York Times article about high deductible plans:
"Our deductible is so high, we practically pay for all of our medical expenses out of pocket.  So our policy is really there for emergencies only, and basic wellness appointments." 
"I will never be able to go over the deductible unless something catastrophic happened to me. I’m better off not purchasing that insurance and saving the money in case something bad happens.”
Just what, exactly, do they think insurance is?

Instead of primarily protecting us  from the risk of catastrophic expenses, we now expect health plans to pay for our routine care as well, tell us which providers we can see, negotiate discounts on our behalf, and help us manage our care.  Maybe those are good things, maybe not, but what they are not are things that only health insurance could do.  In fact, even helping us finance care is not something that only health insurance can do.  

We could be thinking of different approaches to financing our health care.  Why shouldn't anyone be allowed an HSA?  Crowdsourcing and microloans are all the rage in financial circles, especially with the FinTech revolution to enable them.  There's no reason these couldn't be used for health care expenses.  

Or think of approaches analogous to life insurance, with payouts based not on death but on catastrophic health events -- a lengthy hospital or nursing home stay, for example.  I'm pretty sure actuaries could price these, but I'm not as sure that many people would be willing to buy them.


But none of that is going to happen if financing innovators have to worry about being considered in the business of health insurance, which would then impose a raft of requirements on them that would force them to look and act much like the health insurance we have now.  And that'd be a shame.

Innovating in health care shouldn't just be about doing what we are doing with better technology, but must also be about rethinking what can help us achieve better health, who is truly best qualified to assist us with that, and what our range of options is to finance our health needs.  We can't be limited by traditional notions about the practice of medicine or the business of insurance.

If we want to think about health care differently, let's really be different.

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