Usually this time of year people like to either look back at significant events of the year just ending, or to prognosticate about what might happen in the new year. Well, neither my rear view mirror nor my crystal ball are quite that good, so I'll use my last post of the year to cite some examples of the kind of innovations that most fascinate me, ones that suggest the future may come sooner and/or be quite different than we expect.
Or maybe they'll prove to be red herrings. It's hard to say.
I'll give three examples. How and even whether any of them relate to health care, we'll get to later. In no particular order:
Tell me your password: If you go online with any regularity, chances are good that you've got a password. Probably, in fact, a whole bunch of them. With online security becoming ever-more important, more sites require passwords, and tougher/harder-to-remember ones at that. The trouble is keeping track of them all.
People use different strategies to deal with this ever-growing plethora. Some people have good enough memories to recall them all, although I don't know any such people. Others create lists to keep all their passwords, or utilize apps to store and even create passwords for them. Ironically, those apps themselves require a password, which creates kind of a cat-chasing-its-own-tail scenario.
But passwords are so 1990's.
Google and Yahoo, separately, are testing getting rid of passwords, replacing that step with a message sent to your smartphone, which you can use to authenticate the log-in attempt. Of course, if you have failed to lock your phone, or have forgotten its password, you're out of luck.
Other new approaches include using fingerprints, which have the drawback that they, too, are now digital and thus can be stolen, or facial recognition, as Windows 10 now allows. Hey, as if recognizing your face isn't enough, UK-based start-up AimBrain claims its software can recognize you by how you use your device, making passwords unnecessary.
I don't know what approach will win out, but, given how much people hate them, how poorly they use them, and how easy they are to hack, I'm willing to bet that in five or ten years we won't be using passwords.
Give me the cash: We love our credit and debit cards. Not all that long ago, it seems, we mostly used credit cards only for larger purchases, and debit cards not at all, but now you can pretty much use them about everywhere, for any amount. Still, you probably go out with some cash on you, just in case.
Unless you live in Sweden, that is.
Sweden appears to be closer to a cash-free economy than just about anywhere. According to The New York Times, cash is only used for twenty percent of consumer payments in Sweden, versus around seventy-five percent in the rest of the world (surely that is a typo, right? 75%?). Some Swedish banks don't even keep cash on hand. Seriously. As one student said, "No one uses cash. I think our generation can live without it."
In a cashless society, people use credit/debit cards, or smartphone-based approaches like Apple Pay or Google Wallet. Those approaches still are primarily based on card networks, but don't require you to give your card info to a merchant.
Money is, after all, notational, even actual currency. It only works because we all agree it has value, and whether it is cash or digital isn't fundamentally important. As Bitcoin is slowing proving, "money" doesn't even need to be something issued by governments or central banks; just a bunch a people agreeing to accept it allows it to have value.
I don't know if the winner is going to be cards, electronic transfers, Bitcoins, or something else, but in ten or twenty years you may have trouble getting a merchant to accept your cash.
Cutting the cords: This is a hot topic. I've written on it myself. Instead of using a landline for telephone service, we figuratively cut that landline and rely on our mobile phone. Instead of being forced to take whatever array of channels our cable company forces upon us, we choose our own shows or our own packages of shows, usually streaming via the Internet.
The cable companies prepared for the future by becoming ISPs, so they love broadband, which they can charge more for (despite our abysmal speeds). The landline telephone companies are either out of business now or have become mobile carriers. But neither may be really ready for the future. Here's the fact that makes me think so: home broadband use is actually declining.
According to the Pew Research Center, broadband use declined from 70% in 2013 to 67% in 2015. That doesn't sound like much, but it is statistically significant, and it is a shocking reversal of prior trends; remember, at the beginning of the century broadband use was essentially zero and was still below 50% as late as 2006. Fifteen percent have dropped cable or satellite service; a third of younger Americans have dropped or never had pay TV.
The reversal is attributed to more people thinking that kind of connectivity is too expensive, especially when thy can get much of the content on, you guessed it, their smartphones.
All this sounds bad for cable but surely good for the mobile telephone companies, yet they shouldn't get too cocky. We may not need them either. Google has launched Loon -- "balloon-powered Internet for all" -- while Facebook is using drones to accomplish the same. Right now both giants are testing these approaches in rural or third-world areas, but to the extent they succeed they will certainly help change the paradigm.
Cable and mobile phone companies should remember that consumers' using the Internet through them was, in some ways, a fortuitous happenstance, and that if they are too greedy -- how much are those packages and data plans? -- or too shortsighted, the future may no longer include them.
In 20 or 25 years, cables and mobile phone networks may be as outdated as analog broadcasting and television antenna are now.
OK, so these examples may not be about health care, or may only impact health care in the same way they impact other industries. The importance of them, to me, is less in their direct applicability as in their reminding us that the world -- even for health care -- doesn't always evolve incrementally or even predictably.
And I love that.
Sunday, December 27, 2015
Wednesday, December 16, 2015
Oh, And It Is Also An EHR
You wouldn't -- I hope -- still drive your car while trying to read a paper map. Hopefully you're not holding up your phone to follow directions on its screen either. Chances are if you need directions while you are driving, you'll be listening to them via Bluetooth, glancing at an embedded screen on your dashboard, or maybe looking at a heads-up display on your windshield that doesn't even make you take your eyes from the road. Or maybe you're just riding in a self-driving car.
But when it comes to your doctor examining you, he's usually pretty much trying to do so while fumbling with a map, namely, your health record. And we don't like it.
A study in JAMA Internal Medicine found that patients were much more likely to rate their care as excellent when their physician didn't spend much time looking at their EHR while with them; 83% rated it as excellent, versus only 48% for patients whose doctors spent more time looking at their device's screen. The study's authors speculate that patients may feel slighted when their doctor looks too much at the screen, or that the doctors may actually be missing important visual cues.
Indeed, a 2014 study found that physicians using EHRs during exams spent about a third of the time during patient exams looking at their screen instead of at the patient. It is a dilemma; the records hold important information, and inputting new information is generally thought to be more accurate when done at point-of-care rather than at some point after the exam, so doctors are damned if they do and damned if they don't.
As one physician told the WSJ, "I have a love-hate relationship with the computer, with the hate maybe being stronger than the love."
No wonder that the president of the American Academy of Family Physicians says: "We've taken this technology and we've embraced it, but I think a lot of us don't believe it's ready for prime-time. We've got this interloper in the exam room, but it's not there to help with the medical side as much as it's there to check boxes for insurers."
I might quibble that the familiar physician shibboleth about EHRs being there to serve insurers' purposes rather than to improve care perhaps is one reason why they are not ready for prime time, but I certainly don't dispute the fact that they are not. After we've spent the past several years and over $30b of federal incentives to persuade physicians to adopt EHRs, physician satisfaction with them appears to be declining.
Know any health care professionals who rave about their EHR like they do their iPhone?
The problem is that we forget that the record is not the point. It wasn't the point when it was on paper, and putting it in an electronic format doesn't make it the point. The information in it is a tool -- just a tool. It is supposed to help the physician diagnose the patient, and record what happens to the patient, so he/she can be better diagnosed in the future. Figuring out what is wrong with a patient and what to do about it is the point.
Paper records were siloed and made the physician draw his/her own conclusions without providing any assistance. EHRs have the potential to draw data from larger patient populations, even if they don't yet do so very effectively, and can also give some assistance to physicians, like warning about drug interactions. But working with them still involves looking at too many screens and having to populate too many boxes. No wonder physicians are employing scribes.
Don't get me started on medical scribes.
Let's picture a different approach, one that doesn't start with paper records as its premise. Let's start with the premise that we're trying to help the physician improve patient care by giving him/her the information they need at point of care, when they need it, but without getting in the way of the physician/patient interaction.
Let's talk virtual reality.
Picture the physician walking into the office not holding a clipboard or a computer or even a tablet. Instead, the physician might be wearing something that looks like Google Glass or OrCam -- not a conspicuous headset like Oculus but something unobtrusive (a concept that investors are already pouring money into developing). There might be an earbud. And there will be the health version of Siri, Cortana or OK Google, AI assistants that can pull up information based on oral requests or self-generated algorithms, transcribe oral inputs, and present information either orally or visually.
When the physician looks at the patient, he/she sees a summary of key information -- such as diabetic, pacemaker, recent knee surgery -- overlaid on the corresponding portion of the patient's body. Any significant changes in blood pressure, weight, and other vitals are highlighted. The physician can call up more information by making an oral request to the AI or by using a hand gesture over a particular body part. List of meds? Date of that last surgery? Immunization record? No problem.
The physician can indicate, via voice command or hand gesture, what should be recorded. It shouldn't take too long before an AI can recognize on its own what needs to be captured; the advances in AI learning capabilities -- like now recognizing handwriting -- are coming so quickly that this is surely feasible. Keeping an EHR up-to-date should be child's play compared to, say, beating Ken Jennings at Jeopardy! or Gary Kasparov at chess.
In short, the AI would act as the medical scribe, without the patient even realizing it or the physician having to worry about it.
More importantly, the AI could quickly pull up/synthesize any pertinent literature, or assist the physician in coming up with a diagnosis and/or treatment plan -- as Watson is already doing for cancer. Maintaining and presenting the EHR are the finger exercises, if you will; helping the physician deliver better care is the main function. And without intruding on the physician/patient relationship.
Building better EHRs is certainly possible. Improving how physicians use them, especially when with patients, is also possible. But it's a little like trying to make a map you can fold better while driving. It misses the point.
We need a whole different technology that subsumes what EHRs do while getting to the real goal: helping deliver better care to patients.
But when it comes to your doctor examining you, he's usually pretty much trying to do so while fumbling with a map, namely, your health record. And we don't like it.
A study in JAMA Internal Medicine found that patients were much more likely to rate their care as excellent when their physician didn't spend much time looking at their EHR while with them; 83% rated it as excellent, versus only 48% for patients whose doctors spent more time looking at their device's screen. The study's authors speculate that patients may feel slighted when their doctor looks too much at the screen, or that the doctors may actually be missing important visual cues.
Indeed, a 2014 study found that physicians using EHRs during exams spent about a third of the time during patient exams looking at their screen instead of at the patient. It is a dilemma; the records hold important information, and inputting new information is generally thought to be more accurate when done at point-of-care rather than at some point after the exam, so doctors are damned if they do and damned if they don't.
As one physician told the WSJ, "I have a love-hate relationship with the computer, with the hate maybe being stronger than the love."
No wonder that the president of the American Academy of Family Physicians says: "We've taken this technology and we've embraced it, but I think a lot of us don't believe it's ready for prime-time. We've got this interloper in the exam room, but it's not there to help with the medical side as much as it's there to check boxes for insurers."
I might quibble that the familiar physician shibboleth about EHRs being there to serve insurers' purposes rather than to improve care perhaps is one reason why they are not ready for prime time, but I certainly don't dispute the fact that they are not. After we've spent the past several years and over $30b of federal incentives to persuade physicians to adopt EHRs, physician satisfaction with them appears to be declining.
Know any health care professionals who rave about their EHR like they do their iPhone?
The problem is that we forget that the record is not the point. It wasn't the point when it was on paper, and putting it in an electronic format doesn't make it the point. The information in it is a tool -- just a tool. It is supposed to help the physician diagnose the patient, and record what happens to the patient, so he/she can be better diagnosed in the future. Figuring out what is wrong with a patient and what to do about it is the point.
Paper records were siloed and made the physician draw his/her own conclusions without providing any assistance. EHRs have the potential to draw data from larger patient populations, even if they don't yet do so very effectively, and can also give some assistance to physicians, like warning about drug interactions. But working with them still involves looking at too many screens and having to populate too many boxes. No wonder physicians are employing scribes.
Don't get me started on medical scribes.
Let's picture a different approach, one that doesn't start with paper records as its premise. Let's start with the premise that we're trying to help the physician improve patient care by giving him/her the information they need at point of care, when they need it, but without getting in the way of the physician/patient interaction.
Let's talk virtual reality.
Picture the physician walking into the office not holding a clipboard or a computer or even a tablet. Instead, the physician might be wearing something that looks like Google Glass or OrCam -- not a conspicuous headset like Oculus but something unobtrusive (a concept that investors are already pouring money into developing). There might be an earbud. And there will be the health version of Siri, Cortana or OK Google, AI assistants that can pull up information based on oral requests or self-generated algorithms, transcribe oral inputs, and present information either orally or visually.
When the physician looks at the patient, he/she sees a summary of key information -- such as diabetic, pacemaker, recent knee surgery -- overlaid on the corresponding portion of the patient's body. Any significant changes in blood pressure, weight, and other vitals are highlighted. The physician can call up more information by making an oral request to the AI or by using a hand gesture over a particular body part. List of meds? Date of that last surgery? Immunization record? No problem.
The physician can indicate, via voice command or hand gesture, what should be recorded. It shouldn't take too long before an AI can recognize on its own what needs to be captured; the advances in AI learning capabilities -- like now recognizing handwriting -- are coming so quickly that this is surely feasible. Keeping an EHR up-to-date should be child's play compared to, say, beating Ken Jennings at Jeopardy! or Gary Kasparov at chess.
In short, the AI would act as the medical scribe, without the patient even realizing it or the physician having to worry about it.
More importantly, the AI could quickly pull up/synthesize any pertinent literature, or assist the physician in coming up with a diagnosis and/or treatment plan -- as Watson is already doing for cancer. Maintaining and presenting the EHR are the finger exercises, if you will; helping the physician deliver better care is the main function. And without intruding on the physician/patient relationship.
Building better EHRs is certainly possible. Improving how physicians use them, especially when with patients, is also possible. But it's a little like trying to make a map you can fold better while driving. It misses the point.
We need a whole different technology that subsumes what EHRs do while getting to the real goal: helping deliver better care to patients.
Friday, December 11, 2015
It's a Doc's Life
There is an old expression "it's a dog's life" used to describe a life that is hard and unpleasant. That expression is probably outdated; most dogs seem to live pretty comfortable lives. Based on recent research, though, maybe we should be saying "it's a doc's life" instead.
It has kind of a certain ring to it, don't you think?
Let's look at some of the new research, starting with a study by the Mayo Clinic. They updated a survey they did in 2011, and found a number of disturbing issues, including:
It has kind of a certain ring to it, don't you think?
Let's look at some of the new research, starting with a study by the Mayo Clinic. They updated a survey they did in 2011, and found a number of disturbing issues, including:
- More than half (54%) of physicians report at least one symptom of burnout. That compares to 45.5% in 2011.
- Only 41% of physicians reported being happy with their work-life balance, compared to 48.5% in 2011.
- Physicians fared worse on both burnout and happiness with work-life balance than the overall population, even adjusting for age, gender, relationship status and hours worked.
- Pretty much every specialty showed declines on both burnout and work-life balance.
The authors believe that American medicine is at a "tipping point" due to the burnout and lack of work-life balance, and that there is an urgent need to address the underlying causes. It'd be hard to disagree with them.
The study would be disturbing in its own right, but it is not the only such study that showed up just this month. A study in JAMA by Mata, et. alia found that almost 30% of resident physicians reported depression or depressive symptoms. As one of the authors said: "What we found is that more physicians in almost every specialty are
feeling this way and that's not good for them, their families, the
medical profession or patients,"
No kidding.
The study was a meta-study, analyzing results of other studies, and the prevalence ranged from 21% to 43% in the various studies, so the 30% may be conservative. As with the Mayo study, the problem appears to be getting worse, with the results showing a slight but statistically significant increase over the five decades analyzed.
An accompanying editorial called resident depression "the tip of a graduate medical education iceberg." It notes that training itself has changed little from the 1950's or 1960's, while "the actual delivery of medical care in 2015 would be unrecognizable to those same physicians." New care options and resulting ethical dilemmas, more pressures on reimbursement and on demonstrating value, malpractice concerns, EHRs, and increased patient demands create a world that the graduate medical education system leaves residents ill-equipped to deal with.
The editorial calls for a fundamental rethinking of our approach to the graduate medical education system. Again, it'd be hard to argue with that conclusion (and the rethinking shouldn't be limited to graduate medical education).
If any further evidence of a problem was needed, the 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians provides some. I'll leave the international comparisons for another day, but I was struck by a few of the findings for U.S. primary care physicians. Twenty-four percent report not being well prepared to manage patients with multiple chronic conditions. Less than half are well prepared to handle patients needing palliative care or long term home care, or patients with dementia. And less than a third are prepared for patients needing social services, those with mental health issues, or those with substance use issues.
Given that one in four of American adults have multiple chronic conditions, one in five have mental health issues, and about one in ten have substance use issues, well, I'd say primary care physicians should be pretty worried.
No wonder that only 16% of those U.S. primary care docs think our health care system works well (which was, by the way, by far the lowest across the 10 countries), or that 43% report their job is very or extremely stressful. No wonder they're getting burned out.
Despite the above findings, another JAMA study found that at least one kind of primary care physician -- family practice residents -- still had high hopes. Family practice residents reported that they planned to provide a broader scope of services than practicing family practice physicians, such as prenatal care and inpatient care management. Whether that is recognition of a changing role or simply naive expectations remains to be seen. As one of the authors told Reuters, "it may be that the previous generations have had these same intentions and for numerous reasons are not able to practice the way they intended."
In other words, real world, meet residents. Residents, real world. Try to get along.
Look, I get it. Being a physician is not what it once was. No more physician-as-God, no more white coat mystique. Their business model has radically changed from largely independent artisans to more typically being employees with productivity expectations, whose judgement is constantly challenged by patients, payors, administrators, and/or lawyers. That must be hard to accept.
But, then again, I don't know many people who don't think their job hasn't changed significantly in the past twenty years, with more pressure, higher expectations, 24/7 demands, and more reliance on technology. Physicians can rightfully argue that their role is different in that people's lives depend on their decisions, but other professions -- e.g., police officers, air traffic controllers, even civil engineers -- could claim the same.
It's tough all over.
We should be worried that physicians are depressed. We should be worried that they feel burnt out. We should be worried that they don't feel ready to manage the kind of complex patients they are seeing more of. These are problems that need to be recognized and addressed. But the life of the physician isn't going back to what it was in the 1960's, and that is not a bad thing.
It should be a great time to be a physician. We've never known as much about what causes various health issues, never had as many diagnostic tools, never had as many treatment options, and never had as much potential for people to be educated about their health and to be an active participant in their care. If all that isn't exciting to someone, perhaps being a physician isn't the right profession.
For what it is worth, both medical school applicants and enrollees have reached record levels. Let's hope they're not in for a big disappointment when they find out what a doc's life is really like.
Wednesday, December 2, 2015
The White Coats Are Coming! The White Coats Are Coming!
Let's say you were in a social setting, or even some business settings, and you introduced yourself to someone using your first name but that person's response was to introduce himself/herself using their last name and a honorific. You might think they were oddly formal. If, in those same settings, someone greeted you by your first name while introducing himself/herself using an honorific and his/her last name, well, you might think he/she was stuffy, if not a jerk.
Yet this happens all the time in health care settings.
Now, in the past, I've been critical of the use of the term "patients" to describe us laypeople in the health care system, arguing that it connotes a certain passive, secondary status about us. Ashley Graham Kennedy, a philosophy professor at Florida Atlantic University, goes me one further: in a BMJ opinion piece, she asserts that "the title 'doctor' is an anachronism that disrespects patients."
How about that?
Professor Kennedy cites situations where doctors introduce themselves as doctors while not taking into account their patients' own professional titles. How many of us have had a physician casually use our first name while expecting us to use their title? If we happen to be sitting on an exam table or in a hospital bed wearing a gown that leaves us half exposed, the asymmetry is even more pronounced.
She notes that we don't need titles or even white coats -- more on that in a bit -- to figure out who our caregivers are or what their role in our care is. More on point, she argues that the title is an explicit expectation that we are to treat them with respect, due to the training that the title signifies, whereas respect is something that deserves to be earned, such as by how we are treated.
It is the 21st century after all. We know that not all physicians are equal, that not all medical education and training is the same, and that not even physicians know everything, even within their specialty. If we're supposed to automatically respect all physicians, it better work both ways.
Personally, I don't mind calling a physician "doctor," although if he/she calls me by my first name (which I'd prefer) I'd expect that to be reciprocal. What I wonder is what the title really means anyway. There are a lot of "doctors" out there. If someone introduces themselves as "Dr. X," you don't know if that means an M.D./D.O., or if it means DDS, DMD, DC, DPM, Pharm.D., DVM, OD, Au.D, Ph.D or ScD. I'm sure that list isn't even complete, even within health care. So as a means of automatically signifying respect for our physician, it's a pretty poor marker.
Some of the reactions to Professor Kennedy's argument are even more interesting. While she believes that the deference the title expects is incompatible with patients being equal partners with their physicians, some respondents -- who usually seem to be physicians -- argued that the supposed partnership is not, in fact, equal, since physicians' training and experience makes them experts in a way patients can never equal, no matter how much Internet research they do.
I think those kind of responses kind of make Professor Kennedy's point.
The doctor/patient relationship is at its most asymmetrical when there is some acute event -- e.g., we have a heart attack, we need our appendix out, we need chemo. But with more of our health care spending going to chronic conditions that, in many cases, are linked to lifestyle choices, the asymmetry is greatly reduced, and physicians should think twice about assuming they know more about maintaining our health, especially if they can't demonstrate that they "practice what they preach" when it comes to those kinds of healthy choices.
If the title "doctor" is a verbal indicator of expected respect, the white lab coat is a tangible one. Almost all U.S. medical schools bestow one as part of their graduation ceremony (although this tradition is, surprisingly relatively new). The fashion of physicians wearing them had to do with the (belated) acceptance by the medical establishment in the latter part of the 19th century that, yes, germs mattered; the coat was to suggest they kept their environment as sterile as in a lab.
Ironically, of course, the white coat itself may (or may not) be a carrier for germs, which has led the NHS to adopt a "bare-below-the-elbows" policy.
This is, apparently, a hot topic. There are more issues than one might have imagined, including what physicians think patients want and -- my favorite -- how cartoons would portray physicians without a white coat. Another opinion piece in BMJ bemoaned how the NHS "bare-below-the-elbows" policy has led to "scruffy doctors," urging them to "put your ties back on."
Not everyone agrees that the more casual attire leads patients to view doctors as scruffy and thus possibly lacking in hygiene. (Dr.) Phillip Lederer wrote an excellent article on the controversy recently, reminding physicians that they'd still be a doctors even without the white coat. He concluded: "There is no harm in avoiding white coats, but there could be danger in wearing one."
That would seem like the killer argument, but apparently it is not.
I mean, really, I can see wearing a white coat if the physician actually works in a lab, such as a pathologist, but it is hard to see it as much else other than a status symbol if they are actually seeing patients. Health care is full of status symbols, including not just the white coats and automatically calling physicians "doctor" but also those nice parking spaces reserved for physicians that patients and their families often have to walk past, or, for that matter, major donors getting their names on health care buildings.
We shouldn't take any of them more seriously than if, say, all physicians started wearing monocles to further model those 19th century physicians. The point is, it's not supposed to be about their status, but about our health.
Paul Revere may have never actually shouted "The British are coming! The British are coming!" but he did help herald a revolution. Maybe by rethinking some of the traditional status symbols in health care we can signal a revolution of our own, fighting for a health care system in which we are more responsible for our own health and are expected to be more equal partners with the people who help us with that.
Or we could try the monocles.
Yet this happens all the time in health care settings.
Now, in the past, I've been critical of the use of the term "patients" to describe us laypeople in the health care system, arguing that it connotes a certain passive, secondary status about us. Ashley Graham Kennedy, a philosophy professor at Florida Atlantic University, goes me one further: in a BMJ opinion piece, she asserts that "the title 'doctor' is an anachronism that disrespects patients."
How about that?
Professor Kennedy cites situations where doctors introduce themselves as doctors while not taking into account their patients' own professional titles. How many of us have had a physician casually use our first name while expecting us to use their title? If we happen to be sitting on an exam table or in a hospital bed wearing a gown that leaves us half exposed, the asymmetry is even more pronounced.
She notes that we don't need titles or even white coats -- more on that in a bit -- to figure out who our caregivers are or what their role in our care is. More on point, she argues that the title is an explicit expectation that we are to treat them with respect, due to the training that the title signifies, whereas respect is something that deserves to be earned, such as by how we are treated.
It is the 21st century after all. We know that not all physicians are equal, that not all medical education and training is the same, and that not even physicians know everything, even within their specialty. If we're supposed to automatically respect all physicians, it better work both ways.
Personally, I don't mind calling a physician "doctor," although if he/she calls me by my first name (which I'd prefer) I'd expect that to be reciprocal. What I wonder is what the title really means anyway. There are a lot of "doctors" out there. If someone introduces themselves as "Dr. X," you don't know if that means an M.D./D.O., or if it means DDS, DMD, DC, DPM, Pharm.D., DVM, OD, Au.D, Ph.D or ScD. I'm sure that list isn't even complete, even within health care. So as a means of automatically signifying respect for our physician, it's a pretty poor marker.
Some of the reactions to Professor Kennedy's argument are even more interesting. While she believes that the deference the title expects is incompatible with patients being equal partners with their physicians, some respondents -- who usually seem to be physicians -- argued that the supposed partnership is not, in fact, equal, since physicians' training and experience makes them experts in a way patients can never equal, no matter how much Internet research they do.
I think those kind of responses kind of make Professor Kennedy's point.
The doctor/patient relationship is at its most asymmetrical when there is some acute event -- e.g., we have a heart attack, we need our appendix out, we need chemo. But with more of our health care spending going to chronic conditions that, in many cases, are linked to lifestyle choices, the asymmetry is greatly reduced, and physicians should think twice about assuming they know more about maintaining our health, especially if they can't demonstrate that they "practice what they preach" when it comes to those kinds of healthy choices.
If the title "doctor" is a verbal indicator of expected respect, the white lab coat is a tangible one. Almost all U.S. medical schools bestow one as part of their graduation ceremony (although this tradition is, surprisingly relatively new). The fashion of physicians wearing them had to do with the (belated) acceptance by the medical establishment in the latter part of the 19th century that, yes, germs mattered; the coat was to suggest they kept their environment as sterile as in a lab.
Ironically, of course, the white coat itself may (or may not) be a carrier for germs, which has led the NHS to adopt a "bare-below-the-elbows" policy.
This is, apparently, a hot topic. There are more issues than one might have imagined, including what physicians think patients want and -- my favorite -- how cartoons would portray physicians without a white coat. Another opinion piece in BMJ bemoaned how the NHS "bare-below-the-elbows" policy has led to "scruffy doctors," urging them to "put your ties back on."
Not everyone agrees that the more casual attire leads patients to view doctors as scruffy and thus possibly lacking in hygiene. (Dr.) Phillip Lederer wrote an excellent article on the controversy recently, reminding physicians that they'd still be a doctors even without the white coat. He concluded: "There is no harm in avoiding white coats, but there could be danger in wearing one."
That would seem like the killer argument, but apparently it is not.
I mean, really, I can see wearing a white coat if the physician actually works in a lab, such as a pathologist, but it is hard to see it as much else other than a status symbol if they are actually seeing patients. Health care is full of status symbols, including not just the white coats and automatically calling physicians "doctor" but also those nice parking spaces reserved for physicians that patients and their families often have to walk past, or, for that matter, major donors getting their names on health care buildings.
We shouldn't take any of them more seriously than if, say, all physicians started wearing monocles to further model those 19th century physicians. The point is, it's not supposed to be about their status, but about our health.
Paul Revere may have never actually shouted "The British are coming! The British are coming!" but he did help herald a revolution. Maybe by rethinking some of the traditional status symbols in health care we can signal a revolution of our own, fighting for a health care system in which we are more responsible for our own health and are expected to be more equal partners with the people who help us with that.
Or we could try the monocles.
Friday, November 27, 2015
Hoping for Some Health Care Pi
Raspberry Pi thinks even $20 or $35 is way too much to pay for a computer. That's why they just announced the Raspberry Pi Zero, which they're happy to sell for a startling $5. That's right, $5. Not $5 on some sort of monthly installment plan or as a cloud-based monthly subscription service, but a straight up purchase of a programmable computer for only $5.
I wish health care had a Raspberry Pi to drive down its costs in a similar fashion.
For those of you who had not been familiar with Raspberry Pi, their mission is to get inexpensive computers in the hands of more people, especially children. They recognized that many families can't afford several hundreds or thousands of dollars for a computer, as you'd normally pay at Best Buy or Amazon. And they believe it is imperative to let more people -- again, especially children -- have the opportunity to experiment with programming.
Their first computer, the Raspberry Pi 1 Model B, was introduced in 2012 for $35, and was followed over the next few years with other models that were as low as $20. They made them cheaper and/or more powerful, but never more expensive. Not content with selling some 6 million of these low cost computers, and following the advice of Alphabet Inc's Chairman Eric Schmidt that it was "hard to compete with cheap," they developed and rolled out the Zero, figuring $5 was as low as they could go. No kidding.
The initial batch of the Zeros sold out within a day.
Sure, for the $5 you're not getting an Apple MacBook or a Microsoft Surface Book, but it is powerful enough to play games, connect to the Internet, and use its simple programming language to connect it to home devices, create your own games, maybe even build a robot or two. I'll probably be sticking to my PC -- I'm not likely to be building any robots anyway, much as they fascinate me -- but I'll bet there are a bunch of teens or even preteens who could do some pretty cool things with a Zero.
For $5, why not? It might be a great stocking stuffer or Hanukkah gift.
Meanwhile, in health care we're not surprised to read headlines like "Cost of Skin Drugs Rising Rapidly," reporting on a study that found prices of 19 brand name dermatologic drugs have risen 5 fold, on average, over the past six years, with most of those increases happening more recently. It'd almost be funny if we weren't the ones paying these huge increases, which of course we are, either directly or through higher health premiums.
I'm not going to pile-on any further about prescription drug increases, especially not after reading the analysis in Health Affairs by Kenneth Thorpe and Jason Hockenberry that suggests prescription drugs may not be quite the culprits we're getting used to thinking they are. No, there are plenty of parties in the health care system that make the health care equivalent of a $5 computer almost impossible to imagine.
We have, after all, a health care system in which heart patients apparently do better when the top cardiologists aren't around, because fewer things are done to them, and in which "inaccurate and unreliable tests" are resulting in unnecessary care, raising costs, and putting patients at risk, according to the FDA.
Sure, we have organizations like Diagnostics For All, which works on developing "low-cost, easy-to-use, point-of-care diagnostics," with particular interest in their use in developing countries. (A couple of months ago I might have cited lab pioneer Theranos as another example, but that's probably not such a good idea right now). Many people think mHealth is a particularly potent way to introduce low-cost care options, again mostly for developing nations. UNICEF is sponsoring The Wearables for Good campaign to help spearhead this kind of effort.
But let's face it: when it comes to health care, we are a developing nation; we just pay more for it than anyone else.
Even after ACA, we still have some 32 million non-elderly uninsured, some 44 million insured people avoid getting care due to concern about costs, only half of Americans rate the quality of our care as at least good, and by more objective measures our health care system is closer to the bottom than to even the middle when compared to other "developed" countries.
So where is, say, our $5 EHR? We can't even get EHRs that physicians like. Where is our $5 MRI? Their range in prices is eye-opening, but it's safe to say even the cheapest would make a full price computer look cheap. One could argue that we have $5 drugs, what with close to 80% of prescriptions filed being generic, but I don't see many people jumping up and down with excitement about how cheap their prescriptions are.
For that matter, where is our Mozilla, our Wikipedia, or our Linux, offering widely used free services of tremendous value?
In our health care system, we think we're winning if we slow the rate of growth, although it remains above overall inflation. Even new entrants seem to be more interested in getting their piece of the $3 trillion pie than in doing what Raspberry Pi is doing for computers.
Who is going to be our Eben Upton, our Jimmy Wales, our Linus Torvalds? Wouldn't it be cool if it ended up being one of those kids tinkering on his Zero?
I wish health care had a Raspberry Pi to drive down its costs in a similar fashion.
For those of you who had not been familiar with Raspberry Pi, their mission is to get inexpensive computers in the hands of more people, especially children. They recognized that many families can't afford several hundreds or thousands of dollars for a computer, as you'd normally pay at Best Buy or Amazon. And they believe it is imperative to let more people -- again, especially children -- have the opportunity to experiment with programming.
Their first computer, the Raspberry Pi 1 Model B, was introduced in 2012 for $35, and was followed over the next few years with other models that were as low as $20. They made them cheaper and/or more powerful, but never more expensive. Not content with selling some 6 million of these low cost computers, and following the advice of Alphabet Inc's Chairman Eric Schmidt that it was "hard to compete with cheap," they developed and rolled out the Zero, figuring $5 was as low as they could go. No kidding.
The initial batch of the Zeros sold out within a day.
Sure, for the $5 you're not getting an Apple MacBook or a Microsoft Surface Book, but it is powerful enough to play games, connect to the Internet, and use its simple programming language to connect it to home devices, create your own games, maybe even build a robot or two. I'll probably be sticking to my PC -- I'm not likely to be building any robots anyway, much as they fascinate me -- but I'll bet there are a bunch of teens or even preteens who could do some pretty cool things with a Zero.
For $5, why not? It might be a great stocking stuffer or Hanukkah gift.
Meanwhile, in health care we're not surprised to read headlines like "Cost of Skin Drugs Rising Rapidly," reporting on a study that found prices of 19 brand name dermatologic drugs have risen 5 fold, on average, over the past six years, with most of those increases happening more recently. It'd almost be funny if we weren't the ones paying these huge increases, which of course we are, either directly or through higher health premiums.
I'm not going to pile-on any further about prescription drug increases, especially not after reading the analysis in Health Affairs by Kenneth Thorpe and Jason Hockenberry that suggests prescription drugs may not be quite the culprits we're getting used to thinking they are. No, there are plenty of parties in the health care system that make the health care equivalent of a $5 computer almost impossible to imagine.
We have, after all, a health care system in which heart patients apparently do better when the top cardiologists aren't around, because fewer things are done to them, and in which "inaccurate and unreliable tests" are resulting in unnecessary care, raising costs, and putting patients at risk, according to the FDA.
Sure, we have organizations like Diagnostics For All, which works on developing "low-cost, easy-to-use, point-of-care diagnostics," with particular interest in their use in developing countries. (A couple of months ago I might have cited lab pioneer Theranos as another example, but that's probably not such a good idea right now). Many people think mHealth is a particularly potent way to introduce low-cost care options, again mostly for developing nations. UNICEF is sponsoring The Wearables for Good campaign to help spearhead this kind of effort.
But let's face it: when it comes to health care, we are a developing nation; we just pay more for it than anyone else.
Even after ACA, we still have some 32 million non-elderly uninsured, some 44 million insured people avoid getting care due to concern about costs, only half of Americans rate the quality of our care as at least good, and by more objective measures our health care system is closer to the bottom than to even the middle when compared to other "developed" countries.
So where is, say, our $5 EHR? We can't even get EHRs that physicians like. Where is our $5 MRI? Their range in prices is eye-opening, but it's safe to say even the cheapest would make a full price computer look cheap. One could argue that we have $5 drugs, what with close to 80% of prescriptions filed being generic, but I don't see many people jumping up and down with excitement about how cheap their prescriptions are.
For that matter, where is our Mozilla, our Wikipedia, or our Linux, offering widely used free services of tremendous value?
In our health care system, we think we're winning if we slow the rate of growth, although it remains above overall inflation. Even new entrants seem to be more interested in getting their piece of the $3 trillion pie than in doing what Raspberry Pi is doing for computers.
Who is going to be our Eben Upton, our Jimmy Wales, our Linus Torvalds? Wouldn't it be cool if it ended up being one of those kids tinkering on his Zero?
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.
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:
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.
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.
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:
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.
Yet.
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.
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.
Yet.
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.
Wednesday, November 11, 2015
Someone Must Be On Drugs
As is probably true for many of you, I'm busy looking at health plan open enrollment options for 2016. I have to confess that for the past few years I've been guilty of just sticking with the same plan, so it has been too long since I've had to shop. Plus, I'm helping my mother pick her Medicare options for next year. All in all, I'm awash with health plan options.
I'm torn between thinking that the people designing the plans are extremely clever, have a perverse sense of humor, or were under the influence of psychedelic drugs at the time.
It's not that there aren't plenty of options. I've got different levels of HMO, POS, and PPO options, from multiple carriers. My mother has many choices of Medicare Supplements, with Part D options, as well as Medicare Advantage options (both HMO and PPO), each from multiple health insurers.
Nor is it that having choices is bad. Researchers have discussed the "tyranny of choice" (or "paradox of choice") for some time, meaning too many choices can be paralyzing for consumers. I have to admit that when I go to the cereal aisle in the grocery store I feel overwhelmed, but, whether it is cereal or health plans, I'd still rather than more choices than fewer choices.
It's just that, well, the options are so damn confusing. I was in the health plan business for a long time, and helped develop some of the first plan selection tools for consumers, But when it comes to evaluating some of the options now available, I find it practically impossible.
Austin Frakt recently wrote in The New York Times about this problem. He cited a few studies specifically on point about health insurance, such as:
I'm most frustrated with prescription drug coverage. Not that long ago, the only variables were the copays for generic versus brand drugs. Now there are often five or six different tiers of coverage -- such as preferred generic, other generic, preferred brand, other brand, and "specialty" -- with different copays or coinsurance at each tier, each of which can also vary by retail versus mail order, and for "preferred pharmacies."
Moreover, the health plan's formulary, which determines what tier a drug is in, can change at any time. Plus, as has been illustrated recently, the prices of any specific drug can change without notice, sometimes dramatically. If either of those happens to one of your drugs, say goodbye to your budget.
It's all enough to make your head spin.
The health plans would no doubt argue that their various approaches to prescription drug coverage are necessary in their efforts to control ever-rising costs for prescription drug costs. Well, they aren't working.
Prescription drug prices continue to soar, even for generic drugs. They have become a political issue, with the Senate now launching a bipartisan investigation into prescription drug pricing and the Presidential hopefuls from both parties being forced to take positions on how they would control them. For once, politicians are in sync with their constituents; the latest Kaiser Health Tracking Poll found that affordability of prescription drugs tops their priority list for Congress and the President.
I've long thought that the pharmaceutical industry was ahead of the rest of the health care industry. They were doing electronic submission of claims over forty years ago. They pushed for direct-to-consumer advertising in the late 1980's, and quickly jumped on that bandwagon. While providers only grudgingly adopted EHRs, they quickly moved to e-prescribing. Other health providers had to move away from discounted charges twenty years ago, whereas drug companies still mostly use that approach and are only starting to tip-toe into more "value-based" approaches, as with the recent Harvard Pilgrim-Amgen deal.
And the backroom rebate deals between drug manufacturers and payors put a lie to any claim that at least drug pricing is transparent.
It's not only prescription drug coverage that is increasingly complicated, what with narrow networks, gatekeepers, different copays for different types of medical services, bundled pricing, or numerous other gimmicks used in health plan designs. The collateral damage in the ongoing payor-provider arms race is consumer understanding.
Making things more complicated for consumers is not the answer.
In typical fashion, the health care industry has tried to address the confusion by creating a new industry that doesn't actually solve the problem but does manage to introduce new costs. Many enrollment sites --the Medicare plan finder, public exchanges, private exchanges, broker sites like ehealth, or health insurer sites -- offer tools that purport to estimate your costs under your various health plan options. Yet consumers still don't understand their options.
We keep treating health care as a multi-party arrangement between providers/health plans/employers/government/consumers, which is why everything ends up so complicated. Drug company rebates or medical device manufacturers' payments to providers are prime examples of the kind of insider trading that goes on. It's usually the consumers that come last. And that's the problem.
I think back to 1990's cell phone plans. Consumers never knew what their next bill would bring, between peak/non-peak minutes and the infamous roaming charges. No one liked it, no one understood it, and for several years no one did anything about it. Then AT&T came out with a flat rate plan that essentially said, "we'll worry about all those for you," and soon all carriers had to adopt a version of it.
I keep hoping for that kind of breakthrough with health insurance.
I'm torn between thinking that the people designing the plans are extremely clever, have a perverse sense of humor, or were under the influence of psychedelic drugs at the time.
It's not that there aren't plenty of options. I've got different levels of HMO, POS, and PPO options, from multiple carriers. My mother has many choices of Medicare Supplements, with Part D options, as well as Medicare Advantage options (both HMO and PPO), each from multiple health insurers.
Nor is it that having choices is bad. Researchers have discussed the "tyranny of choice" (or "paradox of choice") for some time, meaning too many choices can be paralyzing for consumers. I have to admit that when I go to the cereal aisle in the grocery store I feel overwhelmed, but, whether it is cereal or health plans, I'd still rather than more choices than fewer choices.
It's just that, well, the options are so damn confusing. I was in the health plan business for a long time, and helped develop some of the first plan selection tools for consumers, But when it comes to evaluating some of the options now available, I find it practically impossible.
Austin Frakt recently wrote in The New York Times about this problem. He cited a few studies specifically on point about health insurance, such as:
- One study found that 71% of consumers couldn't identify basic cost-sharing features;
- Less than a third of consumers in another study could correctly answer questions about their current coverage;
- Researchers found that consumers tended to choose plans labeled "gold" -- even when the researchers switched the "gold" and "bronze" designations, keeping all other plan details the same.
I'm most frustrated with prescription drug coverage. Not that long ago, the only variables were the copays for generic versus brand drugs. Now there are often five or six different tiers of coverage -- such as preferred generic, other generic, preferred brand, other brand, and "specialty" -- with different copays or coinsurance at each tier, each of which can also vary by retail versus mail order, and for "preferred pharmacies."
Moreover, the health plan's formulary, which determines what tier a drug is in, can change at any time. Plus, as has been illustrated recently, the prices of any specific drug can change without notice, sometimes dramatically. If either of those happens to one of your drugs, say goodbye to your budget.
It's all enough to make your head spin.
The health plans would no doubt argue that their various approaches to prescription drug coverage are necessary in their efforts to control ever-rising costs for prescription drug costs. Well, they aren't working.
Prescription drug prices continue to soar, even for generic drugs. They have become a political issue, with the Senate now launching a bipartisan investigation into prescription drug pricing and the Presidential hopefuls from both parties being forced to take positions on how they would control them. For once, politicians are in sync with their constituents; the latest Kaiser Health Tracking Poll found that affordability of prescription drugs tops their priority list for Congress and the President.
I've long thought that the pharmaceutical industry was ahead of the rest of the health care industry. They were doing electronic submission of claims over forty years ago. They pushed for direct-to-consumer advertising in the late 1980's, and quickly jumped on that bandwagon. While providers only grudgingly adopted EHRs, they quickly moved to e-prescribing. Other health providers had to move away from discounted charges twenty years ago, whereas drug companies still mostly use that approach and are only starting to tip-toe into more "value-based" approaches, as with the recent Harvard Pilgrim-Amgen deal.
And the backroom rebate deals between drug manufacturers and payors put a lie to any claim that at least drug pricing is transparent.
It's not only prescription drug coverage that is increasingly complicated, what with narrow networks, gatekeepers, different copays for different types of medical services, bundled pricing, or numerous other gimmicks used in health plan designs. The collateral damage in the ongoing payor-provider arms race is consumer understanding.
Making things more complicated for consumers is not the answer.
In typical fashion, the health care industry has tried to address the confusion by creating a new industry that doesn't actually solve the problem but does manage to introduce new costs. Many enrollment sites --the Medicare plan finder, public exchanges, private exchanges, broker sites like ehealth, or health insurer sites -- offer tools that purport to estimate your costs under your various health plan options. Yet consumers still don't understand their options.
We keep treating health care as a multi-party arrangement between providers/health plans/employers/government/consumers, which is why everything ends up so complicated. Drug company rebates or medical device manufacturers' payments to providers are prime examples of the kind of insider trading that goes on. It's usually the consumers that come last. And that's the problem.
I think back to 1990's cell phone plans. Consumers never knew what their next bill would bring, between peak/non-peak minutes and the infamous roaming charges. No one liked it, no one understood it, and for several years no one did anything about it. Then AT&T came out with a flat rate plan that essentially said, "we'll worry about all those for you," and soon all carriers had to adopt a version of it.
I keep hoping for that kind of breakthrough with health insurance.
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