Today on THCB Spotlights, Matthew interviews Todd Clardy who is the EVP of Marketing at Accolade. Accolade is a company well-known for being in employee/patient advocacy. They’ve created an advocacy model that focuses on creating an outstanding member experience and supporting patients through their whole journey, whether it’s an acute or chronic condition or helping people maintain their health and wellness. Where do Amazon, Google and Haven fit into this space? Find out how many people have got this and how Accolade will be expanding going forward.
At the end of the year my patients and I will start over. That is what changing EMRs does to us. I have mixed feelings about data migration, if it even happens.
I will move into a new virtual environment and my patients will take on slightly different appearances, maybe even alter their medical histories. Some will perhaps be asking me to edit diagnoses that have haunted them since we went from paper to computer records almost a decade ago.
With our first EMR, we scanned in a few things from patients’ paper records – sometimes only a few pages from years or decades of first handwritten and later typed notes. Much got lost, because we were doing something we never really had thought through, and we had to do it with a clock ticking: “Hurry, before the Federal incentives go away”. The Feds wanted EMRs because the vision was that more data would help research and population health and also reduce medical errors.
This time, another factor is pushing us forward: The EMR we have will no longer be supported after a certain date, and for an EMR that requires continuous tinkering in order to do basic tasks consistently, that is an untenable scenario. Only yesterday, I was suddenly unable to send prescriptions electronically and it took the national headquarter’s involvement to get me up and running again.
Our old EMR will become “read-only”, and who knows how much structured data will “migrate” from the old to the new system. And some information that should have been structured isn’t, because the old system’s search function was clunky enough that if we couldn’t find the exact word for a rare diagnosis in someone’s medical history, we would give up and choose the generic “neurologic disorder” and then free text the thing we might not even be spelling correctly. That still displayed intelligibly enough while the system was live, but will that migrate to the new system – who knows? Of course, there will be opportunities to correct old mistakes and omissions, as long as there is time…
The only way to view this inevitable transition is as an opportunity to undo old beginner mistakes, bad habits and workarounds. Having worked with two systems in my two clinics, I feel this is a bit like learning a new language or instrument; I know better what functionality I am looking for and will recognize it when I see it – just like a Spanish word I don’t know might look similar to a French word I do know for the same thing.
Wise from my positive experiences of screen sharing, I will bring patients along on this journey. I will be sitting next to each one with my laptop in front of us. I will invite them to update their history and increase the transparency of how I work, because there isn’t enough time in the day to keep the EMR invisible from my patient and then do all that work outside the appointment. Also, this is an era of increasing patient centeredness and I want to embrace that as much as I can.
I am determined to become as expert as possible with the new system so that I can document everything in real time in the visit and use more of my non-patient time in front of the screen to build templates and things like that.
In a way I feel a bit like many, many years ago when, as a student or budding writer, I opened a brand new notebook and put my pen to it for the first time. I loved fountain pens, crisp paper, leather bindings and the potential of all that clean, empty space.
Instead of feeling this EMR change will be a chore, I feel like a new school year or a new writing project is just about to begin.
Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.
If you’re used to health tech meetings filled with go-go entrepreneurs and the investors who love them, a conference of academic technology experts can be jarring.
Speakers repeatedly pointed to portions of the digital health superhighway that sorely need more concrete – in this case, concrete knowledge. One researcher even used the word “humility.”
That history should provide a sobering perspective on the distinction between inevitable and imminent (a difference at least as important to investors as intellectuals), even on hot-button topics such as new data uses involving the electronic health record (EHR).
I’ve been one of the optimists. Earlier this year, my colleague Adrian Gropper and I wrote about pending federal regulations requiring providers to give patients access to their medical record in a format usable by mobile apps. This, we said, could “decisively disrupt medicine’s clinical and economic power structure.”
Indeed, the regulations provide “a base on which innovation can happen,” declared Elise Sweeney Anthony, executive director of the policy office of the Office of the National Coordinator for Health Information Policy, at one session.
But a base is only that. While Apple has already unveiled an app allowing people to see their health record on their iPhone, as yet there’s no “transformative business model” propelling hospitals to reach out to patients, said Julia Adler-Milstein, director of the Center for Clinical Informatics and Improvement Research at the University of California, San Francisco. Nor is there any indication from her research that many patients are interested.
“It’s still early days,” she added.
Similarly, Fitbit and Google announced their intent to combine patient-generated health data with clinical information in the EHR well before Fitbit agreed to Google’s $2.1 billion takeover bid. However, researchers studying the implementation requirements for this type of integration see far more than a bit that doesn’t yet fit.
One challenge for any app using patient-reported health data is standardizing symptom descriptions in a way patients will understand and yet still yields clinically useful results. Not to mention concerns about data validity. (See: “Want to cheat your Fitbit? Try a puppy or power drill.”)
“It’s appropriate to have humility,” said Robert S. Rudin, a senior information scientist at RAND. He added, in language virtually identical to Adler-Milstein’s, “This is still early days.”
A major symposium theme was “proactive health care,” or using patients’ health data to prevent or ameliorate illness. One focus was screening patients for the hodgepodge of food, housing and other non-medical issues known as “social determinants of health” (SDOH). The process seems straightforward: ask patients about their circumstances, load the answers into a database and apply algorithmic analysis. Out pops guidance for addressing the social and economic factors that account for 40 percent of each individual’s health outcomes, compared to the 20 percent from clinic care.
Once again, however, important elements remain unresolved. Are the questions valid? Can one trust patients’ recall? Does the whole process even improve outcomes? One recent analysis even warned that some “efforts could worsen health and widen health inequities.”
“I’m not sure we’ve worked out these basic issues,” said Jessica Ancker, an associate professor in Weill Cornell Medicine’s division of health informatics
For example, the Google and Ascension Health execs who launched the much-criticized “Project Nightingale”could have have benefited from a blunt warning about big data from Lamiece Hassan, a health data research fellow at England’s University of Manchester.
“People have expectations about what information to share and how that information flows,” she said. “Just because the data are accessible doesn’t make it ethical.”
Michael L. Millenson is president of Health Quality Advisors LLC and adjunct associate professor of medicine at Northwestern University Feinberg School of Medicine. This article originally appeared on Forbes here.
Quil Health CEO, Carina Edwards, tells us what’s happening at the digital health startup born from the partnership between Comcast NBCUniversal and Independence Blue Cross. The new “baby” is just about a year old. How’s it fairing? And how involved are the “parents”? Carina talks about the company’s patient engagement platform that connects via phone, web, and cable TV. That means 30 million Comcast subscribers can sync their TV with their Quil app and literally ‘watch’ their care plan along with their Nightly News. Will Al Roker be making another appearance on Quil soon? This, and all the important questions about their business model and client base are answered here!
Filmed at the HIMSS Health 2.0 Conference in Santa Clara, CA in September 2019.
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt. Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
Jane Sarasohn-Kahn, health economist, advisor and author of “HealthConsuming: From Health Consumer to Health Citizen” explains how consumers are getting screwed by the American health system because of the industry’s lack of transparency and lack of privacy laws that protect patient data. Jane weighs in on the consumerization of healthcare, which she believes has put the patient into the position of the “payer” — but without any of the information, buying power, or right to manage their money like a true consumer. How do we, as patients, move from healthcare consumers to “health citizens”? Jane’s done the research, and she’s sharing it here!
Filmed at the HIMSS Health 2.0 Conference in Santa Clara, CA in September 2019.
Jessica DaMassa is the host of the WTF Health show & stars in Health in 2 Point 00 with Matthew Holt. Get a glimpse of the future of healthcare by meeting the people who are going to change it. Find more WTF Health interviews here or check out www.wtf.health.
Today on THCB Spotlights, Matthew speaks with Jeremy Orr, CEO of Medial EarlySign. Medial EarlySign does complex algorithmic detection of serious diseases, working on early detection of cancer and the progression of chronic disease such as diabetes. Tune in to hear more about this AI/ML company that has been working on their algorithms since before many had even heard about machine learning, what they’ve been doing with Kaiser Permanente and Geisinger, and where they are going next.
Filmed at the HLTH Conference in Las Vegas, October 2019.
No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.
But the problem being experienced by an
increasing number of patients is going to a covered (in-network) facility for
medical care, and being seen by an out-of-network physician. This happens because
not all physicians working in hospitals serve the same master, and thus may not
all have agreed to the in-network rate offered by an insurance company.
This is a common occurrence in medicine.
At any given time, your local tax exempt non-profit hospital is out of network
of some low paying Medicaid plan or the other.
In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.
Insurers act as proxies for patients when
negotiating with the people that actually deliver healthcare – doctors.
Largely, the system works to funnel patients to ‘covered’ doctors and
hospitals. Patients that walk into an uncovered facility are quickly
redirected. But breakdowns happen during emergencies.
There are no choices to make for patients
arriving unconscious or in distress to an emergency room. It suddenly becomes
very possible to be seen by an out of network physician, and depending on the
fine print of the insurance plans selected some or none of these charges may be
covered.
Physicians that typically prefer banal
chants of “health is care for all” and avoid deep dives into policies
that determine physician reimbursement may want to pay attention to the debate
because it provides a clear picture of the forces currently trying to shape the
conversation about how to value physicians. The news is not good.
Practically speaking, no physician wants the hassle of being out of network. Ethically, few physicians have the stomach for bankrupting patients, and attempting to collect from the uninsured isn’t a desirable brand to cultivate. For those patients left with a balance, its actually illegal on the part of physicians to not attempt to collect. On the inevitable non-receipt of the balance, steep discounts or a write-off follows. So despite the heated rhetoric surrounding physicians ‘fleecing’ patients, the amount of real dollars collected from patients is never mentioned. While this number is hard to ascertain, a good proxy may be medical bankruptcies, which is a relatively rare event. So the amount of smoke that has been generated from, what in absolute terms, is a small fire has little do with patients and everything to do with how we figure out what to pay physicians.
The traditional leverage physicians have employed against insurers is the ability to not accept rates offered by payers. This isn’t unusual – its fundamental to every negotiation between two parties where the laborer isn’t conscripted. A mango seller has a price below which he won’t sell mangos. The negotiation would go much differently if the mango seller was compelled to sell his mangos at some price. The problem for insurers is that the pressure from patients to have in-network doctors is intense. Patients pay steep monthly premiums so they won’t get large, potentially bankrupting health care bills when they need medical care. And so the ability of physicians to not accept a proffered rate is fundamental to the negotiation between insurer and physician. The threat of a doctor being out of network raises the in-network rates. The threat of not getting a mango belie a certain price raises the price of the mango. Not complicated.
Further more, physicians that deliver services during emergencies – anesthesiologists, ER physicians, orthopedic trauma, neurosurgery – have greater leverage than physicians who don’t deliver emergency care. Insurers are far more effective at negotiating with primary care physicians because a primary care physician who chooses not to accept the contract of a certain insurer effectively shuts themselves out of that network. Insurers have no such luck directing patients in times of emergencies. The demand for services in this context is ‘inelastic’, giving physicians significant latitude in negotiating contracts with insurers. This is a giant thorn in the side of insurance companies that complain high medical premiums are a direct result of the high prices they must pay for these services.
‘High’, of course, is a relative term. They think of the rates they pay relative to the rates Medicare pays. Medicare enjoys one of a kind leverage because it is a legislatively created behemoth consolidating the buying power of the entire over 65 population under a government administered and enforced program. That leverage means Medicare rates are significantly lower than private rates, and specialties with greater inelastic demand are able to extract significant multiples of Medicare rates.
Insurance companies would like nothing
more than legislative help that would limit the amount they have to pay
physicians. Their ally in this fight is the simple fact that health care isn’t
quite like selling mangoes. In the healthcare marketplace, vulnerable patients
arrive in emergency departments in extremis with little ability to make choices,
and so many argue this is the very place the government needs to protect
hapless citizens.
The solutions that comes from health
policy/economists is also endorsed by the Senate Health, Education, Labor and
Pensions committee (HELP). This bipartisan group supports federally benchmarked
caps on rates that can be charged that are pegged to the median (50%)
in-network rate for an area. So if a patient happens to be seen by a physician
that is out of network, the insurer would pay the median in-network rate in the
area. But in this plan, there would be no incentive going forward for insurers
who contract at higher than the median in-network rates to stay in-network.
What would be the point? Just drop the contract, since the out of network rate
gets you 50% of the area in-network rates. This creates a race to the bottom
that effects reimbursement rates for all patients.
Physicians in practice and in congress
favor a different approach to get patients out of the line of fire: Independent
Dispute Resolution (IDR). The IDR, implemented in New York City in 2015, seeks
to take patients out of the middle by sending disputes between providers and
insurance to binding arbitration. Generally, the effect is that providers and
insurers settle disputes between themselves before a third party gets involved.
The desire to avoid potential third party arbitration also has the effect of
increasing in-network rates. This isn’t theory. The New York legislation
increased in-network provider participation, saved patients money, and lowered
in-network physician rates.
Interestingly, the health policy
community has taken the tack of rejecting the physician endorsed solution, and
accusing supporters in the provider community as greedy shills interested in
profits over patients. A frequently raised point is the fact that some Private
Equity firms own ER groups and are lobbying for IDR and against median
benchmarking. Apparently, any policy that would result in Private Equity
profiting is a bridge too far for the policy community. It goes unmentioned
that in the battle between insurers and doctors, the health policy community
places itself squarely on the side of health insurance company profits.
There is also remarkably little
appreciation for the second order effects of decreasing reimbursement to
physicians expected to be ready for emergencies. The vessel that bursts in your
brain requires a team acting quickly to recognize and treat this emergency.
Will neurosurgeons, anesthesiologists , and emergency medicine physicians of
quality be available at 2 am? Neurosurgeons are likely to choose to avoid being
on call, and recommend transferring patients to facilities with the scale and
infrastructure to keep Neurosurgeons on call for emergencies. Transfers to quaternary
care facilities take time. Time is brain. The amount of brain damage is the
difference between slight weakness of that right hand grip while drinking a
glass of wine at home or a dense paralysis of the entire right half of your
body that translates to a nursing home and a feeding tube. The potential downsides of policy that
reduces reimbursement to a highly specialized group and thus could reduce
access are not small, but seem to be underappreciated by policy ‘experts’
bending the ear of members of Congress.
Policy experts are experts not because
they have any experience trying to manage and run a physician practice, but
because they are lords of the empiricism found in the peer reviewed literature
of the day. For some reason this puts
them on a level playing field with the people who run practices and have to
meet payroll every 2 weeks. Its certainly possible the process of running a
business is entirely too narrow a field of view, but its unclear that the
policy experts field of view is more enlightening.
Zach Cooper at Yale has done a lot of work in this space, and one of his paper’s that is cited often is derived from claims data provided by a large private insurer. The general hypothesis of the study is that large profit hungry private firms that own ER practices flung across the nation engage in predatory activity once they acquire a local ER group. This ultimately raises costs to the patient, and thus damages societal welfare as a whole. Using the company websites of the private firms, the researchers were able to divine that the two companies (TeamHealth and EMcare) were involved in a whopping 9% of their national sample. In order to understand how the entry of these firms may impact medical charges and reimbursement, the investigators found a total of 26 hospitals the firms initiated contracts with in the time frame studied.
The authors divine many thing from the
raw data. To support the claim that arrival of the private groups may have
increased out of network rates to fleece patients and improve their leverage
for in-network rates the authors examine the data and conclude: “In Panel
A of Figure 3, the raw data show a clear increase in out-of-network billing
rates at hospitals immediately after EmCare entered.” The strange thing, however, is that the raw
data of the 16 hospitals there was data on that looked at OON rates after EM
health enters a market, shows a clear temporal association of rates rising
after EM health arrived in only 2 cases. In 4 hospitals, OON rates started to
rise before EM health entered, and in the remaining cases, OON rates were
either unchanged, or were seen to decrease.
The authors proceed to firmer footing
when they discuss the charges billed, because the insurer they are working with
has been nice enough to provide this information for every patient they
received a charge for. They find that the entry of EMcare increases charges by
$556.84 (96%). They note that some of this increase occurred because the
intensity of coding that reflects how sick the patient is increased significantly
soon after EMcare enters. The implication, of course, is made that this
upcoding is improper, yet no support is provided for that assertion. It is just
as plausible that physicians were
undercoding the severity of patients prior to EMcare entering the market – this
narrative defying possibility goes unmentioned.
The absolute amounts being discussed also
bears attention. The OON payments that
were paid by insurers after EMcare entered the market increased by $402.67.
Patient cost sharing payments increased by $45. Now it is possible that
patients may have balances beyond these paid charges, but even this amount
comes to $195. These averages paid here exclude ~ 217,000 claims where insurers
paid nothing because of a claim denial.
These numbers aren’t zero, but for emergency medical care, these numbers
($195+ $45) are still far south of the average apple watch.
The most vulnerable patients of course,
don’t have health insurance, and aren’t buying apple watches. For this group, the total potential liability
could range from $578 to $1135. It
isn’t known what is actually collected from this group of patients as the
administrative costs of trying to collect in this population are not small, and
there is most certainly a reputational cost to bear in the community for
generating these bills.
The underlying assumption that runs
through the paper is that the price being paid for these services is too high
because patients are unable to shop for care in an emergency. But this ignores the fact that in our
current system, its the insurance company that acts as an agent for the
patient. They are well aware when they
sign patients up for a health care plan that an out-of-network may happen. So while much of the focus in this debate is
on the bill generating providers, one wonders how it came to be that that
insurance plans are allowed to sell plans to patients that don’t offer any out
of network coverage. Should a facility
be considered in-network if physicians that work at the facility are out of
network? Shouldn’t patients be informed of this by their insurance company? The
insurance company is fully aware of the consequences – so why is the bill that
passes through to patients a surprise? The only party with foreknowledge of
what may happen is the insurance company.
They have every ability to shop on the marketplace, and it is their
failure to secure a contract and then communicate this to their customers that
results in ‘surprise’ bills.
In order to buttress the idea of ‘high’
cost, the paper attempts to use reference Medicare payments. Its noted that Internists are paid 158% of
Medicare rates, orthopedists 266% of Medicare rates while the rates paid to the
2 ER firms in the paper are 364% and 536% of Medicare rates. It only serves passing mention that the
average amounts paid exclude 217,000 claims where nothing was paid because the claim was denied. There is also no mention made of the
difference between elective care provided by orthopedists and internists versus
the almost entirely emergent care provided by ER physicians that is delivered
without consideration of the patients ability to pay. ER physicians are legally (because of a law
called EMTALA) and ethically bound to take care of patients who arrive in the
ER in distress. This means they shoulder
a far heavier responsibility for uninsured care than almost any other
specialty. Most physicians who deliver
care in the outpatient setting require a payment arrangement be made prior to
seeing a patient. The ER physician has
no such recourse. Not mentioning this
when discussing rates paid to ER physicians, and other physicians delivering
care in emergencies is a feat of obfuscation and deception.
The researchers and other commentariat
from the policy community also seem to fail at understanding the motivations of
doctors in the current system. I can think of no physicians that want patients
getting these bills. In the current
third party payer system, opacity is the physicians friend. Given the reputational cost, and the
administrative cost of trying to collect these bills, physicians more so than
policy wonks are highly motivated for a solution that takes patients out of the
mix and generally endorse the previously mentioned third party arbitration
system.
This is reluctantly analyzed by Cooper
et. al., as well. Implemented in New
York in 2014, the study finds that the OON rate went from 20% in 2013 to 6% in
2015. Unimpressed, the authors dismiss
the solution as being “administratively complex and potentially
costly” because it requires patients to know about, and fill out a one
page form if they were to receive a bill.
This ‘analysis’ misses the fundamental point that IDR results in a huge
drop in the chance these bills are being sent to patients, or that most
disputes are resolved without even involving the IDR.
One is struck by the hubris of the
inevitable conclusions the researchers arrive at based on data provided from
one insurer and an analysis of 2 firms. As noted previously, the raw data
consists of a small handful of hospitals from this already small sample, and
doesn’t even tightly demonstrate the relationship of price to firm entry. Even
if we assume prices rise, the conclusion that consolidation raises prices.
Water, I’m told, is also wet. No data is provided on changes to the local
marketplaces in this small sample during the time studied. Profit seeking is
certainly one plausible explanation, but its also just as possible that a
greater proportion of underinsured or poorly insured patients arriving in the
ER during the same time was responsible for raised rates. Apparently the policy
memory is amnestic to The Dartmouth institute that changed the landscape of
healthcare policy with its reports of regional variation Medicare spending. The
small problem was that this dataset didn’t take into account private insurance
spending. Subsequent publication of data from the economists the insurance
industry uses (Cooper et. al) invalidated the Dartmouth data. Context matters.
So this battle has little to do with
patients. The rejection of the IDR in
favor of an untested proposal physicians don’t endorse is part of an
ideological battle waged by a group of folks that have decided health care is
too expensive (it is) and that physicians need to be devalued to create a
better system. Data to support this
ideology conveniently comes from those with an outsize interest in paying less
for physician labor: the insurance industry that pays for healthcare in our
current system. Given that the only data
the insurance companies really have is the amount that they pay for services
rendered, it should perhaps come as little surprise the conclusions draw from
this data is as weak as it. Importantly, this data has little bearing on what
the right price for these services are, what the best mechanism to get the
right price is, or what the downsides of untried, untested policies are.
There is a real argument worth having
about health care prices and how they can be lowered. A number of regulatory
straitjackets harm competition and creates a landscape of large players that
have kept prices high. Sitting inside the guts of the healthcare system, it is
easy to see rent seekers in every health care sector that proliferate.
Physicians aren’t entirely blameless, and a better more efficient may very well
see many physicians making less, but it would be wise to act more like the
skilled surgeon rather than the butcher to avoid killing the patient.
Anish Koka is a cardiologist in practice in Philadelphia. This article originally appeared on his blog here.
Adam Gafney’s recent Boston Review article, “What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.
A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.
Gafney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care. Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”
That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.
As Gafney recounts, a young Reinhardt at
age 19 relocated to Canada just in time to witness the birth of their National
Health Care System. He travels next to New Haven to receive his PhD in
Economics from Yale, and then settles into a long and distinguished career at
Princeton.
In Priced Out, Gafney finds an evolved Reinhardt, one who acknowledges that the problem is not simply opaque pricing (“It’s the prices stupid.“), and certainly not over-utilization of services as Atul Gawande popularly promoted, but rather the wasteful and rigged privatized system awash in ill-gained profits.
As Gafney reports, “Reinhardt describes
in Priced Out,
hospitals and other providers have met insurers’ bloat through profound administrative
distention of their own.” And “a cosmic law is that every dollar in
expenditures is somebody’s income…(creating) fundamentally a political problem,
not a technical one.”
For the solution, Gafney turns to Canadian Robert Evans rather than Reinhardt, who “described in 1991 the special sauce of cost containment…universalism in conjunction with simple source funding.” In summary, Gafney writes, “The way we pay for health care has produced a curious but deadly mix of deprivation and excess. There is no great mystery behind it. It’s the financing, stupid.”
As Code Blue’s tracking of the
medical history however reveals, this declaration is incomplete without two
important additions. The complexity Americans struggle with today was
intentional, and the MIC would have been unable to execute their opaque, profit
sharing conspiracy without the reinforcement of all sectors (including many
patient support groups) reinforced by an integrated career ladder for academic
medicine with overflowing and hidden conflicts of interest.
My own mentor, Columbia health economist Eli Ginzberg, cautioned in his 1990 book, The Medical Triangle, “The competitive market is an opponent, not an ally of cost containment.” Eight years earlier, Reinhardt’s Princeton colleague, sociologist Paul Starr, in The Social Transformation of American Medicine, commenting on similar risks with an air of hopefulness, wrote: “A trend is not necessarily fate.”
But my own research, tracking the
evolution of the collusive Medical-Industrial Complex over the three quarters
of a century following World War II and into the present, suggests that Starr’s
fears expressed in 1982 of “private
plans controlled by conglomerates whose interests will be determined by the
rate of returns on investments” was well founded.
How and why American medicine arrived at
this point is now clear. Instead of embracing a thoughtful approach to
strategic health planning following WWII, our nation encouraged a free
enterprise and entrepreneurial attack on disease, even as our military built
out rational national health systems for Germany and Japan. Along the way,
major health sectors—including the medical profession, hospitals, insurers, and
pharmaceuticals—infiltrated government bodies, weakening regulatory controls as
they pursued self-interest and profitability ahead of the interests of American
patients, families, and communities.
Cross-sector leaders like myself helped
the various MIC sectors populate and socialize one another’s territories, at
times competing, and at other times colluding in the pursuit of career
advancement, deregulation, and federal funding. The new information age helped
spawn complex insurance and delivery systems focused on mining and monetizing
proprietary patient databases. These required expanding nonclinical workforces
and encouraged the opaque gaming of the system and diversion of profits. More
and more money flowed in to an ever-increasing number of derivative
organizations, many flirting at the edges of criminality, that figured out how
to gain entry into the increasingly complex pharmaceutical, insurance,
hospital, patient care, electronic medical record, medical education, and
scientific research supply chains.
As we entered the new millennium, players
within the various MIC sectors discovered common political ground with the help
of their overlapping lobbyists in Washington and statehouses across the land.
But articles like Gafney’s and books like Code Blue have increasingly
exposed these opaque and collusive networks, making it clear that MIC
complexity is intentional and conspiratorial, and must be opposed.
The majority of Americans now agree that
universal health coverage is a central underpinning of a civilized society,
essential to creating a stable government, an empathetic culture, and
productive healthy citizens. Implementing such a program requires careful and
thoughtful governmental planning and execution with integration of a wide range
of other social services. It must be budgeted with careful prioritization, but
it is certainly doable.
As Dr. Gafney suggests, the required
corrective action now is far more comprehensive and centers on the 800-pound
gorilla we must subdue to truly free ourselves from the MIC syndicate’s
stranglehold: our perverse, profit-driven, and incredibly wasteful health
insurance system. Could the transformation we need be as simple as removing the
age restrictions on Medicare and Medicaid, proposed by some on the left,
thereby letting every citizen in on the benefits enjoyed by seniors and the needy
during the past half century? Certainly that is one option worth discussing.
But to embrace true reform, we must follow
the money and follow the data, and build on progress already made. Clearly the
time has come for the US to join the rest of the industrialized world and
consolidate health insurance into a standardized single-payer/multi-plan system
that provides a secure package of basic benefits for all. The first step should
be establishing minimum standards and a centralized control system, which would
trigger a cascading series of changes leading to more detailed answers to the
question “How do we make America healthy?”
In the Declaration of Independence, our
nation’s founders proclaimed that equality was self-evident. Nearly 250 years
later, what has become equally self-evident is that there is no equality
without reasonable access to health care, and that universal insurance coverage
is the only system that truly can provide access that is reasonable. Rather
than resisting this approach once seen as “un-American,” our citizens are
beginning to see single-payer/multi-plan universal access to affordable and
effective care as the essential next step to ensuring what should be every
American’s birthright—life, liberty, and the pursuit of happiness.
Mike
Magee MD is a Medical Historian and Health Economist at the Presidents’ College
at the University of Hartford. He is the author of Code
Blue: Inside the Medical Industrial Complex (Grove Atlantic/2019). (www.mikemagee.org)
As recent events in northeastern Syria make clear, the number of displaced people in the world is rising — as are their health needs.
In 2018 I went with a team of other doctors to a Syrian refugee camp in Lebanon. At one stop, a woman offered us homemade bread as we examined her husband, although the couple had very little money and not enough food for themselves. As we ate the bread, she asked if we could leave them extra medications since they didn’t know when the next humanitarian mission would come through their camp.
Her request was reasonable in the situation – indeed, many other refugee families we treated asked us the same thing. Their host countries’ healthcare systems are simply not equipped to handle their needs. Lebanon alone has almost 1.5 million refugees, an increase of 1/4 of their population.
But expecting vulnerable and displaced people to hoard needed medicine is neither sustainable nor humane. Instead, we must make it part of the social contract for healthcare corporations to use some of their massive wealth to help reduce disparities in global access to healthcare. Pharmaceutical companies and the retail industry have already created efficient models healthcare corporations could follow.
Currently, many nongovernmental organizations raise money to send volunteers to refugee camps and other areas with dramatic unmet need. Often these volunteers ask their hospitals to help by donating equipment. Sometimes healthcare companies will also donate equipment or medications, but the path to achieve these contributions is neither easy nor guaranteed.
On both my trips to Lebanon, the healthcare providers on our team cobbled together bags of medications, pacemakers and other equipment we needed to do our work there. Most of the equipment came from our local hospitals, with a smaller percentage coming from the medical companies.
Yet most healthcare companies have mission statements that describe increasing health and wellness. For example, a highly respected company, Johnson & Johnson, writes in their Credo, “We must help people be healthier by supporting better access and care in more places around the world.”
I propose that these healthcare companies send their own representatives to refugee camps around the world to see firsthand what their lifesaving products could do. The price would be small for them, compared to the cost to NGOs operating on a shoestring budget, or volunteers paying out of their own pockets. The logistics would be easier for them as well. Many of these companies already operate in countries that host refugees.
Once on the ground, representatives could work with NGOs that know the local landscape to donate medications. A model for this action is the pharmaceutical companies that make HIV medications. Many African countries have a very large population with HIV, and patients are not able to pay for medications as they do in more affluent countries. In these regions, pharmaceutical companies often sell the medications to local governments or NGOs at a substantially lower price than they do in the United States, for example. Certainly in Africa, pharmaceutical companies are not motivated purely by profit.
Another model for philanthropy comes from the retail industry. For example, the sock company Bombas advertises that for every pair of socks sold, it donates one pair. This sell-one-give-one model could be applied to the pharmaceutical or medical device industry as well.
Donating medical supplies would have tax benefits for the companies. In addition, providing supplies directly from the source would eliminate waste and inefficiency in the system. Currently, a hospital purchases a device from a company and then donates that device to an NGO. But it’s much cheaper for the company to donate the device directly because the cost of the device is cheaper to the manufacturer than to the consumer.
A downstream benefit would be that if the refugees had more access to medications, they would be healthier and less of a burden to the local healthcare systems, which are already incapable of handling the additional patient volume. Additionally, by using fewer local resources, animosity towards refugees for taking away resources could be diminished.
In the camps, local citizens and the West at large often see the “poor, dirty refugee.” But most of the refugees are proud, honorable citizens that had to flee due to no fault of their own and would love to go back to their lives if given the opportunity. That is sadly not possible. Seeing them hoard medications because they don’t know if our visit will be the last group they see for six months or three years is not only heartbreaking, but immoral in the face of the resources that are already available to healthcare corporations.
Some will argue that “charity begins at home” — there will always be needs that go unaddressed. However, we should not be paralyzed to inaction because other places and people also need our assistance. We start somewhere and make a difference in one life, one camp, one city or one country.
When I was visiting the couple in Lebanon who offered us the bread, I kept thinking of the children’s story about an impoverished village and an individual who began to make a meal out of a stone. Soon, others offered vegetables and meat. In time, they made this stone soup into a real soup, capable of feeding the entire village. Likewise, the occasional visit from a foreign doctor with a little medicine and cobbled-together equipment cannot do much for the millions of suffering refugees; however, with the help of NGOs and medical companies, small acts can be magnified and scaled to sustain our global village.
Dr. Krishnan is a cardiologist and Associate Professor at Rush University Medical Center in Chicago, as well as a Public Voices Fellow at Rush University.
Healthcare providers are
moving forward with their digital initiatives, pursuing intranet development, implementing e-prescribing software, and deploying
EHR systems and patient portals to enhance patient care, maximize staff
efficiency, and improve the bottom line.
However, while medical professionals
are largely enthusiastic about digital healthcare solutions, the disparity
between the rate of clinical support and patient utilization of some of this
software, patient portals in particular, is enormous. Even though patient
self-service solutions have become ubiquitous in medical facilities nation-wide,
over 62% of US hospitals report that their patient portal systems are used by less than a quarter of all patients.
Patients still don’t see
enough value in patient portals, voicing concerns over the steep learning curve,
lack of training, anxiety regarding data security and confidentiality, and
other issues. Addressing these challenges is critical to encouraging patient
buy-in and getting more patients involved in their health.
Since most medical
facilities in the country already have patient portals in place, the next step
to overcome barriers to their adoption is to expand these systems to deliver
features that will get more patients involved.
A Friendly User Interface
A clunky and inconsistent
user interface is a major stumbling block that makes it impossible for many
patients to make it past the sign-up screen. Even if patients feel motivated to
use a self-service portal, when they crash upon a counterintuitive UI, their initial
enthusiasm quickly gives way to frustration and resignation.
Disappointing experience
with a patient portal can discourage patients from any further attempts to use it
in the future. For that reason, one of the first improvements to consider for any
existing patient self-service system should be UX optimization. A skilled frontend development team can enhance the design and navigation of any
patient portal to create a seamless user experience and keep patients involved.
An Effective Mobile App Combo
The smartphone
market penetration in the U.S. exceeds 70%. The general shift toward mobile devices also
impacts healthcare consumers, as they are increasingly engaging with their
health using mobile tools.
To address this trend, nation-wide
healthcare services suppliers such as UnitedHealthcare support patients with
custom mobile patient portal solutions that make it possible for the users to
take care of their health on the go. Smaller medical providers are also catching
up, leveraging out-of-the-box apps and extending them to deliver patient
self-service capabilities on mobile devices.
Digital Forms
Digital patient
registration forms ease the registration workflow by offering a simple and
time-efficient way for patients to fill out their details and consents before
the first appointment.
By reducing patient wait
time in medical facilities and enabling end-to-end secure control over the
submitted data, digital forms are a simple method of encouraging patient
communication. Online forms also benefit healthcare services suppliers by alleviating
the front-desk burden, minimizing the likelihood of clinical errors,
streamlining patient flow, and delivering a holistic view of a patient and their
medical history.
Many available patient
portals already support online registration; others can be easily extended with
custom functionality or integrated with one of the available off-the-shelf
solutions.
API Integration
While most patient portal
solutions by default support integration with core EHR systems, by extending an
open API, they can also connect to other third-party digital solutions and
medical IoT devices, such as step counters, glucose monitors, or sleep
trackers.
Considering the growing use
of wearables by US consumers that’s more than tripled since 2014, open APIs
become an instrumental feature of any patient portal.
When patients couple their
portal profiles with e-health wearable devices, they can automatically upload
and sync all their health data to gain a detailed insight into their health and
well-being over time.
Thanks to real-time
information flow between various tracking devices and health systems, physicians
can regularly and easily review patient vitals to make informed diagnostic and
treatment decisions.
Encrypted Messaging
Top patient portal
solutions, like those of Nextech, MyChart, or Athena, embed secure messaging to
offer an alternative to face-to-face medical appointments through asynchronous,
direct communication with physicians.
This type of interaction
can be of particular advantage to patients with chronic illnesses or mobility
issues, and those living in remote areas. Because of the highly-sensitive
nature of the data processed through patient portal systems and regulatory
compliance requirements imposed on healthcare providers (HIPAA, to start with),
all patient-doctor communication must be properly secured with data encryption.
Streamlined Payments
According to a report by TransUnion, 62% of patients say that knowing their healthcare expenses in advance impacts the likelihood of their pursuing care, while 68% of healthcare consumers fail to pay off their medical bill balances fully.
To resolve these concerns,
comprehensive patient self-service solutions such as Experian Health feature a
payment management component that supports a wide range of payment options,
providing patients with greater transparency when it comes to managing health finances.
These features include e-payments,
billing queries, insurance support, payment history and retrieval, and more. By
extending these features, healthcare organizations can not only augment patient
engagement and increase patient portal utilization but also monitor and manage
patient collections to boost recovery rates.
Toward a More Convenient Access to Healthcare
Healthcare organizations
make persistent efforts toward patient-centric, value-based care. Introducing
and enhancing patient portal solutions makes this task easier, allowing medical
providers to promote proactive patient self-care and spur meaningful patient interactions.
Empowering patients with a sense of authority and responsibility for their health with patient portals creates opportunities for better patient engagement, which in turn drives better treatment outcomes. On top of that, fostering patient activation through self-service patient software enables providers to become eligible for MIPS and other incentive programs and further refine the quality of their healthcare services.
Sandra Lupanova is SharePoint and Office 365 Evangelist at Iflexion, a software development and IT consulting company headquartered in Denver.
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