This is another in the health care discussion continuum. I am hearing a lot of ridiculous statements from politicians. Let’s look at some ways that would actually reduce health care costs and if we really want to go there.
I spent a lot of time discussing universal health care, the built in inefficiencies, and how it will lead to poorer quality physicians and care in an earlier entry. I am clearly convinced that universal government-run health care is a disaster and will make mediocre care available for everyone. As I said in that piece, 40 million Americans have poor care now but universal health care will make sure everyone does.
Rationing Care – We could do what the British and other socialized medicine care countries do. They don’t call it rationing. They call it an effective use of resources to deny care to significant portions of their population. The way they do it is with actuarial tables. For example, if the median age of death in the country is 74 and you are 76, no matter your medical health state, you are a bad investment for medical resources. If you prescribe to those statistical methods, you probably also believe that when you reach a certain age, you should just jump off a building or head on down to the Soylent Green plant for processing. Additionally, under mandatory universal health care, someone like Warren Buffet with a billion dollars earned, gets the same care as John Q. Suckerfish, who had lived his life on welfare. A system like this will set up generational war where the younger members of society will hoard the health care dollars despite having no where near the need for them. Do you really want to see your parents and grandparents denied care, even if they are in good health, based purely on an actuarial table? I don’t think we want to go there.
Improving efficiency – Everyone always talks about improving efficiency in health care. You might notice that they always do it in generalities. President Obama continually talks about the “billions of dollars we can save by improving efficiency in health care” but the only specific he ever mentions is electronic medical records. I have addressed the problems with those in an earlier post. When people talk about improving efficiency in generalities, it is a sure sign that they have no idea what they are talking about. It is a straw man. It is like saying “I am for better schools” or “I am for a strong defense”. Unless you have specific proposals, you reek of fecal matter from male cows when you discuss it.
Get Out of My Emergency Room – One method of reducing costs which has been widely recognized for years is moving people back to seeing their family primary care physicians and physician assistants. The same office visit which costs $75 at the family physician office costs $600 at the local emergency room. I have worked in many emergency rooms where every Sunday night, mothers bring in their children with minor complaints of colds, fevers, etc. to inquire whether their children should go to school tomorrow or not. It is major waste of health care dollars. If a family physician or pediatrician held office hours Sunday evening, the emergency room would only have half as many patients and the cost would be reduced by a factor of ten. The reasons that emergency rooms exist is because doctors historically did not want to have to work twenty four hours a day. Since internists and surgeons would be called in at all hours of the night to see patients, they came to hire physicians to man the medical facility at night. That eventually led to the creation of the emergency medicine specialty.
Many people now use the emergency room as their local clinic. Part of the reason for this is that emergency rooms are not allowed to turn away patients. Therefore, a person can choose not to pay for health insurance and just show up. Who picks up the cost? The taxpayers of the local area. In an analogous manner to the emergency room physician, why not have physicians or practitioners man clinics at night to allow primary care to be done at the clinic rate rather than the emergency room rate? If people use their existing health policies to make office visits instead of using the emergency room, huge savings are possible.
Private Health Insurance – Over the years, business interests have put in place laws which severely restrict which health care plans people can purchase. For example, in most places, you cannot buy a policy across a state line. If you live in Maryland, for example, you cannot buy a policy from a health insurance company in Utah. The system was set up by the local legislature after lobbying from the local health insurance company to set up a monopolistic system. The system guarantees no competition and therefore no reason to improve policies or reduce premiums. It is the same as universal health care in that the system is bloated and inefficient. To reduce costs almost immediately, those state line restrictions should be dropped. This must be done in combination with the next section to induce competition among health insurance providers. A family will buy the health insurance policy with the best benefit package and lowest premiums available if those plans are in competition.
Third Party Payers – This section goes hand in hand with the prior one. Companies always complain about runaway health care costs as the reason they are unable to make a profit. It many cases, it is true. No one who has company-provided health care cares what it costs because they never see the premiums. As long as you can get care for your family and keep your job, there is no reason to care about the premiums. I believe one answer is to get rid of third party payers. If your employer gives you, as part of your pay and benefits package, money to buy health insurance instead of providing a policy, you then have a vested interest in knowing what it costs and finding the best policy available for the best price. A system like that would provide a lot of flexibility. It would be like automobile insurance in some ways. If you are a young healthy person, you could opt for low premiums with higher co-pays (deductibles) because the likelihood of having a serious illness in your twenties or thirties is fairly low. As you age, you can adjust your policy for higher premiums with lower co-pays because the likelihood of your needing medical care increases. If you have an individual or family policy that you own personally, you can take it with you if you change employers. Since you would buy the policy while you are young, you would not run into the problem of changing jobs in your late forties and finding the new premiums prohibitively expensive. If any policy anywhere in the country was available, people would shop for the best policy around. Insurance carriers would then be forced to compete with better benefits and lower premiums in order to attract customers. This is the way that free markets always improve services for customers.
Did you ever notice that when you buy a slice of pizza in New York City that it is really good? There is nothing genetic about the people in New York that makes them better cooks and the ingredients are the same as everywhere else. Why is that? It is because if you don’t make a good pizza slice, there are three more places down the street that do and you go out of business. That is the way competition works. If competition in the health insurance industry is opened, policies will improve and prices will improve. People will be able to maintain their policies no matter where they move and if they change their job. The market will fix the problem if we let it. For those unable to purchase policies due to physical or mental disabilities, the government can help them. No one has a problem with that. The prices will be less expensive to the government because of the competition in the industry and it will cost less in tax dollars. I should point out that I do have a problem with providing tax money for health care to able-bodied people who choose not to work or buy a policy. They have chosen their own fate as people in the United States are free to do.
Tort Reform – Many physicians are now required to practice what is known in the sector as “defensive medicine”. What that amounts to is getting your ducks in a row before the inevitable frivolous lawsuit. Extra expensive radiology studies, laboratory tests, and follow up visits are the norm to prevent litigation. In the obstetrics field, there are two kinds of baby births: perfect and lawsuit. It doesn’t matter if the birth mother is a crack-smoking alcoholic who performed as a professional wrestler while eight months pregnant, if the baby isn’t perfect, the Ob/Gyn is getting sued. That is because there are law firms that do nothing else but sue physicians and hospitals. In Pennsylvania, the same malpractice insurance policy for a general surgeon that costs $37,000 a year in premiums in Virginia, costs $135,000. Why is that? Are surgeons that much worse in Pennsylvania? No, it is because the tort laws in Pennsylvania are set up for lawyers to make money. You will find this to be true in every Democratic state. Since the Trial Lawyers Association is the biggest single contributor to the Democratic Party, you will never see tort reform in one of those states. About 36% of the general surgeons in Pennsylvania have left the state. They cannot afford to practice there. They have to make $135,000 before they make a penny to keep. The does not include paying office staff, leases for offices, supplies, administrative costs, licenses, continuing medical education or any of the other routine costs of running a practice. Therefore, they move or stop practicing. Pennsylvania screws itself. Of course, that won’t stop the legislators from complaining about the situation, even though they caused it. It is a lot like Christopher Dodd and Barney Frank talking about the housing crisis. Next time you think medical care is too expensive; go to see your lawyer to get that coronary artery bypass surgery. I’m sure he can hook you up.
In summary, there are a number of ways to reduce health care costs which are far preferable to government-run universal health care. I have pointed out a few but not all. I am sure I will visit this subject again.
Showing posts with label Medicine. Show all posts
Showing posts with label Medicine. Show all posts
Saturday, March 7, 2009
Thursday, March 5, 2009
Universal Health Care
Health care costs in the United States are rising at a rate significantly higher than the rate of inflation. Corporations which provide health care to their employees are hammered by those increases. There is much discussion about how to slow the increase and improve efficiency. The Democratic Party has been pushing for government-run health care since the Clinton administration. Since it a huge agenda item for the Obama administration, let’s look at some of the issues involved.
Let’s start first with the people who actually provide health care. I will talk mostly about physicians but one must remember that in a private practice environment, if the physician makes less money, everyone associated with that physician makes less money also. One of the things which is coming out of the administration spokespeople is that they want to reduce waste, improve efficiency, and reduce payments to physicians. Let’s talk about reducing payments to physicians. I am a physician and I can honestly say that I don’t know a single physician who went in to the practice of medicine exclusively to make a lot of money. That being said, for those readers who might not know what is involved in becoming a practicing physician, let me give you a clue. I spent the requisite twelve years in public school getting good grades. Because my family could not afford to pay for college, I did an enlistment in the Navy to obtain Veterans Administration benefits. Using, those benefits and working full time, I obtained a chemical engineering degree in five years. I spent four years in medical school on a military scholarship and with loans because I could not afford medical school without them. I then spent five years working about 110-120 hours a week with virtually no days off to finish a surgery residency. I spent two more years completing a trauma/critical care fellowship. If you add that up, that is twenty eight total years of education. I paid for the scholarships with years of my life. Is it reasonable to think that after all those years of effort that I should be financially secure? Should I be held in contempt because I expect my efforts to be rewarded? I am not rich by any stretch of the imagination. With all of that education, should I make the same salary as a bank clerk, automobile mechanic, carpet installer, or ice cream vendor? It is an interesting question. In fact, should I be salaried at all or should I be paid by the services I provide? If I am a better surgeon than the guy down the street, should I make more money? I don’t make one tenth of what a professional baseball player makes. Is a baseball player more valuable to society than a surgeon? To place fixed salaries on any profession is to encourage mediocrity. If all baseball players make the same amount of money, there is no reason for anyone to try to become a star. There is no incentive. If you reduce incomes of physicians to the same level as any profession that requires one-year training program or a college degree, where is the incentive for someone to go through what I went through? I love taking care of patients but I am not a financial masochist. It took me sixteen years to pay off my medical school loans. Government-run socialized medicine is a one way ticket to mediocre physicians. Smart people will find something else to do.
What are people entitled to? There is discussion about whether health care is a right. Is everyone entitled to everything at any time? In an ideal world, that would be possible but in a real world with fixed resources, it is not. If it is not possible for everyone to have everything, who decides who gets what? The Democrats want the government to decide. That is happening in England now. They use actuarial tables to decide by your age what health care to which you are entitled. For example, past a certain age, if you having a failing heart valve, the government will not pay for a valve replacement because they have decided that it is a bad investment. It certainly does save costs. They do the same for interventional radiology, transplants, x-ray studies, etc. It is only another small step for the government to decide who lives and dies. It will be like planned obsolescence. You reach a certain age and you will be considered useless to society and we find ourselves cast in Soylent Green. Another government, years ago, went through these logical steps: why spend a lot of money on people who don’t contribute to society; why allow those people with genetic defects or insanity to reproduce; why spend money housing those people who aren’t reproducing anyway; why not terminate those people because their life is worthless and miserable, we would be doing them a favor. They called the science eugenics and it led to millions of deaths. In the current American system, decisions are made with your physician based on your individual story. I make these decisions all the time. A socialized set of rules will lead to philosophical questions. If you are a fifty year old award-winning teacher, do you deserve less care, based on an actuarial table, than a twenty-five year old crack dealer who was shot committing his fifth violent felony? If you are sixty five years old and are an active member of society, you have different options than a sixty-five year old in a skilled nursing facility who is completely unaware of the surroundings and has multiple chronic debilitating diseases. Is that cruel or is it just a better use of resources? While private insurers do limit treatment payments, the individual has a voice in choosing the limits of their coverage by the premiums they chose to pay. In a government run system, the rules will be fixed in concrete and the individual circumstances won’t be considered. The fixed salary, robotic doctors will practice under constraints and algorithms which will take decisions away from the doctor, patient, and family and leave in the hands of government health care administrators. That will lead to a dual system of medicine: a fee for service upscale system for the wealthy and a government-run mediocre system for everyone else. It is another step on the road to mediocrity. The Democrats argue that currently 40 million people have poor health care. They want to make sure everyone has equally bad health care.
Any government program has inherent flaws. The first is trying to write rules that apply to 300 million people and address all circumstances is impossible. Whenever it is tried, like in the tax code, it leads to tens of thousands of exceptions that no one can understand. It never works. Another generic problem with the way the United States government works is the way that money is handled. In private industry, the people who do the work own the money. Private industry will invest money in order to save money or improve efficiency any time they see a chance to do so. It is those investments and improvements which drive the economy and fill market niches. In the government, the people who own the money and the people who use it are separate. The government puts that system in place to try to control expenditures. The problem with that system is that the people who dole out the money don’t understand the work being accomplished and the only way that they can look good is to spend less money. Therefore, every year the money people have the goal of restricting spending no matter the outcome. There is no better example than the military supply system. It is onerous and unwieldy and the deck plate workers can’t understand the system or find what they need. Anyone who has ever worked in a government program knows that the program always asks for more than they expect to use. They also save money until the end of the fiscal year in case something comes up. If they spend less than their budget, the budget will be reduced the following year. Therefore, the left over money at the end of the year is always spent on something, no matter how redundant or unnecessary. If you plotted spending by month, you would find every government agency spends huge sums in September before the close of the fiscal year. It is built into the system. It wastes vast sums of taxpayer money. Universal government-run health care will be inefficient and wasteful. All government programs are. Any one who says differently has no experience with the government.
Pharmaceutical companies, medical equipment companies, medical service companies, and health care in general, is better in the United States than anywhere else in the world. I have heard the arguments using statistics about longevity and birth rates deaths, etc. But sensible people vote with their wallets. Does anyone leave the United States for anywhere on the Earth looking for higher quality care? People go all the time for cheaper care but not for better care. Pharmaceutical companies and medical equipment companies are not altruistic. They are in business to make a profit. Most of the advances in medicine, prosthetics, and equipment are developed in the United States and marketed around the world. If you take away the profit motive, those developments will slow to a crawl. The only reason that pharmaceutical companies invest so heavily in research and development is that they stand to make profits when successful drugs are marketed. If that profit potential is taken away, only government research, funded by tax money, will continue.
The very basis of the success of the United States is the market system. It is the best system ever developed to provide incentive for hard work and new ideas. The fact that the individual who works hard or develops a better product receives the benefits of his/her hard work or ingenuity is the thrust behind the success. People do not work hard when there is no incentive to do so. It is the reason communism and socialism always produce poor economies. If I work twice as hard and receive the same benefits, it is only a matter of time before I work down to the lowest level which allows me to keep my job. It brings up more philosophical questions. If I have been a producer, worked hard my entire life, and contributed to society in good behavior and tax revenues to the government, am I entitled to more benefits than the person who did not work and lived off the government (my earnings)? If the Democrats answer is no, why would anyone work? If everyone gets the same thing no matter whether they work hard or not, welcome to the Soviet Union. Some people will say it isn’t fair to have some with more benefits than others. I believe it isn’t fair to those who work hard and produce to be restricted in their benefits to the same level as those who don’t. At the same time I say that, I also say that there is clearly some base line level of care that all citizens should be receiving. Notice I said citizens. No one who is in the country illegally is entitled to a dime of publicly funded health care. It is insane to provide that kind of incentive to people to sneak into the country.
In summary, universal government-run health care will lead to poorer quality physicians, lesser paid assistants, rationing of health care based on broad-based rules not on individual needs, less new products and medications, and inevitable inefficiency and waste. It is a terrible idea and flies in the face of the very system that made the country great.
Let’s start first with the people who actually provide health care. I will talk mostly about physicians but one must remember that in a private practice environment, if the physician makes less money, everyone associated with that physician makes less money also. One of the things which is coming out of the administration spokespeople is that they want to reduce waste, improve efficiency, and reduce payments to physicians. Let’s talk about reducing payments to physicians. I am a physician and I can honestly say that I don’t know a single physician who went in to the practice of medicine exclusively to make a lot of money. That being said, for those readers who might not know what is involved in becoming a practicing physician, let me give you a clue. I spent the requisite twelve years in public school getting good grades. Because my family could not afford to pay for college, I did an enlistment in the Navy to obtain Veterans Administration benefits. Using, those benefits and working full time, I obtained a chemical engineering degree in five years. I spent four years in medical school on a military scholarship and with loans because I could not afford medical school without them. I then spent five years working about 110-120 hours a week with virtually no days off to finish a surgery residency. I spent two more years completing a trauma/critical care fellowship. If you add that up, that is twenty eight total years of education. I paid for the scholarships with years of my life. Is it reasonable to think that after all those years of effort that I should be financially secure? Should I be held in contempt because I expect my efforts to be rewarded? I am not rich by any stretch of the imagination. With all of that education, should I make the same salary as a bank clerk, automobile mechanic, carpet installer, or ice cream vendor? It is an interesting question. In fact, should I be salaried at all or should I be paid by the services I provide? If I am a better surgeon than the guy down the street, should I make more money? I don’t make one tenth of what a professional baseball player makes. Is a baseball player more valuable to society than a surgeon? To place fixed salaries on any profession is to encourage mediocrity. If all baseball players make the same amount of money, there is no reason for anyone to try to become a star. There is no incentive. If you reduce incomes of physicians to the same level as any profession that requires one-year training program or a college degree, where is the incentive for someone to go through what I went through? I love taking care of patients but I am not a financial masochist. It took me sixteen years to pay off my medical school loans. Government-run socialized medicine is a one way ticket to mediocre physicians. Smart people will find something else to do.
What are people entitled to? There is discussion about whether health care is a right. Is everyone entitled to everything at any time? In an ideal world, that would be possible but in a real world with fixed resources, it is not. If it is not possible for everyone to have everything, who decides who gets what? The Democrats want the government to decide. That is happening in England now. They use actuarial tables to decide by your age what health care to which you are entitled. For example, past a certain age, if you having a failing heart valve, the government will not pay for a valve replacement because they have decided that it is a bad investment. It certainly does save costs. They do the same for interventional radiology, transplants, x-ray studies, etc. It is only another small step for the government to decide who lives and dies. It will be like planned obsolescence. You reach a certain age and you will be considered useless to society and we find ourselves cast in Soylent Green. Another government, years ago, went through these logical steps: why spend a lot of money on people who don’t contribute to society; why allow those people with genetic defects or insanity to reproduce; why spend money housing those people who aren’t reproducing anyway; why not terminate those people because their life is worthless and miserable, we would be doing them a favor. They called the science eugenics and it led to millions of deaths. In the current American system, decisions are made with your physician based on your individual story. I make these decisions all the time. A socialized set of rules will lead to philosophical questions. If you are a fifty year old award-winning teacher, do you deserve less care, based on an actuarial table, than a twenty-five year old crack dealer who was shot committing his fifth violent felony? If you are sixty five years old and are an active member of society, you have different options than a sixty-five year old in a skilled nursing facility who is completely unaware of the surroundings and has multiple chronic debilitating diseases. Is that cruel or is it just a better use of resources? While private insurers do limit treatment payments, the individual has a voice in choosing the limits of their coverage by the premiums they chose to pay. In a government run system, the rules will be fixed in concrete and the individual circumstances won’t be considered. The fixed salary, robotic doctors will practice under constraints and algorithms which will take decisions away from the doctor, patient, and family and leave in the hands of government health care administrators. That will lead to a dual system of medicine: a fee for service upscale system for the wealthy and a government-run mediocre system for everyone else. It is another step on the road to mediocrity. The Democrats argue that currently 40 million people have poor health care. They want to make sure everyone has equally bad health care.
Any government program has inherent flaws. The first is trying to write rules that apply to 300 million people and address all circumstances is impossible. Whenever it is tried, like in the tax code, it leads to tens of thousands of exceptions that no one can understand. It never works. Another generic problem with the way the United States government works is the way that money is handled. In private industry, the people who do the work own the money. Private industry will invest money in order to save money or improve efficiency any time they see a chance to do so. It is those investments and improvements which drive the economy and fill market niches. In the government, the people who own the money and the people who use it are separate. The government puts that system in place to try to control expenditures. The problem with that system is that the people who dole out the money don’t understand the work being accomplished and the only way that they can look good is to spend less money. Therefore, every year the money people have the goal of restricting spending no matter the outcome. There is no better example than the military supply system. It is onerous and unwieldy and the deck plate workers can’t understand the system or find what they need. Anyone who has ever worked in a government program knows that the program always asks for more than they expect to use. They also save money until the end of the fiscal year in case something comes up. If they spend less than their budget, the budget will be reduced the following year. Therefore, the left over money at the end of the year is always spent on something, no matter how redundant or unnecessary. If you plotted spending by month, you would find every government agency spends huge sums in September before the close of the fiscal year. It is built into the system. It wastes vast sums of taxpayer money. Universal government-run health care will be inefficient and wasteful. All government programs are. Any one who says differently has no experience with the government.
Pharmaceutical companies, medical equipment companies, medical service companies, and health care in general, is better in the United States than anywhere else in the world. I have heard the arguments using statistics about longevity and birth rates deaths, etc. But sensible people vote with their wallets. Does anyone leave the United States for anywhere on the Earth looking for higher quality care? People go all the time for cheaper care but not for better care. Pharmaceutical companies and medical equipment companies are not altruistic. They are in business to make a profit. Most of the advances in medicine, prosthetics, and equipment are developed in the United States and marketed around the world. If you take away the profit motive, those developments will slow to a crawl. The only reason that pharmaceutical companies invest so heavily in research and development is that they stand to make profits when successful drugs are marketed. If that profit potential is taken away, only government research, funded by tax money, will continue.
The very basis of the success of the United States is the market system. It is the best system ever developed to provide incentive for hard work and new ideas. The fact that the individual who works hard or develops a better product receives the benefits of his/her hard work or ingenuity is the thrust behind the success. People do not work hard when there is no incentive to do so. It is the reason communism and socialism always produce poor economies. If I work twice as hard and receive the same benefits, it is only a matter of time before I work down to the lowest level which allows me to keep my job. It brings up more philosophical questions. If I have been a producer, worked hard my entire life, and contributed to society in good behavior and tax revenues to the government, am I entitled to more benefits than the person who did not work and lived off the government (my earnings)? If the Democrats answer is no, why would anyone work? If everyone gets the same thing no matter whether they work hard or not, welcome to the Soviet Union. Some people will say it isn’t fair to have some with more benefits than others. I believe it isn’t fair to those who work hard and produce to be restricted in their benefits to the same level as those who don’t. At the same time I say that, I also say that there is clearly some base line level of care that all citizens should be receiving. Notice I said citizens. No one who is in the country illegally is entitled to a dime of publicly funded health care. It is insane to provide that kind of incentive to people to sneak into the country.
In summary, universal government-run health care will lead to poorer quality physicians, lesser paid assistants, rationing of health care based on broad-based rules not on individual needs, less new products and medications, and inevitable inefficiency and waste. It is a terrible idea and flies in the face of the very system that made the country great.
Friday, February 13, 2009
Centralized Medical Records, Behavioral Modification and Security
The currently debated “stimulus” bill has about $300 million in it for establishment of an electronic medical record system for the government. I mentioned this briefly in a previous post but think it should probably be explored in more depth.
The idea of a central repository for all medical records has great merit in an ideal world. Information would be available, no matter where a patient was located, about past medical history, allergies, current medications, and past surgical history. Since everyone is altruistic and no one would access information that was not required, the system would be wonderful in an ideal world. We don’t live in an ideal world.
A central repository of any information of value is a hackers dream. That information would be so valuable to obtain that it could be sold surreptitiously to potential employers, insurance providers, for personal motives, etc. by anyone with access and enough temptation. Miscreants could erase or modify the records for profit or for malicious reasons. The government would counter with a back up system of records. That just provides a broader target to access the information. Even without hacking through computer safeguards, the records could be compromised by individuals through bribes or other personal motives. This is a relatively common occurrence when it comes to national security issues in the United States. People with agendas or personal political philosophical differences with the government pass information to liberal publications like the Washington Post and New York Times which routinely publish classified information. Even more recently, out of one hundred forty anonymous screening tests for baseball players concerning steroids, only the name of Alex Rodriguez was leaked to the press. Someone clearly had an agenda against Alex Rodriguez. It is easy to see similar leaks for candidates for office, other sports figures, celebrities, and for personal vengeance. A history of a sexually transmitted disease, elective abortion, or potential debilitating disease could be used for extortion or political blackmail.
The breadth of the system is inherently a security and bandwidth problem. In order to be effective, the records will have to be available to any medical facility in order to care for patients wherever they present for care. That means that tens or even hundreds of thousands of facilities will have access to the system. A system that large will be similar to the AHLTA military system which is slow, unwieldy, and crashes regularly. A system with that kind of capability probably doesn’t exist outside of the military or National Security Agency anywhere in the world. An electronic health record system which is undependable would be a danger to patients as necessary patient information would not be available when required. Additionally, with the many thousands of access points to the system, there is no practical way to adequately maintain the security of the system. It is like a fence with thousands and thousands of gates, any one of which when breeched makes the entire system accessible.
As a physician, I am well aware of the tendency of health care administrators to now view patient care as a “product line”. In a group of physicians, I have once actually been instructed by a senior administrator to increase patient throughput even if it increases risk of inadequate diagnosis. The reason I bring this up is that there is a tendency for anyone under a time constraint to avoid “reinventing the wheel”. Errors in records in a central repository will propagate because the information will convey authority and go unchallenged. Errors will be like bad tattoos and go with patients everywhere.
To use the hackneyed Orwellian analogy, all health care information in the hands of the government is not a good idea. I will point out that while the government will be a problem, it may not be the biggest problem. With a records system that will inevitably leak like a sieve, it is only a matter of time before private insurance providers get their hands on the information. With that information in hand, insurance companies will begin to modify their actuarial tables depending on your private information. If they note a minor injury while surfing, skiing, sky diving, playing contact sports, riding, etc. you will have the option of stopping the activity, not being covered while doing it, or paying higher premiums. This type of focus will eventually lead to widespread financial behavioral modification. The analogous government scenario is to force behavior modification by denying benefits for activities, diet, etc. that are not approved by some group of “experts” who decide what they want you to do and not do. This is not a new argument. There was a suggestion years ago that in states with motorcycle helmet laws, if you didn’t wear a helmet, there would be no government funding for your health care should you be injured on a motorcycle. The idea was fairly popular. The same has been suggested for bicycle riding for children and cigarette smoking. The idea being that the government says out of one side of the mouth, “We aren’t forcing anyone to change their behavior” while making the behavior so financially untenable that no sane person would engage in it. It is a slippery slope that eventually leads to only government and insurance approved lifestyles being covered. Anything else leaves you on your own.
One advantage proponents will claim is the ability to gather data about treatment options and outcomes. Former Senator Daschle has already written in his book about using those data to determine which treatments will be available. In other words, the financial behavioral modification will not only be used on patients, it will be used to force physicians to become robotic in their prescribing and treatment patterns. Once again, it will be “Treat the patient in the way you see fit, but we will only pay you if you do it the way we want.” If patients cannot be treated individually, we might as well scrap the entire health care system and have everyone use a site like WebMD to treat everyone. There is no reason to talk to patients and examine them if it isn’t going to make any difference in what you can do for them.
My counter proposal, which I have actually sent to Senators Graham and DeMint, is to not have the government establish an actual computer system but rather to establish national standards for the electronic medical record. The format of the record, type of computer storage file, and transmission protocols could be specified and monitored by the Department of Health and Human Services. In the past, similar standards have been established for radio and television transmission, automobile safety, food safety, air traffic control systems, and other systems. My suggestion is that a commission or committee of overpaid top notch experts to establish standards has miniscule costs compared to establishing and building a huge overpriced ineffective system of computer networks. Additionally, in a free market economy, software developers will come out of the woodwork in droves to develop and market commercial versions of software to make new electronic records and convert existing records. To paraphrase Field of Dreams, “If there is money to be made, they will definitely come”. Having private companies supply the software will create many high-paying jobs and result in substantial tax revenue to the government, instead of costing huge amounts in government payroll. Additional jobs will be created all across the country when people are hired by health care facilities to convert existing records into the standardized electronic format. The government virtually never gets the appropriate value for its contracts, there is no reason to assume that it will on this one. Therefore, in the spirit of the American entrepreneur, to save hundreds of millions of dollars in taxpayer money and to avoid the Orwellian consequences, I believe the system I am proposing is superior to the current thinking.
The idea of a central repository for all medical records has great merit in an ideal world. Information would be available, no matter where a patient was located, about past medical history, allergies, current medications, and past surgical history. Since everyone is altruistic and no one would access information that was not required, the system would be wonderful in an ideal world. We don’t live in an ideal world.
A central repository of any information of value is a hackers dream. That information would be so valuable to obtain that it could be sold surreptitiously to potential employers, insurance providers, for personal motives, etc. by anyone with access and enough temptation. Miscreants could erase or modify the records for profit or for malicious reasons. The government would counter with a back up system of records. That just provides a broader target to access the information. Even without hacking through computer safeguards, the records could be compromised by individuals through bribes or other personal motives. This is a relatively common occurrence when it comes to national security issues in the United States. People with agendas or personal political philosophical differences with the government pass information to liberal publications like the Washington Post and New York Times which routinely publish classified information. Even more recently, out of one hundred forty anonymous screening tests for baseball players concerning steroids, only the name of Alex Rodriguez was leaked to the press. Someone clearly had an agenda against Alex Rodriguez. It is easy to see similar leaks for candidates for office, other sports figures, celebrities, and for personal vengeance. A history of a sexually transmitted disease, elective abortion, or potential debilitating disease could be used for extortion or political blackmail.
The breadth of the system is inherently a security and bandwidth problem. In order to be effective, the records will have to be available to any medical facility in order to care for patients wherever they present for care. That means that tens or even hundreds of thousands of facilities will have access to the system. A system that large will be similar to the AHLTA military system which is slow, unwieldy, and crashes regularly. A system with that kind of capability probably doesn’t exist outside of the military or National Security Agency anywhere in the world. An electronic health record system which is undependable would be a danger to patients as necessary patient information would not be available when required. Additionally, with the many thousands of access points to the system, there is no practical way to adequately maintain the security of the system. It is like a fence with thousands and thousands of gates, any one of which when breeched makes the entire system accessible.
As a physician, I am well aware of the tendency of health care administrators to now view patient care as a “product line”. In a group of physicians, I have once actually been instructed by a senior administrator to increase patient throughput even if it increases risk of inadequate diagnosis. The reason I bring this up is that there is a tendency for anyone under a time constraint to avoid “reinventing the wheel”. Errors in records in a central repository will propagate because the information will convey authority and go unchallenged. Errors will be like bad tattoos and go with patients everywhere.
To use the hackneyed Orwellian analogy, all health care information in the hands of the government is not a good idea. I will point out that while the government will be a problem, it may not be the biggest problem. With a records system that will inevitably leak like a sieve, it is only a matter of time before private insurance providers get their hands on the information. With that information in hand, insurance companies will begin to modify their actuarial tables depending on your private information. If they note a minor injury while surfing, skiing, sky diving, playing contact sports, riding, etc. you will have the option of stopping the activity, not being covered while doing it, or paying higher premiums. This type of focus will eventually lead to widespread financial behavioral modification. The analogous government scenario is to force behavior modification by denying benefits for activities, diet, etc. that are not approved by some group of “experts” who decide what they want you to do and not do. This is not a new argument. There was a suggestion years ago that in states with motorcycle helmet laws, if you didn’t wear a helmet, there would be no government funding for your health care should you be injured on a motorcycle. The idea was fairly popular. The same has been suggested for bicycle riding for children and cigarette smoking. The idea being that the government says out of one side of the mouth, “We aren’t forcing anyone to change their behavior” while making the behavior so financially untenable that no sane person would engage in it. It is a slippery slope that eventually leads to only government and insurance approved lifestyles being covered. Anything else leaves you on your own.
One advantage proponents will claim is the ability to gather data about treatment options and outcomes. Former Senator Daschle has already written in his book about using those data to determine which treatments will be available. In other words, the financial behavioral modification will not only be used on patients, it will be used to force physicians to become robotic in their prescribing and treatment patterns. Once again, it will be “Treat the patient in the way you see fit, but we will only pay you if you do it the way we want.” If patients cannot be treated individually, we might as well scrap the entire health care system and have everyone use a site like WebMD to treat everyone. There is no reason to talk to patients and examine them if it isn’t going to make any difference in what you can do for them.
My counter proposal, which I have actually sent to Senators Graham and DeMint, is to not have the government establish an actual computer system but rather to establish national standards for the electronic medical record. The format of the record, type of computer storage file, and transmission protocols could be specified and monitored by the Department of Health and Human Services. In the past, similar standards have been established for radio and television transmission, automobile safety, food safety, air traffic control systems, and other systems. My suggestion is that a commission or committee of overpaid top notch experts to establish standards has miniscule costs compared to establishing and building a huge overpriced ineffective system of computer networks. Additionally, in a free market economy, software developers will come out of the woodwork in droves to develop and market commercial versions of software to make new electronic records and convert existing records. To paraphrase Field of Dreams, “If there is money to be made, they will definitely come”. Having private companies supply the software will create many high-paying jobs and result in substantial tax revenue to the government, instead of costing huge amounts in government payroll. Additional jobs will be created all across the country when people are hired by health care facilities to convert existing records into the standardized electronic format. The government virtually never gets the appropriate value for its contracts, there is no reason to assume that it will on this one. Therefore, in the spirit of the American entrepreneur, to save hundreds of millions of dollars in taxpayer money and to avoid the Orwellian consequences, I believe the system I am proposing is superior to the current thinking.
Wednesday, February 11, 2009
Electronic Medical Records
A lot of discussion has gone on recently by the proponents of electronic medical records, including the current administration. I have discussed them before but wanted to take another look, including the views of a user. The military has already implemented an electronic system which was originally called CHCS (Composite Health Care System). When it was first introduced, it provided some valuable services despite its user unfriendliness. It allowed students and physicians to access laboratory results and radiology results without having to trek down to each department and go through a log book to retrieve them. When I was first training in medicine, that is exactly what we had to do each morning and evening. From that stand point, CHCS was a boon to efficiency. Those same tests could be ordered in the system although there was a learning curve as the names of the tests were not very intuitive. There were a lot of problems with the system. For example, if a laboratory technician entered an order from a drop down menu under the incorrect physician’s name, the results of the test would be returned to that physician and that physician would be asked to electronically sign the order. There was no way to correct the mistake. Even the administrators of the system could not fix them. Physicians were constantly receiving results and signing orders on patients they had never met. Rather than quibble on the other inconsistencies and problems with that system, let us move on.
The next iteration of the system was originally CHCS II, but has subsequently been renamed AHLTA (Armed Forces Health Longitudinal Technology Application). The AHLTA system has many of the same advantages in that no matter where you go (in theory) your drug allergies, medications, past medical history, etc. are available to a new physician to whom you present for care. That is not entirely true as I have been deployed eight times in the past five years and have never had access to the AHLTA system on any deployment. While the AHLTA folks consistently crow about the advantages of the system, they never discuss what it is like to use it. Let’s look at some of the results:
The Navy has decided that in order to improve efficiency, they want the physicians to see seventy five per cent of the productivity of major Health Maintenance Organizations (HMOs). Part of the reason is to lower costs, and part of the reason is that they are having trouble keeping enough people in the Navy to serve the patient population. In the brick and mortar hospitals, the current requirement for a General Surgeon is to see forty five clinic patients a week (based on HMO productivity). If that is only seventy five percent of what an HMO doctor sees, why should that be a problem? First, the average physician in civilian practice averages four support personnel per physician. The civilian practices know that the only person in a surgery office that makes a dime for the practice is the surgeon. Therefore, people are hired to keep the surgeon from doing anything which is not billable. Record keeping, billing, coding, telephones, communication, cleaning, education, etc. are all handled by trained assistants, freeing up the surgeon to do surgery and outpatient care for which billing can be generated. In the Navy, there are four physicians for each support person. Those people are Civil Service and we all know how much incentive the Civil Service has to work hard: none. Therefore, Navy physicians type their own notes, write their own consults, fill out their own preoperative and post operative packages, make phones call, schedule procedures, etc. I forgot to mention above that those forty five patients have to be seen in only two clinic days a week. Broken down evenly, this means twenty two patients on one clinic day and twenty three on the other.
Meanwhile back at the AHLTA system: Even after the training required to use the system, it is so cumbersome that trying to find your way through it is very time consuming and frustrating. I know how bad it is for surgeons. I can’t imagine how bad it is for primary care physicians who see such a wide variety of diagnoses. There are templates which can be customized for a specialty, which can save time but any unusual case will take a lot time to do the note. Additionally, the system can not keep up with the amount of usage so it is slow and crashes regularly. I have found the average AHLTA note to take between ten and twenty minutes to do even with a template. Therefore, twenty two times fifteen minutes equals three hundred thirty minutes. That is five and one half hours a day entering notes into AHLTA. If a surgical appointment is 20 minutes long, that means four hundred and forty minutes, or seven hours and twenty minutes a day talking to and examining patients. So far, we are up to twelve hours and fifty minutes each clinic day. Why do patients go to see a surgeon? Because they might need an operation. Assuming that only half of the patients need surgery, that means eleven preoperative packages (preoperative orders, admission paperwork, consent forms, notice to parent command, history and physical examination, etc.) need to be completed in addition to the AHLTA note for those eleven patients. Just for argument, let’s say that they only take fifteen minutes each (not realistic). That is another three hours and forty five minutes a clinic day. Now we are up to fifteen hours and thirty five minutes each clinic day. That is assuming that the physician never goes to the rest room, eats, or takes a break from paperwork. Additionally, the physician needs to round and care for inpatients which requires going to the ward or intensive care unit. Does anyone wonder why people leave for increased salaries and lots of administrative support?
Another phenomenon of the electronic record in the military is that performance evaluations have become partly based on the amount of relative value units (RVUs) billed as interpreted by the coding of each visit by the system. Subsequently, the smart physicians have learned to “game” the system and turn every visit into a coding bonanza with their templates. The coding is not based on what you do, it is based on what you write. Therefore, the smart ones learn to produce templates that over code visits by entering extraneous and unnecessary data into the AHLTA system. If you do what is considered a normal work up on a patient, you will fall way behind the coding curve. Since everyone is now forced to play the competitive coding game for advancement, even more time is spent on the computer entering redundant and irrelevant information.
Another interesting thing about the AHLTA system which has not been improved is that information, once entered is almost impossible to remove. Errors and diagnoses follow the patient around like a bad tattoo.
I wonder about the wisdom of a central repository of private medical information. I can see not only hackers but the Orwellian use of that repository for behavior modification and other abuses. It will not be hard for advocates to argue that anyone with a risky hobby (e.g., surfing or skiing) or diet should pay more for insurance or might not be looked on as favorably for employment. The proponents will argue that the privacy of the system will be guaranteed but if it is available to any physician (as it has to be to provide medical safety), it will be available to nearly anyone eventually. I believe a better alternative is for the government to establish standards for the format of electronic medical records and have them stored locally at physician offices or hospital records facilities. If records are required in another location, a secure and verified request can be made for those records and they can be instantly electronically transmitted to the requesting location. That system would also allow tracking of who requested records and for what reason. That should reduce the incentive for anyone to pry unnecessarily and would increase privacy.
Proponents of the electronic medical record argue that they will reduce medical errors by having allergies and medications available. That is intuitively true. I wonder how many errors will be produced by the lack of time to talk to and examine patients caused by the increased requirement for computer time to input data. If you want to reduce errors and provide better care, get some support personnel for the physicians so they can spend time taking care of patients and have some “scribes” enter the data into computers.
The next iteration of the system was originally CHCS II, but has subsequently been renamed AHLTA (Armed Forces Health Longitudinal Technology Application). The AHLTA system has many of the same advantages in that no matter where you go (in theory) your drug allergies, medications, past medical history, etc. are available to a new physician to whom you present for care. That is not entirely true as I have been deployed eight times in the past five years and have never had access to the AHLTA system on any deployment. While the AHLTA folks consistently crow about the advantages of the system, they never discuss what it is like to use it. Let’s look at some of the results:
The Navy has decided that in order to improve efficiency, they want the physicians to see seventy five per cent of the productivity of major Health Maintenance Organizations (HMOs). Part of the reason is to lower costs, and part of the reason is that they are having trouble keeping enough people in the Navy to serve the patient population. In the brick and mortar hospitals, the current requirement for a General Surgeon is to see forty five clinic patients a week (based on HMO productivity). If that is only seventy five percent of what an HMO doctor sees, why should that be a problem? First, the average physician in civilian practice averages four support personnel per physician. The civilian practices know that the only person in a surgery office that makes a dime for the practice is the surgeon. Therefore, people are hired to keep the surgeon from doing anything which is not billable. Record keeping, billing, coding, telephones, communication, cleaning, education, etc. are all handled by trained assistants, freeing up the surgeon to do surgery and outpatient care for which billing can be generated. In the Navy, there are four physicians for each support person. Those people are Civil Service and we all know how much incentive the Civil Service has to work hard: none. Therefore, Navy physicians type their own notes, write their own consults, fill out their own preoperative and post operative packages, make phones call, schedule procedures, etc. I forgot to mention above that those forty five patients have to be seen in only two clinic days a week. Broken down evenly, this means twenty two patients on one clinic day and twenty three on the other.
Meanwhile back at the AHLTA system: Even after the training required to use the system, it is so cumbersome that trying to find your way through it is very time consuming and frustrating. I know how bad it is for surgeons. I can’t imagine how bad it is for primary care physicians who see such a wide variety of diagnoses. There are templates which can be customized for a specialty, which can save time but any unusual case will take a lot time to do the note. Additionally, the system can not keep up with the amount of usage so it is slow and crashes regularly. I have found the average AHLTA note to take between ten and twenty minutes to do even with a template. Therefore, twenty two times fifteen minutes equals three hundred thirty minutes. That is five and one half hours a day entering notes into AHLTA. If a surgical appointment is 20 minutes long, that means four hundred and forty minutes, or seven hours and twenty minutes a day talking to and examining patients. So far, we are up to twelve hours and fifty minutes each clinic day. Why do patients go to see a surgeon? Because they might need an operation. Assuming that only half of the patients need surgery, that means eleven preoperative packages (preoperative orders, admission paperwork, consent forms, notice to parent command, history and physical examination, etc.) need to be completed in addition to the AHLTA note for those eleven patients. Just for argument, let’s say that they only take fifteen minutes each (not realistic). That is another three hours and forty five minutes a clinic day. Now we are up to fifteen hours and thirty five minutes each clinic day. That is assuming that the physician never goes to the rest room, eats, or takes a break from paperwork. Additionally, the physician needs to round and care for inpatients which requires going to the ward or intensive care unit. Does anyone wonder why people leave for increased salaries and lots of administrative support?
Another phenomenon of the electronic record in the military is that performance evaluations have become partly based on the amount of relative value units (RVUs) billed as interpreted by the coding of each visit by the system. Subsequently, the smart physicians have learned to “game” the system and turn every visit into a coding bonanza with their templates. The coding is not based on what you do, it is based on what you write. Therefore, the smart ones learn to produce templates that over code visits by entering extraneous and unnecessary data into the AHLTA system. If you do what is considered a normal work up on a patient, you will fall way behind the coding curve. Since everyone is now forced to play the competitive coding game for advancement, even more time is spent on the computer entering redundant and irrelevant information.
Another interesting thing about the AHLTA system which has not been improved is that information, once entered is almost impossible to remove. Errors and diagnoses follow the patient around like a bad tattoo.
I wonder about the wisdom of a central repository of private medical information. I can see not only hackers but the Orwellian use of that repository for behavior modification and other abuses. It will not be hard for advocates to argue that anyone with a risky hobby (e.g., surfing or skiing) or diet should pay more for insurance or might not be looked on as favorably for employment. The proponents will argue that the privacy of the system will be guaranteed but if it is available to any physician (as it has to be to provide medical safety), it will be available to nearly anyone eventually. I believe a better alternative is for the government to establish standards for the format of electronic medical records and have them stored locally at physician offices or hospital records facilities. If records are required in another location, a secure and verified request can be made for those records and they can be instantly electronically transmitted to the requesting location. That system would also allow tracking of who requested records and for what reason. That should reduce the incentive for anyone to pry unnecessarily and would increase privacy.
Proponents of the electronic medical record argue that they will reduce medical errors by having allergies and medications available. That is intuitively true. I wonder how many errors will be produced by the lack of time to talk to and examine patients caused by the increased requirement for computer time to input data. If you want to reduce errors and provide better care, get some support personnel for the physicians so they can spend time taking care of patients and have some “scribes” enter the data into computers.
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