Friday, March 25, 2016

The Three Horsemen

In a set of recent JAMA Viewpoints three of the key players in the delivery of the ACA are giving their updates on the progress of the bill.

First is the assessment from the one who seeks to just pass on when he turns 75 I believe[1]. His assessment is mixed but full of praise. What is most telling is his last set of comments. He states:

Even though the ACA is not a perfect bill, it has improved the US health care system. If venture investing is a trustworthy indicator and if additional reforms enabled by the ACA, such as more payment change and drug cost controls, are implemented, Americans can be optimistic about the future of the US health care system.

This single paragraph is in my opinion the most telling. First he admits the ACA is not perfect. Far from it. As we have already noted it has added some 15 million new participants costing the taxpayers about $15,000 per year per participant. This is more than Medicare participants who being older should have been costlier albeit having paid some 50 years’ worth into the system. The conclusion of efficacy is not justified. Second the grab to venture investing as a proof of success is truly mind blowing! There is no basis for this assertion. Why not indicate the rise of ISIS as well? Coincidence is not correlation is not a proof!

The second horseman is the fellow who brought us Meaningful Use and the EHR[2]. As we have seen since its inception the CMS mandated HER has in my opinion led to higher costs, less patient interaction, and less inter physician communications. The design in my opinion is fatally flawed by setting up islands of non-interconnected data elements with the patient nowhere to be found. As he states as a key step in his proposal[3]:

Third, Shift the Business Strategy From Revenue to Quality: Maximizing revenue continues too much to dominate the business models of health care organizations. That reflects short-term thinking. A better, more sustainable route to financial success is improving quality. This requires mastering the theory and methods of improvement as a core competence for health care leaders. It also requires that the CMS and other payers continue to unlink incomes from input metrics, such as “relative value units” for specialists’ incomes, which are not associated with quality and drive volume constantly upward.

Now as we have noted frequently the term Quality is in the “eye of the beholder”. Quality means what and to whom? The CMS has also promulgated mandatory “quality” measures. If one looks at them there is nothing more than a useless list of check marks adding costs and detracting from the delivery of services!

Now the third horseman. He was the strategists again on health care information. As he stated just after the ACA[4]:

The widespread use of electronic health records (EHRs) in the United States is inevitable. EHRs will improve caregivers' decisions and patients' outcomes. Once patients experience the benefits of this technology, they will demand nothing less from their providers. Hundreds of thousands of physicians have already seen these benefits in their clinical practice.

And how did that work out for us. More cost and less care. We have physicians becoming typists or if they can’t type hiring a third party to sit in the examining room typing away and interfering with patient-physician contact. The result, better patient care and lower costs, it does not seem so.

In his most recent paper he states[5]:

Given some Americans’ skepticism of foreign experience, home-grown examples may be more compelling. The Commonwealth Fund State Scorecard suggests that

(1) if US health spending per person averaged the same nationally as among the 5 lowest-cost states (Utah, Arizona, Georgia, Idaho, and Nevada), an estimated $535 billion (approximately 20%) less would have been spent on personal health services in 2014;

(2) if rates of health insurance coverage averaged the same nationally as among the 5 areas with the highest rates (Massachusetts; Vermont; Hawaii; Washington, DC; and Iowa), an estimated 20 million more Americans would have been insured in 2014; and

(3) if the national levels of mortality amenable to health care averaged the same as among the 5 states with the lowest rates (Minnesota, Vermont, New Hampshire, Utah, and Colorado), an estimated 77 000 fewer deaths would have occurred in 2014.

Let’s look at the above and examine it for facts. First the states of Utah, Nevada, and Arizona have high Mormon populations. Mormons live health life styles. So perhaps it would cost less. Georgia just has less access.

Second, Massachusetts has world class hospitals that do leading edge care. Idaho does not. Vermont is a socialist state in many ways and people pay for that. Hawaii always has high costs, buy a gallon of milk!

Third, look at the demographics of the states with lowest mortality. I reside part time in New Hampshire. It soon will see a rise as obesity takes its toll but for the most part it is rural and of modest income.

Frankly in my opinion this type of sweeping ad hoc propiter hoc argument is baseless. One must ask why. But that does not seem to be in the vocabulary.

It is worth reading the comments of these three who played so much of a role in what has happened. This is the left wing of medicine, yet they managed in my opinion to set the agenda for the next generation, and the cost may be overwhelming.

Then of course one asks who is the Pale Horse?