Economies of Scale in Health Care Reform

I've been listening avidly to all the different points of view about health care reform, and the only conclusion I've come to is that almost anything is better than what we have.

On Bloomberg the other day, I heard a call for a systemic approach to the practice of medicine from Dr. Eliot Fisher, Director of the Center for Health Policy at Dartmouth. He said there are always better outcomes where groups of doctors collaborate and practice together, as in the Mayo Clinic, the Cleveland Clinic, or even less renowned group practices such as in Grand Junction, Colo. The efficiencies come when a group of physicians are all responsible for a patient's continuity of care, and when they share information such as that possible with electronic health records (EHRs).

Dartmouth has studies that show these kinds of group practices cut costs, and yet we have relatively few of them in the US. Most physicians still practice in groups of four or less, usually four of the same specialty. And fewer than 20% of these small practices have EHRs. In fact, in Arizona, where EHR adoption took off after Gov. Janet Napolitano mandated it, another article just said doctors who had EHRs were abandoning them because they were costly to support and impossible to learn. Your basic family practice guy or pediatrician, practicing what the docs call "Hamster Medicine," where he/she has to see 60 patients a day for five minutes each just to support his office, does not have the time or money to shut the office down to train people on an EHR.

So I dread what will happen when these small practices are forced to implement a complex EHR like GE Centricity, which is both the market leader and the product with the worst user interface. GE has already started a lobbying campaign on behalf of its product, part of which consists of interest-free loans to physicians to install it.

The learning curve for Centricity is steep, especially for the bi-lingual staff of many medical offices, where wages are low and turnover is rampant. I have a physician friend who wrote an EHR himself, and then left that product with his old practice (where they love it) to move to another state. There, he found a group that had chosen Centricity not just for the single group, but for the entire region -- and nobody could use it! They had abandoned entire parts of it because no one knew how it worked.

That's shameful. That won't lower costs. Lower costs will only come from software that works like Amazon.com or Yahoo -- interfaces that make it simple for users to pile in mountains of data without even realizing they're doing it. And to keep the costs down and the learning curve short, the data should be kept in the cloud.

This is, of course, horrifying to the privacy advocates, who have never run a medical office. Well I have, and I can tell you that when the doctor's fax machine is overflowing with test results, they spill out on to the office floor or sit there in a pile, and anyone walking by can see them, until some harried front office person collects them and (perhaps) misfiles them in the wrong patient folder.

How do I know this? Because not only have I run a medical office, but I helped a group practice install an EHR, and one of their "pain" points and biggest reasons for going electronic was the loss of patient records due to misfiling or non-filing.

What other business runs as inefficiently as a medical office? None. What other business is more dependent on paper? None.

What other business could become 1/16 of the American economy without being forced into business process automation? None.

But forcing EHRs down the throats of sole practitioners isn't the answer to reigning in costs. Collaboration is. Collaboration is also the answer to many medical errors and misdiagnoses. I'm not saying that we should "crowdsource" the practice of medicine-although that's happening through various online Health 2.0 sites that consumers rely on when they have insufficient access to care -- but I am saying it might be time to streamline these small practices, put them in groups, and allow them to talk to each other over lunch about the same patient. That way I wouldn't have to tell my internist what my cardiologist said, or wait for the cardiologist to fax over my results to him.

Any kind of information exchange would help. And

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Comments

[velden]

Everything points to the need for at least some government run option for everyone. Insurance companies and the AMA are fighting it with lots of lobbyists and money. But we forget that we still have some power. How about people (patients) start boycotting doctors who are AMA members? The AMA has fought against desegregation, Medicare and now any type of viable government option for heath care. Who really wants a doctor who supports an organization like that? It's easy to find out which doctors are members. Just go to the AMA website.

[timm0]

To large software shops (including the likes of microsoft), the most important thing to have is to have a product with features that are marketable.

Marketing is king - everything else, like usable features, is tangential. Well, the only exception is licensing strategies and gimmicks that lock customers into expensive "support" and "maintenance" contract due to neat-o proprietary data formats so that the prospect of migrating to a competing product will be nightmarishly expensive.

As microsoft has taught the industry, having the largest market share wins customers in the pool of the great unwashed. Even if a doc looked at a tool and said, "wow, this bites," they will doubt themselves and conclude, "but if everyone else is buying it, then I must be missing something because I'm not an expert with this stuff."

The best mandate on this front will be to demand a specific database format for exporting patient records so that anyone making a bad decision on an EHR can be assured of a no-cost migration to a competing product. I've seen what government-designed software projects can yield, so I'm not ready to say that we should have a govt-created EHR that could be implemented for free everywhere... but that IS the better path.

[francinehardaway]

That means we will be migrating people off all the market leaders. But you know that never happens, because people become comfortable even with something bad and incomplete that doesn't solve the problem.

[SMAckley]

Well, the certification of these products is supposed to mandate that they employ standards. HL7 has internationally developed standards for most of the necessary messages. There are several groups working on open source systems which use HL7 v.3 (pure xml) standard messaging. If EHR/EMR products were mandated to use the standards they could all be semantically interoperable so information could flow freely regardless of whatever proprietary code was in place to make the GUI pretty :)

[SMAckley]

So how do you stop the insurance company lobbyists? Anyone who has worked in the health care delivery system or the payer system knows exactly what is broken. Many of us have a pretty good idea about how to fix it. But as long as health care in the U.S. is a game where the goal of the payer is to minimize their medical loss ratio (to pay as little as possible as slowly as possible) and the goal of the provider (facility or practice) is to maximize revenue we are stuck with a system in which quality patient care is usually an afterthought or an accident. There are a few exceptions to this, but very few.

The government is already the largest single payer when you add Medicaid, Medicare, VA, Indian Health Servies, DOD (Champus) and the Federal Employees Health Benefits Program. This accounts for about half of all payments for services delivered. If you add the employees of all 50 states and the various subsidies like disproportionate share payments for hospitals you are well over half.

So why does the mainstream media lobbyist machinery keep talking about single payer as if it's going to end civilization? We are pretty close now, only it's disjointed and inefficient!

[Merlin7]

As long as insurance companies are the main players in the new health care system, none of this will make any difference. Five years from now the system will be worse than ever, except that huge amounts of tax dollars will be flowing down into the black hole of insurance company coffers. Look at Massachusetts. Many Americans are asking the same question Iranians are asking: Where's my vote?

[francinehardaway]

I wish I didn't feel you were right, but I do. The more I study, the more it feels like the insurance companies to me. And "insurance" is a misnomer. They don't insure anything!

[eciaccio]

Au contraire. Insurance companies insure (and ensure) their profits.

But more and more Americans are finally realizing that "health" insurance is a very different thing from health care.

When we get to the point where we are sitting in at our Congresscritters' offices until they finally give us single-payer health care, then we will get change we can really believe in.

But as long as we allow corporate and lobbyist money to bribe the Corporate Tools in Congress, we will be stuck with a system which results in the deaths of 22,000 Americans per year due to unaffordable health insurance or care.