Historian Paul Johnson once wrote that the leaders of the British Colonial Empire “used the state…to enlarge the area in which their inefficiency would matter less.” Such was the product of Obamacare and its ultimate goal — colonialization (aka expansion) of a flawed system. The law failed to control cost, and, while attempting to increase access to insurance, failed to attract a broad cross-section of enrollees. The result: health costs and premiums soared.
No reform, regardless of its political origin, will succeed without a capability to reduce the inexorable rise in health costs.
There are many well-studied reasons for medical cost inflation. On the good side, biomedical innovation has accomplished much.
We revel in cures for cancer, for hepatitis C, and for medicines that render AIDS asymptomatic. The community of dedicated researchers, caregivers, and patients has achieved these remarkable milestones, fueled by both public and private sector investment.
Yes, costs of these treatments were initially large, but in many cases, the costs have been mitigated by competition and patent expiration. The resulting restoration of patients’ health both saves lives and reduces costs over the longer term.
Still, costs continue to escalate. That is largely because the infrastructure of our health sector is seriously flawed. Despite efforts by policymakers and health industry leaders, our health sector is increasingly fragmented, and with fragmentation, comes loss of accountability.
As an example of why fragmentation derives from poor infrastructure, let’s focus on the failure of the electronic health record (eHR) to strengthen the infrastructure of our health sector. Despite public belief, eHRs are not yet interoperable. Interoperability refers to the ability of the information in a patient’s eHR to be transmitted within and between different medical institutions. The difficulty is not because of patient privacy. It is because interoperability is not yet required, and its standards have yet to be agreed upon.
What is the impact of this lack of interoperability? I serve a mostly Medicaid population at an academic medical center in New York City. My patients, many of whom suffer from a several co-morbidities, often seek care from a variety of health care providers. They may be admitted to several institutions, not only over the course of their illnesses, but often in rapid succession.
Some patients find themselves in circumstances where they cannot choose their care environment. For example, ambulances must take a patient in distress to the nearest location, regardless of where their primary care is delivered.
Tests, including costly imaging, ultrasound, and blood work, are often repeated at these different institutions within even hours of each other. Many patients might or might not remember to tell me when I order a heart ultrasound that they received the same test (currently billed at my medical center for $1,200) last week at another institution. Even if that history is obtained, I cannot access the results in real time. The duplicate tests would not be necessary were that patient’s eHR interoperable and accessible electronically. Today, even with patient permission, it cannot.
Further, physicians lack the ability to reconcile the array of medications a patient may be taking, prescribed by multiple providers. Patients often come to my office with a bag of medicines from different doctors (some of whom I did not know they were seeing). I sometimes find they are taking several variations of a medication that works by the same mechanism. This is dangerous because it can mean, with the duplicate prescriptions, that they are taking much higher doses of a drug than any doctor prescribed.
Occasionally, a crucial medication that a patient needs is skipped when it is “crowded-out” by less important meds because patients become confused by too many pills.
All providers should be able to share a patients’ medication list electronically. Yes, a doctor can call the pharmacy, but some patients use more than one pharmacy to fill their prescriptions.
Indeed the costs of eHR implementation are great. All too often, those large hospital systems that have the capital to invest have tailored their eHR systems to enable billing rather than to facilitate patient care. For the most part, eHR systems are unnecessarily complicated, request irrelevant information, and take too much time to complete. Alternatively, small practitioners seldom have the capital to invest in systems that can communicate outside their own practices.
Quality control is rarely if ever provided. Therefore, misinformation, including incorrect diagnoses, can inadvertently be imbedded into a patient’s record.
Thus far, most health care providers, including the federal government, have failed to create an interoperable eHR that is truly portable. This should be the first step. The 21st Century Cures Act recently passed by Congress includes a provision that requires certified health IT products to include software that allows interoperability, but adoption is lagging.
For a healthcare delivery system to better compete and offer better, more cost-effective patient care, it needs to offer an interoperable record: interoperable within its own system, within its geographic locus, within its state, etc. Fragmentation must be avoided and accountability assigned.
Patients can be part of this conversation. They should nominate a quarterback and ask that doctor to review their record for accuracy and ask to which other places it can be transmitted electronically.
For policy makers, attempts to improve access to quality care must be predicated on strengthening infrastructure, with resources appropriated accordingly. Upfront costs would be mitigated by the derived savings. In turn, these efforts would improve quality, and enable personalization of care.
The experience of the ACA in mediating expansion (aka colonialization) with its unmitigated rise in costs and premiums should serve as a cautionary tale. The goal of health reform, regardless of one’s political views, should be to improve the health and well-being of each individual to the benefit of the population at large. Our current system has failed not only to contain costs, but also to provide proper incentives to achieve this important goal.
Indeed, American health care has accomplished much of which to be proud, and yes, it needs vast improvement. But colonialization is not the answer. Improvement can only come when facts emerge from the din of debate, and when resources can be properly aligned to create the safe and caring culture we deserve.
Dr. Slater is a practicing physician in New York City and served as U. S. Assistant Secretary for Health from 2001-2003.