I wrote recently about what I believe to be the two biggest structural defects in the U.S. healthcare system and why Obamacare has no hope whatsoever of being successful in solving them. Obamacare, I opined, is like putting extra syrup on a bad tasting pancake. It may taste a little better for a while, but ultimately a bad pancake is a bad pancake. But, in that post, I offered little in the way of answers. Today, I’d like to start rambling a bit about some answers.
Let’s start with technology. I always hesitate to write about technology in healthcare because it’s kinda what I do for a living. So, when one of my sharp readers corrects my erroneous thinking, it looks a lot worse for me than when I get the bathroom humor wrong. But, here goes nothing.
Stop for a moment and consider all the myriad ways technology has changed your life in the last 10 years alone. Through the wonders of my iPad (a technology I derided, then embraced like it was my third child) I have been catching up on episodes of HBO series I never watched (HBO Go is one of my favorite iPad apps). Most recently, I’ve been watching The Wire, a police/legal drama set in Baltimore. In season 2 (2003, less than 10 years ago), the good guys were eavesdropping on the bad guys’ cell phones. The bad guys figured it out and (literally) tossed their ancient flip phones into the Baltimore Harbor. Then, standing at the Harbor’s edge, the bad guy took out a huge clunky device with an antenna, yanked out a stylus and started tapping on the screen. Bad guy #2 said, “What are you doing?” Bad guy #1 replied, “I’m sending a text message.” Bad guy #1 was nonplussed. And, that wasn’t so long ago. Today, the average teenager sends 1500 text messages per day.
We’ve also made tremendous progress in many aspects of medical technology, particularly in drugs, medical devices, and diagnostics. And, by and large, we’ve made that progress in the face of a hostile and tectonically slow regulatory environment. We have whole new classes of targeted cancer drugs that have made it possible to live many years with what were once quickly fatal forms of the disease. We have new tools and methods for minimally invasive surgeries that have turned what were once life-threatening procedures accompanied by 10 days in the hospital into outpatient procedures with little risk. We have life-saving diagnostic procedures like the colonoscopy, which has made colorectal cancer far more treatable when it is caught early. (Quick diversion: to all my friends over or near 50 (or 40 with any family history), if you haven’t had a colonoscopy, I beg you to go get one. Yes, the prep the night before will make you want to kill yourself, but the propofol is fun (ask Michael Jackson) and it will save your life if you have precancerous lesions.)
All this technology innovation has dramatically improved healthcare, but it has done little to control costs and has, arguably, increased costs in some areas. I say “arguably” because I have not seen a comprehensive study of this issue and I think it would be hard to conduct. There’s no doubt that certain technologies (e.g., expensive imaging technologies that get overused) increase costs, but it is also true that many technologies dramatically decrease costs. The most expensive part of our healthcare system is paying for long hospital stays. Drugs (which account for only about 12.5% of overall costs – a good number to keep in mind when Obama is villifying the big pharma companies) that keep patients out of hospitals are very cost-effective. But, I’m willing to stipulate that technology has probably been, at best, cost neutral to healthcare.
The kind of technology innovation I’m thinking about is more on the delivery side of healthcare. We have done a very poor job of integrating all the phenomenal advances in information technology with healthcare. I actually find it pathetic that 90% of the discussion around “healthcare IT” involves electronic medical records. I mean, c’mon! No matter what airport I’m in, anywhere in the world, I can give American Airlines a 3 letter, 4 digit code (my frequent flyer number) and they can immediately pull up my entire flying history with American. But, if I go to visit my own doctor, who has been my doctor for 15 years, he pulls out a big paper file and flips through pages of handwritten reports. And, worse, when I went to a specialist recently, literally in the same medical office building as my primary care doc, he had none of that information. So, I understand we need to get the electronic medical records piece done, but it seems like little more than the price of admission.
We need to move very quickly to leveraging technology for far more innovative delivery of healthcare. In my blog post that laid out the issues with healthcare, I wrote of the adverse incentives in the payment system that encourage patients to visit doctors simply because someone else is paying for it. I also questioned a system whereby “routine maintenance,” akin to an oil change for your car, is paid for by a third party “insurer.” That’s expensive, inefficient, and totally devoid of the market forces that discipline most other markets. I gave the example of taking a kid to the doctor for an ear infection and having insurance pay for it. Let’s stick with the ear infection example for a moment. One of my kids had chronic ear infections as a toddler. Every time he got a cold, within a few days, he was tugging on one or both of his ears. We knew we had to take him into the doc, who looked into his ears with one of those little scopes that have been around since I was a kid, and said, “yup, he has another ear infection.” She would prescribe an antibiotic, which my son would take for the prescribed number of days and the infection resolved.
Question: was it really necessary to go to the doctor every time this happened? That’s a very expensive way to deliver a very simple service. Not only did we take up a 15 min appointment slot, but we used some portion of overhead for the office space, the receptionist, the nurse, etc. And, that doesn’t take into account the lost economic productivity of my wife and me (we were first time parents so we often both went with him) having to take time off work to take him to the pediatrician. On one of these visits, I asked the doc if she could just show me what to look for when she peeks in his ears so maybe we could buy a scope, do that at home to confirm the infection, and have her call in a script. She looked at me like I had just asked her to saw off one of my legs.
But, this idea stuck with me and we’ve had 17 years of technology advancement since my son was little. So envision this: A two year old with a cold starts tugging on his ears. The parent takes a fully idiot-proof ear scope and puts the tip into the ear canal. The scope is connected to a high resolution video system (which most of us now have on our phones) that records what’s going on in the child’s ear. The parent takes the child’s temperature, blood pressure, and whatever other routine stuff the nurse usually jots down, and enters it, along with a brief description of other symptoms (just as the parent would in the pediatrician’s office). The video and other information is transmitted electronically in real time to the doctor. During a predetermined window of time, which, by the way, could be in the evening or on a weekend, the doctor will review the information, including the HD video of the ear and reply to the parent with a diagnosis and action (e.g., script for antibiotic). The doctor will have the ability to interact on-line or by phone with the parent for follow up questions. But, the doctor may well be conducting this “office visit” sitting in his home office…..in Bangalore. Very low overhead. Yes, I’m serious.
I probably have doctors all over the country (the thousands that read my blog) gasping for breath right now. I’m sure there’s a “look and feel” to a patient that can’t be fully transmitted using technology and might be lost. But, I’m willing to bet that a whole lot of office visits could be avoided with technology. I actually have a small window into this because I have a good friend who’s a doctor and I have sent him text messages with questions in the past, to which he has responded. Had I not had access to his texts, I would have had to set up a visit. And, without giving you TMI, I was texting about a potentially serious condition. His answer said, in essence, “this is not serious, don’t worry about it.” I get to do this because I’m lucky enough to have a friend who’s a doctor. Why shouldn’t everyone have such access to their physician? I understand that we would have to figure out ways to compensate docs for this type of service, but that’s where the innovation comes in and where government could actually help rather than mess things up with more syrup on crappy pancakes.
I want to use one more example that takes it up a notch. One of the leading causes of death and, thus, one of the highest costs to our healthcare system is heart disease. One form of heart disease is congestive heart failure. Patients with chronic congestive heart failure frequently have acute exacerbations of their ailment and end up in the hospital, often in the ICU for several days. That is a big cost to the healthcare system. Several technologies have been developed that are small implantable devices (think pacemaker) that detect these acute flare-ups before the patient feels the symptoms. This information can then be transmitted electronically to the physician, who can quickly alter the patient’s medication to avert the acute episode and, hence, the hospitalization.
This technology exists today – I’m not talking about some theoretical idea. So, why doesn’t every patient with CHF have one of these implanted? The principle issue is reimbursement. Our healthcare reimbursement system is designed to pay doctors and hospitals for treating sick people. It’s not well-designed for keeping people healthy and out of the hospital. In the arcane language of healthcare reimbursement, there is no “CPT code” to get paid for implanting such a device nor, more important, for the ongoing monitoring of the patient waiting for the next acute episode to be avoided. That’s really bass-akwards.
The good news is that this actually highlights an area where the government can get involved to improve our system. Many CHF patients are older and thus covered under Medicare, the government run payment system for older patients. To get a new technology like this covered by Medicare today would take longer than the expected life span of every CHF patient alive today. Meanwhile, the meter keeps running on the costs of unnecessary hospitalizations of CHF patients. If our government wants to help, how about developing an expedited review system to ensure quick reimbursement of new technologies that can take costs out of the system. And, to my friends in government (if I have any), “expedited” means “get it done in 3-6 months,” not “form an interagency task force that will convene quarterly over the next fiscal year and make a recommendation to the CMS for consideration.”
We need to shift US healthcare away from the model of paying to treat sick patients toward keeping patients healthy and out of the most expensive parts of the healthcare system. Technology can play a big role there, but technology will never see the light of day until the payment schema are matched to the way the technology is used. Sadly, Obamacare is all about sticking it to the providers of novel technology (see: Medical Device tax). That’s all about politics – villifying corporate America is one of the chief Obamian campaign themes. Unfortunately, he missed a big opportunity to work with these companies to figure out ways to develop and pay for technologies that will save costs and help patients.