Building Nirvana Without Draining the Swamp

I have recently helped author and have reviewed a draft "blueprint" document from the eHealth Initiative. Concerns were raised that there was no consensus on two issues:

1. Alignment of incentives to compensate for adopting health care information technology
2. Policies for consumer engagement and information sharing.

To summarize for those who don't want to read my lengthy rambles, I can summarize:

• You cannot fix the HIT incentive problem given the complex and bewildering social network we call health care policy. To paraphrase Representative Jim Cooper's comments on partisanship in addressing the federal budget, trying to find the final answer to HIT incentives is "as foolish as a food fight on the Titanic." It will take time and adaptation to a skewed system. You cannot find the definitive HIT solution without arriving at a clearer consensus on the broader health care policy debate.
• You cannot find definitive issues on information sharing when the public is not informed on the current and fragile state of their privacy and when individuals are not held more accountable for their own health care expenses or lack a clear understanding of their social contract when third parties are asked to foot the bills. I am sure that if my daughters had the chance, they would take their credit card bills (which I usually pay) and argue that I should not be given access to their statements!

At greater length, there are two points:

Point 1: Incentives

It should come as no surprise that a consensus cannot be reached. Health information technology enables better health care delivery. The delivery of health care in turn is dictated by policy and compensation. When there is some consensus on policy and compensation, this should be reflected in how organizations pay for technology. I find it ludicrous that any business – be it a medical practice, a pharmacy, or a hardware store, should receive compensation from third parties for fundamental operational expenses. The trap is that we have enmeshed health care practices and providers (a.k.a. businesses) in extraordinary complexity and this drives up costs. My father - a manufacturer competing with China every day - would very much like similar compensation.

But there is something different between my father's circumstances and the plight of the health care delivery system. My father does not have to contend with a confusing array of Medicaid, Medicare, and health plans. My father doesn’t ship product and write it off as "uncompensated services." My father makes hydraulic pumps. These are not in the middle of any complex ethical and social debate concerning an obligation of a nation and individuals to care for the suffering. (His challenges - OSHA, trade policies, employee health care costs - are no less acute, but not directly relevant to this discussion.

ROI may not be the right question to ask - or certainly not the only question. For example:

• What is the ROI of a pediatrician?
• What is the ROI of an ophthalmologist?
• What is the ROI of a community pharmacy?
• What is the ROI for a critical access hospital?
• What is the ROI of a health plan?
  
• How should compensation be affected by geography, patient mix, need? We have a rather complicated fabric.
• Under the current model, is anything in our health care system “sustainable”? Anything at all??

My point isn’t that ROI is a futile area of inquiry, but only that these considerations are part of a broader set of values that place health care in a context more appropriate to its social mission.

This leads to a second issue with compensation. There are three types of actors here:

1. Those that actually pay. More often than not, this is government - more than we believe - because the tax deductions to employers represents a form of government subsidy. Read Jacob Hacker (http://greatriskshift.com/ ). The other payer - ask any uninsured individual or GM retiree - is the individual. That sort of makes sense (if one knew what the full cost and quality were). In my view (and a sentiment echoed by Craig Barrett of Intel) human resource managers and large employers have abrogated their responsibilities and have focused on short term cost controls (through plans, PBMs) at the expense of addressing a fundamentally broken and fragmented system.
2. Those who actually deliver services. This includes pharmacists, home health care, nursing home workers, physicians, disease management companies, and even families. These people incur expenses - be it in time, labor, or materials.
3. Those who are intermediaries trying to address supply and demand. These include health plans, pharmacy benefits managers, state agencies, Medicaid information technology vendors, and other groups. Some of these plans are sincerely trying to add value and improve value, but they are at arms length in many instances. There are others, I believe, who simply say "we got here first" and intend to keep as much of our health care dollars enmeshed in our current complexity since it often appears that the only way to make real money is to sit in the middle, encourage complexity, manage it, and hold onto as much money as one can. I do not call these organizations payers but rather intermediaries. To call an intermediary a payer and then complain that they have too much power is akin to claiming a bank “owns” my money. Intermediaries have money because the funds are not returned to those whose dollars pay for care and those whose efforts require compensation.

How can one possibly tease out health information technology and expect to understand how to pay for it without either assigning the burden to those whose primary business it is to deliver care or to raise the very important point that those who deliver care are placed in competition with one another? (Michael Porter is right: in health care we often compete over the wrong things)

By focusing on HIT as something peripheral to the broader health care debate, we only add to the crippling complexity and distract the public from the far more pressing issue of a bankrupt health care delivery system. If the value chain is skewed to allow intermediaries to hold onto excessive amounts of money, let's fix the value chain. If the system hides costs from the real payers - individuals seeking care and individuals paying taxes, let's fix that. Answer the right questions; fix the right problems; compete over the right things.

One can't come to a conclusive result on health care delivery until one develops a consensus. Until then, it is wise to work within the fragmented system and chip away where we can. It is rather foolish to even claim to fix the ROI problem for HIT without putting it in context of a larger and more confused health care system.

Point 2: Policies for Information Sharing (a.k.a. “You can't build Nirvana on a swamp”)

Recent interest in "medical information banks" and related ideas is in my mind one way people are coming to grips with the fact that their health information - and who has it - is associated with economic consequences to the subject of the information (the patient) and a vast array of other individuals who gain economic value either by disclosing individual information or aggregating information from disparate sources to gain a broader view of an individual, a provider, or a population.

There are a few realities we "consumers" have to face:

• We don't pay all of our own bills - others do. These other parties therefore have some rights to see what they are paying for (much as I want to see the credit card bills I pay for my daughters).
• There is an inevitable tension between the needs of providers and the desires and regrets of the individual receiving care. There are similar tensions among all of the groups of providers, consumers, and intermediaries. The only way out of this is to examine - carefully and over the course of years - the realities of our concerns. For example, how often does "not knowing everything" harm care? There is nothing like building an actual operational health information chain to focus on the important, short-term issues.
• Because we run up a lot of expenses - either because we have no price sensitivity or because we are in dire need of services to care for our chronic and acute care - intermediaries who profit from retaining funds naturally understand that excluding the high-cost individuals helps the bottom line in most instances. This doesn’t mean organizations take active measures to exclude such individuals, but it is reasonable to be suspicious of impersonal organizations who profit at the expense of excluding individuals or groups
• We "consumers" in general don't have a clear understanding on how confusing and porous our current system is, and our so-called "consumer advocates" rarely speak up on that topic, focusing instead on the much more high-profile issue of HIT and exchange. Do "consumers" understand their health care information is kept in data warehouses, sold to pharmacy detailers, and their paper records disclosed to callers and individuals without clear authentication, authorization, or transparent policy? I have often wondered where our leading consumer advocates are when we look at the status quo. Instead of tackling the difficult challenges associated with paper-based records, access, use, and audit trails, advocates tend to migrate to the much "cooler" digital environment and try to create an ideal system in what is at present a confusing and very messy world of paper.

Trying to revolutionize totally health information technology and consumer information rights absent of a consensus for broader health care policy issues is like trying to build Nirvana in a swamp. In my view, it is better to have some consensus on how to drain the swamp before talking about what Nirvana "should" or "must" be like. This is the conundrum of AHIC and teh NHIN II proposals. It's hard to move forward in the absenc of broader consensus on how 16% of our Nation's GDP should be managed. Personally, I am not sure all engaged in federal efforts or laboring on the campaign trail understand this critical point, since in the abstract Nirvana is more attractive to voters than dry land and rhetoric far more fungible than actual results.

The eHealth Initiative Blueprint draft does a god job of identifying the areas of concern. The more I think of it, the more I think we are building a very good blueprint – a part of a broad fabric of such efforts across a spectrum of organizations. But one cannot be expected to have an answer to these questions any more than the the originators of hypertext (e.g., Doug Engelbart), the creators of the internet, Alexander Graham Bell, or the first individual to send an email could have anticipated what emerges.

What is important is framing the questions right. And in this regard, the course of technology advancement at least sometimes follows ones vision for the future. (In other instances, it refines or even re-directs this future.)

Since we do not have a clear vision of the costs, the quality, or the mechanisms for addressing our critical health care delivery challenge and since we don’t have a clear consensus on the conflicts between the rights and responsibilities of the individual and those of society, we should not be concerned; we should not make excuses. No number of planning or discussion phases will "solve" these problems, but only advance our collective understanding much as our democracy was not designed by the Founding Fathers as a road map in three phases: planning, implementation, evaluation. Arguably, the debate about health care in America is very much a debate on our vision of what a democracy should be.

Our major challenge is to ask the right questions. If we ask the wrong questions, we are less likely to get the answers that make a difference.