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Monday, May 16, 2016

EHRs and the ACA: Obama's diabolical plot to enslave physicians

Hang around enough health IT and health policy blogs for any sustained length of time (in particular delving into and participating in the always-fractious comments sections), and you will by now have become utterly familiar with the overwrought, cynical sentiment set forth in the above title. Nothing is ever incrementally better or worse, it's always an existential catastrophe or a totally beneficent "transformative new era in health care." EHRs are uniformly "dangerous, untested, experimental medical devices that harm and kill patients" (which, of course, begs the fundamental question that, if they're "untested," how, precisely, can we summarily know they're causally dangerous?). And, ObamaCare is indisputably "the worst thing since slavery" (according to one very prominent neurosurgeon and former GOP presidential candidate, no less).

You know the riff.

All part of a larger opus, one particularly, predictably notable during this fractious 2016 "money = speech" national election year. Now-failed GOP Oval Office candidate Senator Ted Cruz ominously warns that the nation is "facing the abyss," that "your religious freedoms and 2nd Amendment rights are in dire peril," and that Hillary will "appoint five radical left-wing extremist judges to the Supreme Court" if elected. Oh, the Horrors.


I particularly love how all of these Republican contenders are going to "repeal ObamaCare on Day One" -- all of them having apparently been out sick (albeit with good health insurance) during Article II day in ConLaw.

Equally uniform is the GOP candidates' heartwarming apple-pie assertion that they're going to "return control of health care to the patients."

Perhaps, amid other vague "reforms," by putting their medical data back on paper charts?

I got off into this rant by way of a NY Times article, one brought to my attention by my Facebook pal Jonathan Taplin of USC. Noted writer Gregg Easterbrook:

When Did Optimism Become Uncool

...most American social indicators have been positive at least for years, in many cases for decades. The country is, on the whole, in the best shape it’s ever been in. So what explains all the bad vibes?

Social media and cable news, which highlight scare stories and overstate anger, bear part of the blame. So does the long-running decline in respect for the clergy, the news media, the courts and other institutions. The Republican Party’s strange insistence on disparaging the United States doesn’t help, either.

But the core reason for the disconnect between the nation’s pretty-good condition and the gloomy conventional wisdom is that optimism itself has stopped being respectable. Pessimism is now the mainstream, with optimists viewed as Pollyannas. If you don’t think everything is awful, you don’t understand the situation!...
Pollution, discrimination, crime and most diseases are in an extended decline; living standards, longevity and education levels continue to rise. The American military is not only the world’s strongest, it is the strongest ever. The United States leads the world in science and engineering, in business innovation, in every aspect of creativity, including the arts...
Manufacturing jobs described by Mr. Trump and Mr. Sanders as “lost” to China cannot be found there, or anywhere. As Charles Kenny of the nonpartisan Center for Global Development has shown, technology is causing factory-floor employment to diminish worldwide, even as loading docks hum with activity. This transition is jarring to say the least — but it was always inevitable. The evolution of the heavy-manufacturing sector away from workers and toward machines will not stop, even if international trade is cut off completely...
The lack of optimism in contemporary liberal and centrist thinking opens the door to Trump-style demagogy, since if the country really is going to hell, we do indeed need walls. And because optimism has lost its standing in American public opinion, past reforms — among them environmental protection, anti-discrimination initiatives, income security for seniors, auto and aviation safety, interconnected global economics, improved policing and yes, Obamacare — don’t get credit for the good they have accomplished.

In almost every case, reform has made America a better place, with fewer unintended consequences and lower transaction costs than expected. This is the strongest argument for the next round of reforms. The argument is better made in positive terms — which is why we need a revival of optimism.
"We need a revival of optimism." While I would tend to agree in principle, I won't be holding my breath this year.

In significant measure, I guess I'm still mulling over the relevant implications of my prior post "Anything that CAN be tracked WILL be tracked." Inevitable Tech Forces That Will Shape Our Future. Kevin Kelly, the articulate co-founder of WIRED, and certainly no unreflective Rube, counts himself among the technology "optimists,"  e.g.,
"My optimism is off the chart. I got it from Asia, where I saw how quickly civilizations could move from abject poverty to incredible wealth. If they can do it, almost anything is possible. Let me go back to the original quote about seeing God in a cell phone: The reason we should be optimistic is life itself. It keeps bouncing back even when we do horrible things to it. Life is brimming with possibilities, details, intelligence, marvels, ingenuity. And the Technium is very much an extension of that possibility space." -- Interview with Kevin Kelly – “My Optimism Is Off The Chart”
I'm loving his book "Out of Control" (now free pdf), and can't wait to read his forthcoming one.

Given the financial imperatives of our news media, it's unsurprising that they are predisposed to fan the flames of pessimism and controversy, to stoke the fires of negativism and cynicism. "If it bleeds it leads" goes the venerable media marketing axiom. Acrimony and reflexive disputation sell (whether pertaining to politics or other topics).

Whether what they sell is increasingly toxic to the body politic and humanity writ large is quite another matter.

BTW, for a rational review of some of the actual pros and cons of the ACA ("ObamaCare") see my review last year of Jed Graham's book "ObamaCare is a Great Mess." As I noted last July:
All of the advances in medical science (and clinical pedagogy), health IT, and progressive delivery process QI we can muster will still be hemmed in by national policy. Will we continue to experience our health care in the "Shards" of my recent characterization? Will the ACA be complicit in that chronic fragmentation?
And, of course, when things get too nutty, I frequently find recourse in writing music and lyrics.

With respect to the actual utility and challenges associated with Health IT, you simply can't do any better than spending significant time over at Dr. Jerome Carter's EHR Science.

Health Care is Not a System

The Merriam-Webster dictionary has many definitions for the term system, but the most straightforward, and arguably the most applicable to our health care conversation is “a regularly interacting or interdependent group of items forming a unified whole”. The common wisdom is that our health care system is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation. We usually work ourselves into a frenzy arguing how the government should go about fixing the system, but I would like to take a step back and question the assumption that health care is, or should be, a system. This is not about splitting the hairs of semantics. This is about proper definition of the problem we wish to solve.

You could argue that we use the term system loosely to refer to everything and there are no nefarious implications to calling health care a system. We have a transportation system, an education system, a legal system, a financial system, a water system, a political system and so forth. Note however that we rarely talk about our food system or auto system, fashion system, hospitality system, etc. We call those industries. Starting to see a difference here? Good. Our government obviously regulates both systems and industries, but it regulates them differently. And systems have distinct characteristics that industries seldom have, such as built-in (systemic) mechanisms for discrimination, and institutionalized (yep, systemic) corruption aplenty.

When we begin by assuming that health care is a system, we assume that health care should possess those same characteristics. We assume that health care in Beverly Hills will be, by design, different than health care in Flint, Michigan. We assume that health care delivered in private settings will be different than health care accessed in public settings. We assume that some areas will have sprawling, on demand health care hubs, while others will have none. We assume that public engagement in health care is for show only, while the billionaire class and its carefully constructed echo chamber get to make all our health care decisions. We assume that health care is, and always will be, rigged. And based on these assumptions, we proceed to fix our health care “system”.

You may be tempted to dismiss these thoughts as specious demagoguery, strawmen, soapbox arguments or just plain exaggerations. After all, health care system fixing includes such socially beneficent endeavors as expanding “coverage” for the poor (Medicaid expansion), subsidizing insurance for the less poor (Obamacare exchanges), granting insurance to the sick (preexisting conditions), and a steady drumbeat of accountability, measurement and reduction in “disparities” for “vulnerable populations”. To that I would respond by pointing you to several recent utterings from public figures empowered to effect health care reforms...

The Return of the Broccoli
I’ve written compulsively about the apparent war on doctors in the past, and I am certain I will be writing more, but the war on people is a much more intricate subject. It’s relatively easy to separate a quarter of one percent of people from the herd, paint them as for-profit mass murderers and sic the hungry mobs on them. But then how do you subdue the mobs? For that, my friend, we have government. We have behavioral economics. We have the experts and pundits in that echo chamber. And we have the righteous souls who innocently light the fuse of every calamity.

I’m old enough to remember the debates preceding the Obamacare litigation in front of the Supreme Court, culminating with both Justice Scalia and Chief Justice Roberts pondering whether the government has it within its enumerated powers to make you buy broccoli. Before the broccoli debacle, the same libertarian lunatic fringe wondered if government can order Americans to lose weight, or if the government can mandate that we buy certain products from certain manufacturers. Of course Obamacare and its mandate to buy health insurance or be penalized by the IRS survived these outlandish challenges, and the IRS is doing its best to rake in those penalties...
My comment:
If not a "system," is it even "a market"?

"...The common wisdom is that our health care [market] is broken and hence our government is vigorously attempting to fix it for us through legislation, reformation and transformation..."

Or is it a dystopian perplex of contending markets, public and private. (There's no such thing as a "free market.")

See also my last in-depth look at Margalit's work, "Are structured data now the enemy of health care quality?"



More to come...

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