Strange things are afoot in the normally rarefied world of health care punditry. It’s going primetime. And I’m blaming Steve Jobs.
Last week I was flicking through the TV in my hotel room and I caught a brief glimpse of sensible liberal, and too-clever-by-half young analyst Ezra Klein, on some cable shouting match chat show. I was amazed to find that his “opponent” was Stuart Browning – a self-styled software millionaire who now specializes in propagandizing about the evils of Canadian health care. For some reason I cannot fathom, Browning’s spent the last couple years wandering around with a video camera getting anecdotal quips from any Canadian who thinks that their government should be paying for their immediately desired surgery in an expensive American hospital. The reason for Browning’s sudden prominence has of course nothing to do with his (lack of) influence on the health policy debate amongst people who understand the topic and everything to do with cable TV’s never-ending search for somebody on the right who can ape the style of Lefty filmmaker Michael Moore. As all the world knows, Moore’s next movie, Sicko, (which of course I haven’t yet seen but feel that I know all about by osmosis) goes on general release next week.
In some strange working of the zeitgeist, Sicko is getting hyped and somehow linked, in my mind at least, with the other big release of the summer which has also had an early release to a select few in places like San Francisco, New York and L.A., and which debuts – to the general public – on June 29, this Friday, the same day Sicko opens. I’m talking of course about the Apple iPhone.
Apple CEO Steve Jobs and filmmaker Michael Moore essentially are on the same mission. They both want to convince the American public to take another look at what they’ve been using so far hoping that the re-evaluation will be so dramatic that the scales will fall from their eyes and Americans will suddenly realize they can do much much better than what they’ve had to put up with so far.
The simple fact of the matter is that, like cell phones in the EU, health care works better over there. Why? Better use and management of the technology at hand. It’s not entirely a coincidence that in most major European countries the use electronic medical records by physicians is much more common than it is the US. And we’re not talking a minor distinction here. In countries like Denmark, Norway, the Netherlands, the UK and New Zealand the use of electronic medical records in the exam room by primary care physicians is almost universal. In the US despite years of hype, somewhere under 20% of doctors are using them. If you talk to any senior executive in a private health plan, large hospital chain, large physician group, or government agency overseeing health care, they will tell you that this is a big problem which seriously impacts the quality of care that is delivered in the United States.
Routine use of electronic medical records allows, for example, physicians to check whether their diabetic patients have had their routine eye and foot exams, whether kids have had all their immunizations, or whether women have had their pap smears. That type of technology, if used properly, should significantly improve the care of the chronically ill, who account for most health care costs. That’s one reason why many big American health care provider organizations, most notably Kaiser Permanente, are spending billions of dollars attempting to install electronic medical records for all their physicians. But most American physicians don’t work for, or exclusively contract to, the government or big provider organizations like Kaiser. The only set of American physicians who use electronic medical records on a universal and routine basis do work for the government. Where? At the Veterans Administration which has its own home-grown electronic medical record called VistA.
Now most Americans have made very little connection between the wonders of technology provided by the likes of Steve Jobs and the massive problems many Americans have getting access to health insurance, and because of that, to appropriate health care. I’m pretty certain that Michael Moore doesn’t go off on a long diatribe about the lack of electronic medical records being one of the major problems with the American health care system. And to be fair, it’s not the major problem, at least not compared to the financial crisis visited on those people who get sick without insurance coverage, or whose insurer denied them coverage unfairly – which are, in fact, the main themes of Moore’s movie.
But there is a connection. American physicians work in one of the last remaining cottage industries. They have had little direction or funding help from their customers in government programs like Medicare, or on the private insurance side, to improve the care that they’re offering by doing things like adopting electronic medical records. In fact, theoretically electronic records can actually hurt the finances of doctors and hospitals. Why? Well, about 30% of diagnostic tests have missing results. So if the results aren’t immediately available in the medical record, which is a feature of electronic but not paper records, those tests get done over again, and paid for over again. Because of the bizarre structure of our insurance system, these costs get passed on to employers, consumers, and the government in a way in which they do not have the ability to control or question. Why? Because each of those groups – you, the consumer, the government (which oversees Medicare and Medicaid), and insurers – is each only responsible for a small share of the money flowing into the health care system. And they don’t directly control physicians.
Of course, if we were to move to a system of universal health care coverage which would, by definition, have much more regulation of insurance, the main benefit would be to help people who are currently without insurance or at risk of losing it. They’d be saved from the financial catastrophe that is visited on those without insurance who get sick.
But one of the side benefits would be that the funder of the universal coverage system would either directly or indirectly pay much closer attention to the quality and cost effectiveness of the care being delivered. And these days that means being able to track and assess care delivery, which pretty much by definition requires universal use of electronic medical records. For example, in the UK a government agency called the National Institute for Clinical Excellence (NICE) examines the cost effectiveness of treatments, procedures and drugs, and issues treatment guidelines. And these guidelines are actually followed by primary doctors in the UK in part because their bonuses are heavily linked to how well they follow them. The data to measure their performance comes from those electronic medical records.
Which is, indirectly, why both Sens. Hillary Rodham Clinton and Barack Obama’s health plans both place a lot of stress on expanding the use electronic medical records. Obama’s plan suggest a federal program of $10 billion a year to help physicians get these records. Both Senators and even the trade association of American private insurers support the creation of a federal agency that will perform a role somewhat similar to that of the played in the U.K by the NICE.
Michael Moore may not realize it, but the logic at work in his movie bashing the insurance industry results in the enactment of some type of government program promoting a more effective health care system, as well as a fairer one. And because “more effective” means “less egregiously profitable”, we will likely see more film-makers from the right like Stuart Browning aping Moore’s techniques to try to make sure that the iniquitous status quo remains in place as long as possible.
But then again, I suspect that IBM would have been happier if Steve Jobs had never shown up for a meeting of the Home Brew Computer Club. But I don’t think the rest of us would be.