As per Benjamin Atkinson, who graciously shared with me this piece he’d written a few weeks ago. It’s long, but stick with it. It’s time very well spent:
Epistemological Foundation for Healthcare Reform
To truly effect change in America’s healthcare system, stakeholders must address deeply-rooted beliefs and behaviors. Without change at this level, all manner of novel financial schema, medical nostrums and patient consumerism will lead to neither higher quality nor lower costs. Our current crisis evolved as our culture evolved, and no governmental fiat will reverse this course. To increase access to affordable and effective care, we must renovate our minds and build belief, delivery and information systems that add value.
To rehabilitate our understanding of health and healthcare, we must first confront the barriers to objective understanding. These barriers are built upon the arrogance of the stakeholders in the healthcare system: individual, provider and payer. If we examine each stakeholders actions, and the underlying motivations/beliefs, we will see the problems more clearly, and solutions become perspicuous.
Problem 1: Colossal Hubris of the Individual
In August 2006, the National Association of Health Underwriters issued a white paper listing key current and future healthcare cost drivers:
- Aging Population
- Pharmaceutical Costs
- New Technologies
- Behavioral and Lifestyle Choices
- System Inefficiencies
- Medical Malpractice
- Cost-Shifting
- Increases Utilization
Such factors dominate the discussion about cost in healthcare. However, all of these are either ancillary to, or predicated upon, the more fundamental motive driving demand for healthcare. In pursuit of health, we often wax Quixotic, driven toward an illusory goal. Health, after all, cannot be acquired or possessed. In fact, health cannot even be measured, except as an absence of some symbol of vitality; a decrement in the performance of a life function or activity. So, when we ‘pursue health’, what are we actually pursuing? It turns out, we are pursuing autonomy, the ability to perform our life activities, as we wish. (See Gadamer )
And so, our arrogance blossoms. Conflating the Western doctrines of Reductionism and Rugged Individualism, we make a god of Capitalistic Science. Slowly, we the people, reduce our existence to discrete functions, to be managed or outsourced to a caretaker. As a society we have agreed to fund our desire to live unimpaired through a social insurance schema, essentially underwritten by those possessing more tempered ambitions. Yet, our quest often ends in disappointment, as we find that many of our caretakers also exact a hefty toll upon our self-determination. Such lack of objectivity is characteristic of a state of denial. And, denial is at the very root of our healthcare cost explosion.
An aging population that demands more care and new cures…we hear this song echoed throughout history. The symbols of the problem are all around us, from the pyramids of Giza to the promises of Cialis. Our vision no longer extends beyond our present experience. We’ve lost sight of our history and recoil from our future. Much of our healthcare system serves as life support to the “vital lie”. Ernest Becker won the Pulitzer Prize in 1974 for his eloquent and brilliant examination of the lengths we go, to reduce our lives to an equation we can solve. As it goes for life, in general, so it goes for healthcare, in particular. Our underlying problem is not the denial of access to primary care, or to the latest technology or drugs. Our problem is denial of death.
*Solution 1: Life is terminal. Drop an anchor in eternity and deal with it!
Problem 2: Unmitigated Gall of the Physician
Woe to the physic, caught between the role of healer and the role of dealer. The individual’s reduction of the life experience is subsumed and amplified by a medical community that offers an escape from every corporeal challenge. This criticism is not directed at the medical profession, in general, only at the irresponsible purveyance of unproven and unnecessary ‘cures’.
The grand theft of autonomy occurs when our healer offers us pills instead of coping skills, labels instead of ability, excuses instead of effectual living. This counterfeit medicine was not brought about by some diabolical conspiracy of the Club of Cos. No, as individuals, we demand a salve for our ultimate fear and its myriad symptoms. Beaten down by the organized payers, or herded along in their ignorance, many providers accepted the new terms, doffed their mantle of healer/adviser and donned the apron of healer/retailer. Those who stood by their oath, suffered a reduction in compensation or even left their practice for more ethically palatable pastures.
(A small group persisted and today, with the help of technology, a revival of the adviser/healeris emerging.)
Yet, technology is only part of the answer. (An important part, as we shall see.) First, the physician must begin confronting the individual’s pathological anxiety about degradation of function. The provider must be able to create a dialog around coping, as well as, curing. For there are many more opportunities to cope than there are to cure. Coping gets short shrift in our culture, and the healer is uniquely positioned to guide these conversations. Our society is virtually blind to the personal gains from successfully coping with life’s predicaments (Thank you, Dr. Hadler. ) Lost is the recognition of: the woman’s empowerment in a non-medicated birth, the couple’s new intimacy after sexual function declines, the old man’s new perspective as he views his world at a slow shuffle. This is not devaluing the experience of those who seek medical interventions. Instead, we must devalue the proffering of interventions without consideration of the individual’s autonomy. Advising first, supporting the individual’s decision second, and finally administering treatment; this should be a general protocol. Providers must recover their courage and challenge individuals on these issues, if they are to be true to their oath.
Technology is making the impossible, possible…possibly.
Assuming a provider wished to advise an individual on the best course of treatment, they likely could not. Our medical community has been organized as a million little hamlets, encapsulated and insulated from the torrential flow of data in our modern time. Continuing medical education consists of free luncheons hosted by other members of the Club of Cos and research articles with dubious origins. What is lacking is information about the outcomes of treatments administered. Practicing in isolation has created blind spots. In the retail role, the medical community has been selling ‘cures’ without evidence of effectiveness (e.g. Vioxx, Paxill, etc.). Having outsourced quality control to the tort system, providers have forfeited the integrity of their practice, in the face of the ‘customer’ demand. This can stop, now, if we are willing to renovate our thinking.
For too long, we have relied upon the tacit knowledge of the physician. The training regimen for doctors reinforces this. To make the correct diagnosis requires an immense, mental catalog of exclusions. Unfortunately, tests, diagnoses and exceptions are always increasing, and we cannot expect the human mind to keep up. It is time to make some of this tacit knowledge explicit in the form of rules-based medicine. Clayton Christensen has written about this more eloquently. With today’s technology providers can easily create simple rules, or algorithms, that define the evaluation, treatment and outcome metrics of disease. I envision a palette whereby a physician can drag and drop elements representing the tests, interventions and outcome measures for any illness they treat. The alogorithm(s) must define the 3 intervention options:
Tx – Physical Intervention
Rx – Pharmaceutical Intervention
Ix – Information Therapy
Through the social nature of today’s information networks, the efficacy on any algorithm could be quickly determined after a relatively small amount of feedback. Outcomes metrics should include objective clinical measures, as well as, subjective patient responses. Imagine an Amazon ranking for various treatment options. Yes, these outcomes might be heavily influenced by the physician’s demeanor. The rankings are still valid and valuable in the social networking context. If I were a physician and the doc down the road was getting better results from the same treatment, I’d work hard to find out why.
In short time a new taxonomy of care would emerge from a social network of physicians. CPT codes would be abandoned, in favor of a more robust medical vocabulary. After all, CPT codes were a financial contrivance forced upon the profession. I suspect that the semiotics derived from the CPT coding system have profoundly and more negatively affected the health of the US population than, more so than cigarettes, booze and television, combined. Restoring a natural dialog among/between physicians and patients would energize quality improvements, more so than the latest flavor of P4P.
This opportunity challenges the long-established aporia of the general versus the particular. Aristotle investigated how physicians can practice their art on behalf of their patient (the specific), and on behalf of the medical body of knowledge (the general), simultaneously. In other words, how can a conclusion be drawn from population data, in regards to a specific patient. Aristotle concluded that this paradox was unresolvable, and modern epidemiology supports his assertion. However, now that the long tail is being drawn in ever-increasing resolution, we may be able to avoid instances of this paradox, if not resolve it. Philosophers will have to weigh in on this one. What is certain is the technology is available to break the free-agent model of medical knowledge and share explicit rules and their effectiveness.
The final pillar of physician pride that must be torn down is the irrational protectionism surrounding scope of practice. Again, the rules-based model facilitates this transition. Though Thomas Kuhn did not provide us with a useful definition of a paradigm, he did help outline the process by which information becomes knowledge. Professor Christensen built upon Kuhn’s work when he described how paradigmatic treatments must move downstream to capture value. That is, once medical knowledge is explicit, it can be performed by providers with lower skill levels. I believe his best example is his own diabetes. Once the domain of Endocrinologists, many diabetics now self-manage virtually all aspects of their disease. My own mother has been a diabetic since she was 16. She still visits her Endocrinologist, but only because she likes chatting with her. (That’s another story.)
This virtuous cycle must be embraced by physicians, if value is to be created:
Specialist > Generalist > Extender > Patient (Self-Care)
Only by making medical knowledge explicit can we move care along this path. Physicians must begin sharing information and enlarging the scope of practice for extenders. Patient self-care (autonomy) must be the goal, wherever possible. If an intervention (information, pharmaceutical, physical) does not increase the patient’s autonomy, it is not effective. This is the only way to curb the reductionism that seeks to mechanize our living and deprive us of our chance to heal and grow.
*Solution 2a: Physicians must make patient autonomy a priority.
*Solution 2b: Physicians must leverage technology to transfer tacit knowledge to explicit rules, and crowd-source these rules to determine efficacy.
*Solution 2c: Extenders must be employed more widely to implement these rules and make efficient the delivery of quality and economical care.
Problem 3: “Mammonistic” Temerity of the Insurer
So far, we’ve seen the reduction of an individual’s life to discrete functions he/she wishes to control. From there to the physician, where discrete functional deficits are corrected, in exchange for the individual’s (and society’s) dollars and autonomy. However, it is inside the insurers where de-individuation is completed. Once reduced to a claim number, all pretense of patient care may be dropped. These organizations are not evil, for that is the property of an individual. Nor are the people working at insurers particularly evil. Health insurers are simply focused on costs and shifting costs. There is no place, albeit no systems, for supporting patient autonomy, or provider autonomy, in most cases.
It’s easy to point to the insurers as the source of all that is wrong with healthcare. However, this is the height of hypocrisy. Our society, we the people, demanded this social insurance system, and any who condemn one or another stakeholder are ignorant, unless they admit their own complicity. And if we are party to the wrongs, we must bear up under the task of setting things right. And insurers have at their disposal a way to set things right.
Medical underwriting and adverse selection are topics beyond the purview of this short treatise. Regardless of the financing strategies that politicians manage to bungle, the most vital roles for insurers don’t change. Yes, if we have universal coverage we can create more accurate actuarial models. Yes, if we all embrace healthcare consumerism, we’ll pay more out-of-pocket expenses, but possibly control prices. However, the financing debate is moot without first drawing in stark relief the goals of patient autonomy and quality. If we can begin working on the solutions above, insurers can become more focused on coordinating the best care (You know. The care that increases the autonomy of the patient.), and less focused on simply shifting costs. How would this work?
As providers’ perspectives shift toward autonomy and effectiveness, quality will become more visible. The insurers cost-containment goals will be met by helping patients coordinate care among the best providers. For example, a patient is diagnosed with a serious kidney problem. Today, the generalist will refer the patient to a specialist based on professional/personal relationship or health plan networks. As for quality, it’s a crap shoot. But, if we are working with physicians who have made explicit their treatment protocol and outcomes metrics, the right docs are easy to find. The insurer has an opportunity to save money by making those connections happen. To get the patient to the right specialist it might cost $10,000 in transportation/lodging. Is it worth $10,000 to save a kidney? I’ll leave that for the actuaries. (If it were my kidney and my money, I’d know the answer.)
And, in the example above, specialist care will be limited to the acute episode. Once resolved, the specialist and generalist can agree or collaborate on the maintenance protocols, including the patients preferences. Soon, the patient may require only occasional support from an extender. Eventually, the individual is once again under self-care, having learned how to cope with any residual impact on life functions.
The insurer’s new role will be effective only if the individual performs their part (Solution 1), and the provider performs their part (Solution 2). Until then, the insurance companies have little opportunity to offer real solutions. The original medical relationships, patient and doctor, is where the solutions begin. We can stop beating up the insurers until we make advances, and improve the dialog, at the point of care.
Solution 3a: Harnessing the power of rules-based medicine, insurers must become the evangelists and coordinators of quality care.
Solution 3b: Insurers must foster a new kind of network, the crowd-sourced care network and build pathways from specialist to self-care.
Solution 3c: Insurers must abandon P4P until real outcomes (not process) metrics are being collected from defined (repeatable) treatments.
If anyone would like to enter a dialog about these ideas, please post to clubofcos.org.