As 2015 opens, here are some thoughts on 5 challenges facing us in health care.
1) Adding Fuel to the Health Fire
America’s health care system provides the worst value in the developed world — we pay lots more and don’t get as much for our money. Recent reforms seek to fix the ‘blame’ on hospitals and doctors, strong-arming them into being accountable for high costs and imperfect outcomes. But the health care sector is largely ignoring the fact that health ecology — social, economic and behavioral factors — is what fuels the financial fires of chronic disease and death (see below, under Dark Matter).
The high cost of disease care is mainly due to systemic reliance on biomedical devices, diagnostic and therapeutic procedures and drugs as high tech bandaids. One cannot put out a fire just by trying fancier and fancier extinguishers. One must cut off the fuel supply.
2) Dark Matter / Dark Energy of Health
Health care reform is reviled by many as a government takeover, but aren’t the big bucks going to the financial (insurance) and information technology sectors? The corporate sector is prying control of health care away from clinicians and hospital administrators. Government is assisting the process by creating an ever-rising set of analytical demands, trapping practices and hospitals on an escalator that exceeds their resources. This is forcing many physicians to sell out to become employees (where they can be more readily controlled). Accountability and Meaningful Use together are like blades of scissors that Big Money and Big Data use to cut control away from health care professionals. Hospitals and physician networks, desperate to remain autonomous, are forming organizations agreeing to be held accountable, with Big Money and Big Data appointed as judge, jury and executioner.
Big Data uses claims and diagnosis data to try to predict outcomes — “medical intel”. Take note, readers, if you think Big Data doesn’t deduce much about YOU from that data, think again! HIPAA does not protect anyone from such spying. Oh, the names are changed to an anonymous number, but not to protect the innocent. The ID number is used by Big Data to identify individuals who are outliers in cost and in course of treatment. Medical intel allows Big Money and Big Data to avoid the HIPAA Police, while arming the Guideline Police with a warrant to arrest the doctor who agreed to be accountable for the outlier.
The lurking problem is that the needed data are not being collected (see Statistics, below). The Guideline Police have no way of knowing when the underlying cause for an outlying patient is bad health ecology (very often), rather than bad doctoring (not so often). We physicians really need to assert ourselves with the goal of making Meaningful Use benevolent for our patients. Instead, we feel hostile towards Meaningful Use, because it seems malevolent towards us. All around, not enough people see health care reform as a win-win scenario, choosing to view it as a zero-sum game.
But how will anyone get to truly Meaningful Use when health ecology, driving outcomes, isn’t in the database (see Adding Fuel, above)? Social, economic and behavioral factors are like dark matter / dark energy — we know they’re 85% of what’s out there, but they’re invisible. Nobody can see health ecology because nobody is capturing that data. Physicians seem to be blissfully unaware that they are exposed to being punished, through Meaningful Use, as a result of health ecology factors that nobody is measuring. Worse, at this point, few doctors — The Accountable — are well-positioned to have any influence over health ecology.
3) Lying With(out) Statistics
Health reformers often say, “In God we trust, all others bring data”. Especially if you’re a doctor, you’d better have scientific proof to support your choices in care, because you're being watching (see Big Data, above). Never mind whether or not the monitors fully understand the research nuances that went into Big Data’s Guideline de Jour, or if the patient aligns well with those nuances. Yet, I’ve sat in on many a health plan and quality-improvement meeting, and I don’t believe I’ve ever heard anyone talk about statistical power, boundary conditions of the program design, or flaws in the data. Nothing about statistical methods, F-ratios, P-values, correlation coefficients, outlier methodologies or statistically significant differences. I have asked a few analytical firms how they examine data quality and cleanse errors in the data, only to be told that they don’t.
Physicians are thus held to a high scientific standard, while Big Money / Big Data administrators (who monitor physician adherence to the Guideline de Jour ) use flawed non-scientific analyses to manage health plans and programs. Why are Big Money and Big Data exempt from this kind of best practice? I played a round of golf a couple of years ago with a retired statistician who worked for SAS, the statistical software firm. When I expressed my surprise at how poorly statistics is being used to make business decisions in health care, he shook his head in acknowledgment (see Insanity, below).
4) Intervention Insanity
Everyone knows the joke about insanity — doing the same thing over and over again and expecting a different result. Health promotion / disease care projects usually employ best practice behavioral interventions as proof of quality. Perhaps great news flew past when I wasn’t looking, but hardly any behavioral interventions achieve long-lasting effects in the majority of participants. In exercise and weight management, twenty percent adherence to a modest effect size after 1-2 years is doing really well. With the aid of pharmaceuticals, smoking cessation often doubles that, or better, especially if the program selects cream-of-the-crop participants.
I try to see the glass that's half-full, but when long-term success is 20-30%, long-term failure is 70-80%. Certifying methods that achieve such outcomes as best practice basically locks-in mediocrity (to grade ouselves charitably). If something doesn’t work 80% of the time, the take-home message should be — don't keep doing that, try something else (see Statistics, above). We don’t need to codify mediocrity, we need to systematically explore new methods, new tools and new system designs that better create a culture of health. We need registries to identify new ideas that work, not to continue best practices that stay stuck on what doesn’t work.
Long ago, at the beginning of careers for professionals now in retirement or deceased, cardiovascular rehab programs pushed patients pretty hard — got them running 10k’s and marathons. Cardiologist Thomas Bassler even stated that completing a marathon would confer immunity to heart disease (it didn’t take long to prove him wrong). But long-term adherence was low (see Insanity, above). Experts experimented with the idea of participation and “exercise light”, which, of course, created potential for the pendulum to swing back to higher intensity. Studies now explore how little one must do if it’s very high intensity.
Of course high-intensity can make a patient more robust. Our retired and/or deceased mentors knew that! Continuing to fiddle with exercise dose-response skirts the real problem I hear over and over again:
“Doc, I don’t have time to exercise”.
They don’t have time to chop vegetables for a salad, either. Nor to find spiritual release through play (whether it be a physical activity or mindful participation in something fun like music). Truthfully, most docs hide it, but they themselves don’t have the time. It's hard to get doctors to talk the talk when they're, quite literally, not walking the walk.
Protesting that one doesn't have the time for exercise is really a way of saying that health ecology is not a high-enough priority to make the time. Rather than address the time problem (i.e., STRESS), we go on adding exercise to the list of dutiful chores in a chock-full daily agenda and try to sell it with,
“Hey, on some days, it’s only going to take 5 minutes...plus you can get credit for parking at the far end of the lot and taking the stairs”!!
Where is the spiritual release, and — more important — the search for understanding why so many people don’t prioritize the time for physical activity and play (see Adding Fuel, above)?
Workforce wellness and disease-care programs focus far too much on executing the elements of health ecology — exercise, diet, tobacco and even coping with stress — when what employers, doctors and all of us need to do is re-evaulate and re-create community culture wherein health ecology is our top priority, our highest value.
Onward to 2015...
Solving these interlocking challenges and providing America with higher value for the health care dollar will not be easy, and is going to require looking at the problem from a different perspective. We need to figure out new system designs, create new tools, systematically implement these new ideas under controlled circumstances, and then look for statistically meaningful relationships. As a physician-physiologist researcher, I learned that implementation errors are rare — well-trained people do good work. What’s very common, however, is to unwittingly make assumptions that are not true. Because of this, I fear the Court of Accountability rulings will not go well. The low health care value we are providing Americans is a consequence of our health system design, much moreso than it is due to waste, fraud and abuse. Most troubling of all, we continue to make lots of unwitting assumptions that are false.
Here’s hoping that 2015 will bring you new insights and solutions for these pressing problems.