Sunday, January 30, 2005
I would like you to meet a patient from the year 2015. He lives in a world in which years ago America's leaders made tough but wise decisions. They built on the best aspects of American health care and unleashed the creative power of the competitively driven marketplace. These changes resulted in dramatic improvements to the U.S. health care system — lower costs, higher quality, greater efficiency, and better access to care.
The patient, Rodney Rogers, is a 44-year-old man from the small town of Woodbury, Tennessee. He has several chronic illnesses, including diabetes, hypercholesterolemia, and hypertension. He is overweight. He quit smoking about eight years ago. His father died in his early 50s from a massive myocardial infarction. In 2005, Rodney chose a health savings account in combination with a high-deductible insurance policy for health coverage.
Rodney selected his primary medical team from a variety of providers by comparing on-line their credentials, performance rankings, and pricing. Because of the widespread availability and use of reliable information, which has generated increased provider-level competition, the cost of health care has stabilized and in some cases has actually fallen, whereas quality and efficiency have risen. Rodney periodically accesses his multidisciplinary primary medical team using e-mail, video conferencing, and home blood monitoring. He owns his privacy-protected, electronic medical record. He also chose to have a tiny, radio-frequency computer chip implanted in his abdomen that monitors his blood chemistries and blood pressure.
Rodney does an excellent job with his self-care. He takes a single pill each day that is a combination of a low dose of aspirin, an angiotensin-converting–enzyme (ACE) inhibitor, a cholesterol-lowering medication, and a medication to manage his blood sugar. That's one pill daily, not eight. He gets his routine care at his local clinic. He can usually make a same-day appointment by e-mail.
Unfortunately, chest pain develops one day while Rodney is on a weekend trip several hundred miles from home. The emergency room physician quickly accesses all of Rodney's up-to-date medical information. Thanks to interoperability standards adopted by the federal government in 2008, nearly every emergency room in the United States can access Rodney's health history, with his permission. The physician diagnoses an evolving myocardial infarction by commanding Rodney's implanted computer to perform a series of rapid diagnostic tests. The cardiologist in the "nanocath" lab injects nanorobots intravenously, and remotely delivers the robots to Rodney's coronary arteries. The tiny machines locate a 90 percent lesion in the left anterior descending coronary artery and repair it.
The hospital transmits the computerized information about Rodney's treatment, seamlessly and paperlessly, to Rodney's insurer for billing and payment. The insurer pays the hospital and physicians before Rodney returns home. Payments are slightly higher to this hospital than to its competitors because of its recognized high quality and performance. Rodney's hospital deductible and co-insurance are automatically withdrawn from his health savings account. Because Rodney has met all his self-management goals this year, he gets a 10 percent discount on the hospital deductible.
Chances are, living in a small town in Tennessee, Rodney still has only one hospital to choose from for emergency care. There's no reason to assume that reduced prices and computerization will mean that the number of hospitals increase out of proportion to the population they serve. Ditto his "providers." One of the draw backs to living in a small town is that there's less choice - from grocery stores to lawyers to doctors. The cost of healthcare will likely have skyrocketed, not fallen, to cover the cost of the new nanotechnology and the computer systems. His single pill is expensive and when he feels nauseous or achey, or tired after taking it or he develops serious complications from it, he can't tell which of its components are causing the symptoms. It improves his chances of living longer by about 2 to 3% over ten years.
Whenever Rodney gets upset or anxious or drinks too much coffee or has sex, the little implant in his abdomen sends off an alarm signal that his blood pressure and pulse are too high. Rodney can't make a same-day appointment at his local doctor's office by email because the doctor doesn't get a chance to read his email until after office hours have finished, and doctors still have to examine and treat patients one at a time, so his schedule is no more open than it ever was in the past.
It's nice that Rodney's medical record is so easily at hand, however it's hard to imagine that having it will make diagnosing a myocardial infarction any faster than doing an EKG. Maybe that implant can diagnose a heart attack and send out a signal. And will the nanobots be faster and deliver a better outcome than coronary angiography and angioplasty?
The last part is the most laughable:
The hospital transmits the computerized information about Rodney's treatment, seamlessly and paperlessly, to Rodney's insurer for billing and payment. The insurer pays the hospital and physicians before Rodney returns home.
Yeah, and pigs will fly. Here's what will happen. Because Rodney had his heart attack at an out-of-network hospital in a distant city, his insurance company refuses to pay, leaving Rodney or the hospital to eat the cost of all that fancy technology. Or, since Rodney has catastrophic health insurance and therefore may not be limited to a network, the insurance company reviews Rodneys freely-available health record which they are free to do without his permission, and find that he smoked until a few years ago, that he didn't always fill his prescriptions on time, meaning that he wasn't completely compliant with his blood pressure medication, and that his implanted chip recorded occasional high blood pressure readings. They deny the claim because Rodney didn't hold up his end of the bargain in keeping himself healthy.
Payments are slightly higher to this hospital than to its competitors because of its recognized high quality and performance.
The insurance company sets their standards for quality higher than hospitals can realistically meet and still treat real people. Insurance companies aren't in the business to give money away, and that's not going to change in the future.
Rodney's hospital deductible and co-insurance are automatically withdrawn from his health savings account. Because Rodney has met all his self-management goals this year, he gets a 10 percent discount on the hospital deductible.
Rodney just cost the insurance company a bundle for that nanobot procedure. What's more, he's now at higher risk for future cardiac events. Rodney's premium goes up by 20%.
Having this seamless universal system of health records sounds on the surface like it would be a wonderful thing, but the two groups who benefit the most from it are the insurance industry and the government. The insurance industry will benefit because they'll be better able to assign individuals to risk groups and to review records for denial of payment. The government will benefit because they'll have an easier time auditing charts for denial of payment or investigating fraud. But when it comes to treating a patient for illnesses - especially emergency ones like trauma, strokes and heart attacks - having a complete history is just icing on the cake, not an essential of care.
posted by Sydney on 1/30/2005 12:10:00 PM 0 comments