The health care debate continues to rage in Senate, the media, and in the public discourse. Call it Obamacare, Trumpcare, AHCA, ACA, Better Care Reconciliation Act – the current law, and the current proposals in Congress to change it – all claim to provide affordable access to health care for Americans. In reality, the law is about health insurance reform, and curbing the steep rise of the federal government’s subsidizing of health care for our citizens.
The big underlying problem with affordability in health care is an industry that has not markedly changed the way it delivers services. Notably, unlike other industries, health care in the United States has not been seriously disrupted by information technologies either. The US spends over $ 9,000 per capita on healthcare, more than twice as much as other advanced countries like the UK and Japan, each of which spend under $ 4,000 per capita.
Just as notably, the higher spend in the US does not deliver any significant increase in life expectancy compared to other developed countries. Healthcare spending is 17.8 percent of GDP and growing faster than inflation. Washington, we have a problem — and it’s not going to be solved by insurance reform alone. Frankly, it’s not a problem that can be entirely solved in Washington either.
The US healthcare system is not behind in technology investment compared with other countries. In most ways, it is ahead. Hundreds of billions have been spent, leading to breakthroughs in genome sequencing, HIV drug treatment, targeted cancer therapies, laparoscopic surgery, and less invasive treatments for heart disease. Our health technology is arguably the best in the world, and many of the world’s best doctors train in our medical schools. Make no mistake: If you have the funds, the US is the place to be to get treatment for the most complex of diseases.
Where we are having problems is in the system that delivers health care, from the routine to the complex. Our system can often lead to imperfect, expensive, and frustrating health outcomes.
Healthcare is Not Leveraging Information Technology
To examine this at a basic level, let’s take a look at a typical experience for a doctor visit. If you don’t have a regular doctor, you’ll want to find one in your health insurance network. If you don’t have health insurance, you may have a different set of challenges in finding affordable care. Finding a doctor within your network may be easy, or it may be hard. In many cases, doctors and clinics are listed as part of a health network. But that doctor’s participation may be limited to particular policies from that insurance company. So before you make that appointment, you may need to call the billing department of the doctor to ensure that your specific policy is accepted.
Your next challenge might be trying to figure out what that visit might cost. You will need a lot of luck getting a straight answer on that question. The likely answer is that it depends how much time the doctor spends with you, what tests will be performed, and what your insurance will cover.
If you’ve read this far, you may be wondering what all this has to do with technology. These are areas where the judicious use of today’s technology could alleviate many of these problems. In an industry like financial services, internet technology has enabled consumer access to information that has radically changed segments like banking and investing. In healthcare, not so much.
To cite several examples: Why not have a consumer-accessible database that not only lists which insurance networks they participate in, but also the specific policies they accept? Why not have doctors post pricing, so that consumers can have a sense of what they’re actually going to pay? Better yet, why not integrate insurance reimbursement information with with typical doctor rates for specific services, and make that accessible to the consumer?
To be fair, it’s not that health providers are not investing in information technology. The continued move to Electronic Health Records (EHR) mandated by the Affordable Care Act has made improvements. But EHRs still lack standards for codification of information and in sharing information. This still a huge source of friction in the system that leads to the duplication of tests and services.
Doctor offices still do not really leverage modern communication technologies that could improve care and outcomes. HIPAA privacy rules and litigation fears – as well as lack of time due to patient loads – keep doctors from communicating with patients over email or even secure messaging features that are built into the health portals they are using for sharing test results with patients. A simple question about a test result or a minor symptom typically requires a phone call, which may be answered by a nurse practitioner, but in many practices will force another costly office visit.
Telehealth – a Disruptive Opportunity
On the brighter side, the increasing availability of telehealth services is offering an alternative to easier, faster access to doctors with less cost. Private equity-financed companies like Teladoc, Avizia, and Careclix are using modern information platforms that offer video appointments with doctors. The online nature of these services can streamline some of the friction in the system, and integrate appointments, health records, billing, and payment.
While not every specialty is well suited for telehealth, there are some low-hanging-fruit opportunities in behavioral health, elder care and monitoring, and rehabilitation services, to name some areas with early success. Importantly, more insurance companies have recognized some of these services and provide reimbursement within their networks.
Huge advances have been made in consumer health technology with fitness trackers and their associated smartphone apps and cloud data platforms. Similar advantages exist using sensors attached to the computing and communication power of our smartphones. For example, Philips’ Lumify ultrasound probe connects to an app on a smartphone and can allow doctors and nurses to perform many of the same imaging tests as an office ultrasound machine. Take that type of product a step further with the right software, and a patient could do his own imaging in a telehealth session with a medical professional, and transmit the information in real time to monitor a health issue or diagnose a problem.
Structural Issues and Disruption
The health industry has many structural issues that limit the pace of change. It’s heavily regulated. It relies, in the US, on both government insurance reimbursement (Medicare and Medicaid) as well as private insurance. The insurance component hides the true cost of many health services from consumers, and creates a byzantine system of codes, billing, and pricing levels that has spawned its own cottage industry of billing professionals.
In an article in Harvard Business Review, Michael Porter of Harvard Business School and Thomas H. Lee (formerly at Harvard Medical School) explore new strategies for reinventing healthcare. Very broadly speaking, reorienting the system from a transactional model to an outcome-based model is one of the key initiatives. While this is largely understood in the industry, changing that model is easier said than done.
Porter and Lee also discuss areas where leveraging technology will play a key role – measuring outcomes and costs for every patient, and building an information technology platform that is centered around the patient, not practices or specialties. Such a platform should have the following attributes: patient-focused, accessible to all involved in care, common data definitions, an information architecture accessible to applications, and incorporating expert systems to aid medical professionals in speeding diagnosis and treatment options. The information technology challenge in making this a reality in healthcare may be the most massive one in any industry.
A rethinking of certain commonly accepted practice may be part of solving the cost puzzle as well. Dr. Eric Topol, author of The Creative Destruction of Medicine, wants medicine to use genome sequencing technology to do smarter (and more cost efficient) screening for common diseases. With the cost of individual DNA sequencing now falling below $ 1,000, using genome profiling for the people that are genetically predisposed to certain diseases would help to identify the targets better than mass screening. This could help reduce the costs of mass screening for breast cancer, prostrate cancer, and heart disease. Topol also strongly advocates for the medical community to move faster in embracing artificial intelligence, cloud and mobile technologies to enable more accurate diagnoses, better sharing of patient information, and improve patient outcomes.
Change does not come quickly in the practice of medicine and healthcare delivery. There are many entrenched interests. In 2015, the American Medical Association, the pharmaceutical lobby, and the hospital lobby ranked fifth through seventh on the list of the highest spending lobbies in Congress. Health insurers were not far behind. Health insurance reform is one aspect of the puzzle, and policy will help reshape the industry in some ways.
But if real change in cost and quality is going to come to healthcare, imagination and reinvention is needed. Digital technology is driving rapid change in everything from media to retail to automobiles. Without delving into the politics, the future reality may be that health insurance continues to provide less coverage at ever-higher cost, forcing consumers to seek out alternative care solutions that they can actually afford to pay for out-of-pocket. Ironically, this may be the economic impetus that helps spur more technology-based innovation in healthcare delivery – a revolution we sorely need.
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