Howard A. Green, MD
Dermatology Associates, PA, Palm Beach, FL
There’s nothing new about ‘population health.’ Physicians practicing medicine (notice I didn’t say practitioners practicing healthcare) have utilized population health studies or ‘clinical studies’ for the better part of two centuries. Physicians practicing medicine with patients observed, recorded, tabulated and revealed their findings on charted variables contributing to diagnostics, treatments, prevention and palliation which were subsequently reviewed by peers and publicly published. These studies ranged from just a single patient observed over a short period (also known as a case report) to decades of observations on thousands of patients such as the Framingham Heart Study.
What’s a bit different today in population health is that we have the ability in real time to compress, tabulate and reveal 200 years’ worth of epidemiological and charted patient health information in seconds. The result of interoperable digital compression and rapid revelation and clinical reapplication of preventive, medical, surgical and palliation data according to all charted variables will be a rapid improvement in the cost and quality of clinical outcomes or the Value=Outcomes/Costs of practiced medicine. Thus, population health will benefit patients and their physicians.
While the value of the practice of medicine with physicians and their patients will be improved by the application of interoperable population health, the healthcare industry will be disrupted and devastated.
The healthcare industries which would be displaced by interoperable population health data revelations include the five highest market cap ancillary industries of healthcare, and they’re not willing to downsize or be disrupted. In essence, these industries have deemed themselves ‘too big to fail.’ These five industries would be devastated due to the forced consolidation and downsizing from the outcome or value data revealed by population health via integrated and interoperable EMR/EHR (electronic medical record) (electronic health record) and billing systems. These industries remove the largest share of healthcare dollars from both patients and their physicians. In addition, these industries receive massive taxpayer subsidies or wavers from federal regulations. These industries represent the largest combined donors in America to our congress people and the administration. The industries which would be damaged by population health’s clinical outcome revelations and are preventing the implementation of interoperable population health are:
- Insurance Industry – Few physicians or patients will argue that publicly subsidized and private health insurance companies make their profits for their shareholders, bondholders, executives, bureaucrats and patron politicians by financially or physically rationing access to preventive care, diagnostics, treatments, physicians, hospitals and hospice care. Transparent population health would reveal results of that rationing in different costs and clinical outcomes for patients on different insurance plans. How would it be for business if Humana®/Aetna® patients were dying or more sick than age and disease matched UnitedHealthcare patients? Insurance companies do not want the clinical outcomes of their patients revealed via population health. These insurance companies don’t want to compete capitalistically based on the value or quality or the cost of the clinical outcomes of their patients. Population health would also reveal regional and national disparities of billing and reimbursements which may demonstrate collusion against physicians or hospitals.
- Pharmaceutical industry – Pharmaceutical companies do not want population health to force them to compete capitalistically based on the value or quality or costs of the drugs they produce. It would not be beneficial for pharmaceutical companies if their expensive name brand drug performed no better or even worse than a generic or a competitor’s alternative. In addition, the companies would have to change their direct-to-consumer marketing from, ‘don’t trust your doctor’s history and physical exam, instead ask your doctor if our drug is right for you’ to ‘our drug is more expensive and works no better than the generic alternative or another companies drug, so ask your doctor if our drug is right for you.’ Population health would also reveal regional, national and corporate disparities of pricing and supply which demonstrate collusion against Americans or different population groups.
- Medical Malpractice Industry – In order to use the population health clinical outcome or value data to improve under-performing physicians and institutions, medical malpractice lawyers will need to be curbed. The practice of Medicine remains the only profession in the world prevented from policing itself and performing quality control (QC). Instead of prospectively identifying under-performers and preemptively correcting them via population health value data, we simply retrospectively sue physicians’ scrubs off creating a never-ending cycle of errors and defensive medicine. The medical malpractice trial and insurance industry is huge and neither will want to be neutered in any way by interoperable population health just to improve the practice of medicine in America.
- Academe/Publishing/Hospital – These three symbiotic industries exist based on the rights of refusal and ownership of patient, clinical trial and translational research data and associated intellectual property. Until today, the billion dollar publishing industry has had a sweet deal. Medical researchers provide free content and editing and publishers reap the profits of advertising and subscriptions. Academics ascend their institutional hierarchy via publishing delayed peer reviewed clinical data which would, with interoperable population health, be available instantly via the world wide web either from the bench to the bedside. Thirty years ago academe teamed with the tobacco industry to neuter the Senator Shelby Amendment which would have made all reproduced publicly financed research data available in real time on the web via the Freedom of Information Act. Five years ago the federal government again passed a law demanding the rapid dissemination of publicly funded reproduced research data. Both of these laws have been ignored by researchers, publishers and academic institutions in favor of a 200-year-old delayed publication process. Academe, or your larger tertiary care university-based medical centers, also exist clinically based on the impression that their hospitals produce clinical outcomes which are superior to those of the surrounding communities or regional hospitals. Indeed, the Cleveland Clinic and Mayo Clinic and others have opened a host of satellite facade clinics around the nation staffed by local doctors. Academe doesn’t want to compete capitalistically based on the quality and cost of its outcomes or value which would be revealed by interoperable population health. No self-respecting hospital administrator wants their hospital to be known as having the second best outcomes or costs in diagnosing or treating any disease.
- EMR/EHR and Billing industry – HIT (health information technology), EMR/EHR and billing systems, despite twenty years of products, remain the only IT utilized by any industry which fails to improve the quality or price or value of the product manufactured or produced by the industry. Clinically, the only proven benefit of HIT is to allow physicians and hospitals to up-code office visits utilizing the availability of default software. EMR studies have demonstrated that most physicians spend two hours inputting data for every single hour spent with patients. This physician inputted data is then sold for profit by the EHR companies to ancillary industries without any aggregated benefit for patients or their physicians. Simply stated, this industry consists of dozens if not hundreds of companies all claiming that their intellectual property protected software is ‘the best’ yet deliver nothing of Value=Outcomes/ Costs to the physicians or patients. Standardization and integration via common application programming interface API’s associated with interoperable population health would greatly downsize this HIT industry. The EMR/EHR industry is highly subsidized with government forced purchases by hospitals and physicians and does not want to compete capitalistically or be downsized due to standardization or integration of interoperable population health.
Despite the fact that interoperable value based population health would be extremely beneficial to patients who suffer and their doctors who practice medicine, we’ll never see it happen in our lifetimes due to the five industries which have deemed themselves ‘too big to fail.’ Coincidentally, our lifetimes will be shortened due to the inability of population health to reveal the preventive, medical, surgical and palliative outcomes doctors produce with their patients according to all charted variables.