Big Brother will be watching!

As I was driving home from the airport Wednesday morning I heard an enlightening interview on NPR, my default radio station.

Massachusetts, under then-governor and future Republican presidential candidate Mitt Romney, implemented the nation’s first full-court press toward insuring everybody. Now they’re having trouble paying for it. Imagine that! Who woulda thunk? So Congress is watching closely.

“The first thing they decided – unanimously and right off the bat – was that the current way of paying doctors, hospitals and other medical providers has got to go," reports Richard Knox. "… Massachusetts is going to try to kill off fee-for-service.”

Massachusetts policymakers want to replace it with "global payment" – paying groups of health care providers a flat yearly fee for each patient they cover. "Global means it's for all services," says Dr. Rick Lopez, chief physician executive of Atrius Health, one of Massachusetts' biggest doctor groups. "It includes when the patient comes in to see the physician, hospitalization, pharmacy, skilled nursing facilities, home care services – the whole spectrum."

Gee, that sounds a whole lot like “full capitation,” doesn’t it? That means they’re going back to “gatekeepers,” aren’t they? Remember how much fun that was? The calls in the middle of the night for permission to patronize the ER for belly pain? Patients questioning our integrity and commitment to them, rather than our income?

Ah, but this time it will be different! The problem in the 1990s was that there was no way to track, identify, prosecute and execute the bad apples in the primary care specialties. But now there IS a way! Read this carefully:

"To avoid a repeat of that experience, advocates of global payment say health providers will have to be watched closely. 'You need someone monitoring this,' says Nancy Kane of the Harvard School of Public Health. 'You can't just walk away because you've set the limit.' Kane is a health care finance expert who also served on the recent Massachusetts Payment Reform Commission. She says there are ways these days to prevent stinting on care. 'There's a lot of quality measuring that can go on now that didn't used to be available,' she says. 'We now have electronic medical records. It's easier to monitor what's going on. So I think the whole reporting system and the intention to maintain a monitoring infrastructure is all critical to avoiding the bad days of managed care.'"

Academics and bureaucrats love terms like “monitoring infrastructure.” That’s an Orwellian term for “Big Brother Is Watching You.” It sounds so easy, and so painless. But, of course, the Devil is in the details.

And, of course, there's the problem of the surgeon who examined my nurse for five minutes, sent me a three-page dictation, and charged for a top-dollar consultation physical. The system Massachusetts is heading toward will punish the honest, and reward the liars. Next step: Every encounter will be filmed by a hidden camera, and stored on government servers.

Until I heard the italicized comment above, I thought my friends in the blogosphere – who viewed the EMR as a plot by insurance companies to deny care – might be a bit paranoid. Mea culpa. They were right all along.

Dr. David Kibbe, who is as close as it comes to a guru in FP-IT, penned a great opinion piece in the latest Family Practice Management. He advocates plug-and-play modularity for components of the electronic medical record. Rather than a single vendor providing a comprehensive program at an extortionate price, with the separate elements always lagging the latest innovations in the marketplace, these elements should be disintegrated.

As Paul Nutting wrote in his initital assessment of the National Demonstration Project, “[I]t is possible and sometimes preferable to implement e-prescribing, local hospital system connection, evidence at the point of care, disease registries, and interactive Web portals without an EMR.”

To which I say, “Amen.”

Dr. Kibbe goes on to describe the ugly political state in which the Academy is trapped. (It essentially backed the wrong horse in the Derby, and now there's no winning ticket to cash.) Big vendors are fighting tooth-and-nail to slow the shift to plug-and-play modularity – that is, the same way you can buy separate applications, cheap, for your iPhone. They succeeded in getting the Feds, as part of their incentive program to adopt EMRs, to mandate comprehensive applications from single vendors.

This is an old, and familiar, political game. This is how we continued to subsidize tobacco farmers while we stigmatized tobacco users. This is how we continue to subsidize corn farmers while Americans are fattening on fructose-flavored soft drinks. This is why politicians should be banned from certain activities.  

The fundamental problem, of course, is that we are led by politicians. They’re not bad people. They’re just different than those of us who would rather deal with chronic fatigue syndrome than collaborative back-scratching.

I suppose it’s my own fault – me, and tens of thousands like me. I never liked committee meetings. I liked patients. Mea culpa, mea maximal culpa.

Posted at 11:37AM Aug 27, 2009 by Doug Iliff  |  Comments[0]