Healthcare

The complexity of the healthcare ecosystem and the trans-disciplinary convergence which is essential for its function, makes it difficult to address healthcare as one domain. Divided in various stages for ease of management, healthcare is quintessentially a continuum which commences at birth and may cease at death. In this paper, we have attempted to take a broad view but it still isn’t broad enough. We have focused on issues, such as, data and interoperability, yet it scratches only the surface of these sub-domains. For the specific problem at hand, we propose an “http” approach to adopt open standards to enable medical equipment and devices to share and synthesize data using ICE (integrated clinical environment), a medical device interoperability platform. ICE may help reduce deaths due to preventable medical errors. Thinking about the future of data in personal healthcare, we propose creating an ecosystem which contributes data from multiple health related domains. Data curation and analysis of the information may boost our health related knowledge. Increasing connectivity and improving infrastructure may help, among other things, to uncover facts and observations which may influence the future of global health. Pg. 3 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected] BACKGROUND (US-CENTRIC) The legendary editor of the august New England Journal of Medicine, Arnold S Relman (1923-2014), offered an incisive perspective when he delivered the 171st Annual Discourse at the Massachusetts Medical Society on May 21, 1980 [1]. “According to an article in the Wall Street Journal of December 27, 1979, the net earnings of health-care corporations with public stock shares rose by 30 to 35 per cent in 1979 and are expected to increase another 20 to 25 per cent in 1980. A vice-president of Merrill Lynch appeared a few months ago (prior to this article) on "Wall Street Week," the public television program, to describe the attractions of health-care stocks. According to this authority, health care is now the basis of a huge private industry, which is growing rapidly, has a bright future, and is relatively invulnerable to recession. He predicted that the health business would soon capture a large share of the health-care market and said that the only major risk to investors was the threat of greater government control through the enactment of comprehensive national health insurance or through other forms of federal regulation” [1]. The sluggish progress of the US national health insurance initiatives [2] and the pugilistic powers in action [3] are indicative of the pugnacious influence of private health-care industries on national health policy. A broad national health-insurance program, with the inevitable federal regulation of costs, is an anathema to the medical-industrial complex, just as a national or global disarmament policy may be to the military-industrial complex. President Eisenhower was concerned about the unhealthy aspirations of the militaryindustrial complex and emphasized “we must guard against the acquisition of unwarranted influence” in his farewell address [4]. A similar admonition is applicable to the healthcare industry. Today’s medical-industrial complex is replete with aggressive enterprises vying for global dominance of epic proportions and maximizing profit taking at every step. The transmutation of healthcare, once guided by the ethos of the Hippocratic Oath [5], to a commodity guided by the free market economy to improve efficiency and quality, is deeply flawed. Application of business values [6] and operational optimizations are uninformed efforts by well-intentioned bean counters. Patients are not “consumers” or “clients” and doctors are not “partners” or “service providers” in the classical context of Adam Smith [7]. However, business relationships and “best practices” may be applicable when a hospital or a clinic is purchasing bathroom tissue or contracting for janitorial services or outsourcing valet parking. The latter is an operational function but cannot be referred to as healthcare. Hence, tools of operations management, for example, supply chain management, are useful only to a limited extent to things, equipment, objects or facilities, which are very likely to Pg. 4 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected] be less uncertain in their use or application because the goods or inventory, usually, are uninfluenced or unrelated to the practice of healthcare. These observations, however, have had little impact on the vast cost of consulting fees extracted from the healthcare industry by major firms [8] who continue to pontificate about business best practices to healthcare. Patients who are sick, or worried that they may be sick, generally, are neither capable of understanding their physiological status nor inclined to shop around for bargains. The value of life often far outweighs the consideration of cost. Patients and their families seek and demand the best care they can get irrespective of the price. Hence, the classic laws of supply and demand are ill suited because healthcare “consumers” may not subscribe to the usual incentives to be prudent, discriminating and frugal in their decision. This “decision” is not about profit and loss, even if glib management consultants may view it as a purchase. Health care is neither synonymous nor interchangeable with “medical marketplace” because the canonical rules of competitive economic equilibrium [9] are unlikely to be applicable. The tireless pursuit of the for-profit business process consultants to inflict the so-called supply chain principles from the “marketplace” on to healthcare is fraught with problems. It exhibits a flagrant disregard for the foundational distinction that must choose value over cost in the practice of medicine or the effort necessary to save even a single life. Economies of scale or risk pooling are not always applicable or even desired in health care. The root of the disequilibrium in healthcare is the heavy, often total, dependence of the patient (irrationally referred to as the consumer) on the medical practitioner (nurse or physician, viewed in the business framework as a service provider). The business consultants, administrators and software packages peddling the operational principles extracted from retail stores or grocery chains or manufacturing plants may not be fully cognizant about the seminal work by Kenneth Arrow referred to as information inequality [10]. The latter catalyzed more in depth analysis of markets with asymmetric information pioneered by George A. Akerlof, A. Michael Spence and Joseph E. Stiglitz [11]. It is interesting to observe that few business students, middle managers and corporate executives are able to connect the fact that the Forrester Effect [12] which later morphed as the Bullwhip Effect [13] is partly due to information asymmetry [14]. The resurgence of RFID [15] to ignite the digital supply chain [16] has had limited impact on the reduction of information asymmetry. The reasons may include dead weight of old technology, lack of an engineering systems approach [17], inability to evolve out of the organizational “silo” frameworks and punctuated connectivity. Taken together, productivity gains, if used as a (key) performance indicator (KPI), remains a paradox [18] while limits on our data driven prediction abilities [19] makes predictive analytics more of an art and less of a paradigm. Pg. 5 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected] The incisive foresight available from the application of the principles of information asymmetry to healthcare may explain why the usual assumptions about competitive free markets do not apply. There aren’t any known mechanism to the bridge the chasm of medical knowledge between the patient and physician in order to generate “equilibrium” through the establishment of “symmetric” information. The patient does not choose the plethora of medical tests or the regimen of procedures or plan for medication. Physicians decide the course of action. Hence, it is the physician who will influence 70% or 80% of all the expenditures associated with healthcare. The potential for financial abuse, therefore, is obvious, when private for-profit companies enter the market. Private healthcare companies can conspire to influence the decisions of the physicians to maximize profit [20]. The physician is a profit center – actively engaged in the business of the medical marketplace which is a service industry. This scenario may fit the corner service station at the intersection of Happy and Healthy, serving gas on demand. In Goldfarb vs Virginia State Bar, the US Supreme Court [21] handed down a landmark decision that found that the business activities of professionals were properly subject to antitrust law. Today, we are dealing with increasingly caustic consequences of that decision, as astutely pointed out by Late Arnold S Relman [22] in his 101st Shattuck Lecture at the Annual Meeting of the Massachusetts Medical Society in Boston on May 18, 1991 [23]. It would be a heresy to temporarily conclude this sketchy US-centric background without mentioning the influence of physicians and the organizations they champion (for example, the almighty AMA or America Medical Association). The forbidding political landscape in US healthcare reform was shaped, in part, by the physicians and their refusal to include government health insurance in the 1935 Social Security Act. In 1945, the AMA lobbied against President Harry Truman’s proposed universal health insurance program and delivered the fatal blow. In 1965, much to the chagrin of the AMA, it met with partial defeat when President Lyndon Baines Johnson created Medicare, a federal health insurance program for the elderly, and Medicaid, a combined federal-state program for the poor. President Bill Clinton’s failure was, in part, due to the opposition party who may have bullied the US Chamber of Commerce into withdrawing its support, as published by a senior member of the healthcare reform team, Paul Starr of Princeton University [24]. The timbre of compromises, tempered success and the catastrophic victory of President Obama’s Affordable Care Act on 23 March 2010 [25] capped a struggle for US healthcare reform that commenced even before 1935. The legal name of “Obamacare” is The Patient Protection and Affordable Care Act. One cornerstone of PPACA is patient protection. This paper and our mission is focused on patient safety. Without patient safety, it may be wellnigh impossible to adequately address what is necessary to ensure patient protection. Pg. 6 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected] Quote from: The Health Care Industry: Where Is It Taking Us? by A. S. Relman [23] Physicians can no longer act collectively on matters affecting the economics of practice, whether their intent is to protect the public or simply to defend the interests of the profession. Advertising and marketing by individual physicians, groups of physicians, or medical facilities, which used to be regarded as unethical and were proscribed by organized medicine, are now protected indeed, encouraged by the Federal Trade Commission. Advertisements now commonly extol the services of individual physicians or of hospital and ambulatory facilities staffed by physicians. Most of them go far beyond simply informing the public about the availability of medical services. Using the slick marketing techniques more appropriate for consumer goods, they lure, coax, and sometimes even frighten the public into using the services advertised. I recently saw a particularly egregious example of this kind of advertising in the Los Angeles Times. A freestanding imaging center in southern California was urging the public to come for magnetic resonance imaging (MRI) studies in its new "open air" imager, without even suggesting the need for previous examination or referral by a physician. The advertisement listed a wide variety of common ailments about which the MRI scan might provide useful information — a stratagem calculated to attract large numbers of worried patients whose insurance coverage would pay the substantial fee for a test that was probably not indicated. Many respectable institutions and reputable practitioners advertise in order to bring their services to the public's attention. But in medical advertising there is a fine line between informing and promoting; as competition grows, this line blurs. Increasingly, physicians and hospitals are using marketing and public relations techniques that can only be described as crassly commercial in appearance and intent. Before it was placed under the protection of antitrust law, such advertising would have been discouraged by the American Medical Association (AMA) and viewed with disfavor by the vast majority of physicians. Now it is ubiquitous, on television and radio, on billboards, and in the popular print media. Of course, not all medical advertising is as sleazy. Pg. 7 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected] IN PRAISE OF OTHER IMPERFECTIONS Four common [26] approaches are (a) private-sector (USA, Switzerland), (b) national health service (UK), (c) provincial government health insurance (Canada) and (d) social insurance (France, Netherlands, Germany). Founded in 1883, by Otto von Bismarck, Germany's Statutory Health Insurance (SHI) program insures about 99.9% of the country's population and is administered by private not-for-profit organizations, authorized by law to wield power on behalf of payers and providers. The federal government intervenes in the interest of public goods if the broader interests of society are neglected [27]. The SHI Health Care Structures Reform Law, passed in 2012, created a third care sector called integrated ambulatory specialist care [28]. The latter (IASC) and other efforts (in 2004) are an attempt to mitigate the negative impact on integration due to previous segregation of ambulatory and hospital care delivery. The segregation dates back to a 1931 decree by Chancellor Heinrich Brüning, which granted physicians in private practice a monopoly on ambulatory care and essentially prohibited hospitals from providing outpatient care (the emergency decree was a direct result of a physician strike). Economist Robert J Evans posits that the ethos of equality in the provincial healthcare system of Canada reflects a principle similar to equality before law [29]. The Canadian system is an imperfect hybrid of public funding (government taxes), private providers and universal coverage which is comprehensive in scope, affordable, single-payer, provincially administered yet works as a “national” healthcare system. It reflects political compromises, in face of powerful opposition [30]. The lofty idealism in the Canadian system is but a poisoned chalice to the US medicalindustrial complex. Big pharma, manufacturers and insurance companies poured more than half a billion US dollars to lobby US politicians [31] and even more was invested to commission studies with “alternative facts” to advocate that a US national health insurance scheme modeled on the Canadian system would not work. An excess of a quarter billion US dollars went into the coffers of political parties [32] to convince Americans that they will get inferior health care coverage and fewer choices with a Canadian system [33]. The US political momentum toward the lowest possible common denominator is a tool to preserve corporate interests in healthcare, for example, the lucrative dialysis business [34]. Measures and medication to reduce the need, cost and deaths due to dialysis [35] are often subjected to the vagaries of obfuscation or appears to be mired in chronic controversies [36] orchestrated with Machiavellian shrewdness. Public illiteracy of science and medicine goads forward profit optimization routines. Those who know and can shed light on these unscrupulous practices are failing to sustain their opprobrium and silence fuels repetition. Pg. 8 ● THE ICE AGE COMETH ● [email protected] or [email protected] and [email protected]