Reform School

 

At the last HIMSS event in Atlanta, I routinely asked people what they thought of the health reform effort, at the time still being hotly debated in Washington. Many people admitted they didn’t know what to think, as they were unsure of what the law actually includes, and were—like me—confounded by the very process by which the bill came to pass. Who ever heard of “reconciliation”? Or “deeming”? Can’t you guys just vote?

During the last year, as I tried to keep up with the particulars, I kept thinking back to the observation attributed to Otto von Bismarck, a 19^th century German politician: “Laws are like sausages, it is better not to see them being made.”

True, this bill could prove to be one of those watershed events that historians will use to denote epochal change. However, the new law is so sweeping in its scope I don’t think anyone can honestly say if it will be effective or not. The utter divisiveness which it engendered, would, in the long run, suggest the answer will be no. Obliging people to buy health insurance might prove as unpalatable as forbidding them to consume alcohol, as Congress so notoriously attempted during Prohibition. There are practical considerations as well. As Richard Gamelli, senior vice president at Loyola University Health System, pointed out last week at the Chicago gathering of the Association of Health Care Journalists, paying the penalty for not buying insurance will be cheaper than the insurance premium itself. Multiple panelists at the event made a similar point: no one really knows what the impact of the new law will be. Just this past week, however, Congress got a new analysis from chief Medicare actuary, Richard Foster, that predicted the law would increase health costs, not lower them.

In my view, the problem with the health reform push was that Congress, witnessing an unsustainable rise in health care costs, did not thoroughly analyze what is driving the spike. Instead, politicians on both sides of the aisle just lined up against their conventional bogeymen and assigned blame where politically expedient. Instead of meaningful discussion, we got death panels from the right and insurance company robber barons from the left.

As best I can tell, the working assumption became that rising health care costs are driven by the large number of uninsured. That is, no doubt, part of the equation, but it is only part. The rampant duplication of tests and the widespread inability to practice medicine against proven standards are cost drivers that the bill doesn’t seem to touch. Then there are a host of wild card issues, beyond the law, such as medical malpractice costs and our irresponsible health habits (a little-discussed provision of the bill does, however, mandate that fast food restaurants post the calorie counts of their menus and “a succinct statement” explaining their significance).

One year ago, I thought that the Obama Administration, through its EHR incentive program, was starting to steer the wagon in the right direction, even though common sense suggested that “meaningful use” would wind up being lodged in a bureaucratic vice that’s as tight as the phrase is ambiguous. After all—and I’m not going to mince words here--the only way to avoid duplication is to share data about what has been done, and the only way to practice, and measure, quality is through I.T. The EHR is no panacea to our health system woes, but it is a prerequisite to addressing them. Obama himself underscored that premise last summer before the AMA, giving a rousing speech that led to the once-inconceivable spectacle of physicians cheering a liberal Democrat.

But aside from a passage revamping some EDI standards, the reform bill mostly skirts the role that I.T. can play. Read between the lines, however, and you will see some policy decisions—and I’m not talking about the caloric disclosure provision here--that will make today’s health I.T. controversies seem like child’s play. I’ll tackle the biggest one in my next entry.