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Curbside Consult with Dr. Jayne 5/23/11

May 23, 2011 Dr. Jayne 6 Comments

5-23-2011 6-33-59 PM

I was looking for the perfect quote to start this week’s Curbside Consult and thought I had it nailed. Like many avid readers, I tend to remember bits and pieces of great literature, but not everything. Just enough to do passably well at cocktail parties and trivia nights, but not well enough to lead a book club.

So, when I hit the Internet to validate the quote I was going to use, I was blown away by the parts I had conveniently forgotten.

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…

This is the opening of A Tale of Two Cities by Charles Dickens. I was going to use the best of times / worst of times metaphor to talk about two recent physician visits, one of which was electronic and one was paper. I’ll let you guess at which one was which because the poignancy of the rest of the quote and how applicable it is to healthcare in general strikes me too much to want to talk about anything else.

First published in 1859, the story is set in the tumultuous time of the French Revolution. The opening line serves largely to portray the contrasts inherent in that time — poverty vs. affluence, ignorance vs. enlightenment, good vs. evil, and so on. When you think about it, sometimes it seems that things haven’t changed as much in the last two hundred as we might have hoped. It feels like we’re on the cusp of a different kind of revolution, and not necessarily for the better.

Undoubtedly, this is the best of times for many people. People are living longer, largely due to improvements in health technology. Mechanical replacements for diseased body parts, amazing new drugs, implantable defibrillators — you name it.

We are, however, in a system with a great deal of inequality about how this technology is employed, resulting in a great cost to society and for many a great personal cost as well. Medical bankruptcies are again on the rise, accounting for more than sixty percent of all personal bankruptcy filings. The worst of times, indeed, when people have to choose between purchasing food and filling their prescriptions.

Meaningful Use should be the poster child for the age of wisdom and the age of foolishness. It seemed so promising: “free” federal money for providers to do what they should have been doing all along, implementing systems to improve patient care and strengthen patient safety. Many providers were already doing these things, and it seemed so easy to reward them.

The way it’s unfolding, though, is just sad. The disparity between the Medicaid and Medicare incentive programs is laughable. At times, the whole business feels like a crapshoot. If this were an investigative study, it would never have made it past the Institutional Review Board.

Many of us on the healthcare IT side of things are living in the spring of hope. We’re well on our way to having the right software installed with the right workflows and the right numerators and denominators kicking out at the end.

For some of us though, this will lead right into the winter of despair. Meaningful Use is the ultimate pass/fail class. Miss the mark by half a percent on one measure and you’re out. This doesn’t seem in keeping with the spirit of trying to improve healthcare and health outcomes.

What if we treated patients like this? “I’m sorry Mr. Jones. I know you’ve done a tremendous amount of hard work to get your diabetes under control, including exercising and losing weight. However, your hemoglobin A1c level only came down from 9.0 to 6.2. The goal was 6.0, so you lose. Here’s a scarlet ‘L’ to wear on your shirt. I’m raising your health insurance premiums by 40%.”

Many of my peers have done the math and know that even with the penalties that are coming, they can “do nothing,” see one or two more patients a day, and come out far ahead of their colleagues who are on the MU hamster wheel. Could the unintended consequence of ARRA and healthcare reform be the downfall of Medicare and decreased health outcomes for our growing senior population? Will it be the final blow to an already ailing primary care workforce? Will it be little more than a windfall for technology interests and consultants?

Only time will tell. But I leave you to ponder on the closing lines of the book.

It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to than I have ever known.

E-mail Dr. Jayne.

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Currently there are "6 comments" on this Article:

  1. Wow, nicely said.

    With the power to regulate comes the responsibility to regulate only when appropriate.

    The entire Meaningful Use program seems to be off the rails and in need of more input from people who really care for patients.

  2. I couldn’t agree more. In fact I’ll take it a step further and suggest that MU will actually hurt us more since now the consultant vultures are circling the ‘cash cow’ carcass of incompetent overspending every large healthcare organization is throwing in their front parking lot.

  3. Dr Jayne,

    Well said. I’ve been in Healthcare Informatics for over 30 years and in that time have seen many attempts at reform both here and the UK. What’s always missing from these bureaucratic “Hail Mary’s” is the willingness to accept the patient as part of the solution. The patient is capable of making informed decisions if they have the data. Our focus needs to be providing that data and changing the incentives so that we are focused on wellness not disease.

  4. While I truly appreciate that well written commentary and particularly the use of the full Dickens quote. However I can’t help but watch (and partiicpate) in this process and not think of Joseph Heller’s famous Catch 22

    A logical formulation of this situation is:

    1. Premise: If a person is excused from flying , that must be because he is both insane and requests an evaluation.
    2. Premise: If a person is insane, he should not realize that he is, and would have no reason to request an evaluation
    3. Definition of implication: since an insane person would not request an evaluation, it follows that all people must either not be insane, or not request an evaluation
    4. De Morgan: since all people must either not be insane, or not request an evaluation, it follows that no person is both insane and requests an evaluation
    5. Modus Tollens: since a person may be excused from flying only if he is both insane and requests an evaluation, but no person can be both insane and request an evaluation, it follows that no person can be excused from flying

  5. Excellent – really liked” Meaningful Use should be the poster child for the age of wisdom and the age of foolishness”

    And oh the penalties. How could anyone survive them? Lets see…as I have posted here before an MU penalty could cost a single doc the princely sum of maybe $2k !!! And that is assuming there is a Medicare market basket adjustment of 2% in 2015. Given the state of federal deficits…big assumption. No MB adjustment means – no penalty!

  6. Nice article Dr. J. Supporting to your article some facts/
    perceptions about MU criteria :

    Providers – Benefits or Harms ?? its like putting cart before the horse( problem of creating “meaningful use” rules for health IT before usability issues were resolved)
    Question on Cost + usability ??

    Patients – what is that about ? Is it going to cure us better ?

    Vendors- still struggling to find out its Intrinsic value ….

    Government- “ Trick or treat model” approach to address the need of healthcare reform .

    CURRENT APPROACHES TO U.S. HEALTH CARE INFORMATION TECHNOLOGY ARE INSUFFICIENT http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=12572
    It is reported that HIT in its present form does not support physician cognitive needs and that our approaches to HIT are “insufficient” to achieve stated goals

    Do we need to rework on our approaches ?? Is Meaningful Use criteria turning to be Meaningless + Useless ??

    may be another 864 pages to work on. Get ready !!!







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