To summarize, Chowka warns that nationalized health insurance will lead to nationalized data which will lead to totalitarian control over a pacified population. Basically, he prefers "Murder by Spreadsheet" over Murder at Gunpoint. Sound pretty scary? Not really. Seeing the error in his logic requires a little background in his personal flavor of socializedmedicinopobia though and some definition of terminology.
National health insurance is being promoted by parts of the US public, physicians, hospitals, and politicians based on cost savings and a perceived requirement for full access to medical care. I say perceived because we get to the notion of a "requirement" from different perspectives: moral, Constitutional, even plain old self-defense (i.e., I'll be my brother's keeper if he has a communicable disease), among other rationales.
NHI is not sufficiently justified by improvements in quality of medical care, although there is hope that health will improve with better and wider access. But what if simply nationalizing payment could actually degrade the quality of care?
What is imprecisely called "Universal Health Care" lately is not universal but national, and not care but insurance. The goal is health care, its delivery channel is insurance. The problem to be solved is that the insurance channel is neither wide enough nor reliable. Just when you need it the most, the natural obstacles in the channel (i.e., shareholder value) prevent the flow of care.
National health insurance is a reform platform that reduces insurers from many to one (i.e., one set of rules, one "spreadsheet") and does not address private doctors or hospitals. Most consider the single payer to be the federal government, but as with the Federal Reserve and the SEC there are quasi- or extra- governmental structures that can suffice. But the costs are paid by money collected at the federal level - from many pockets to one pool.
Here's a scenario in DrSteveB's diary to create funds to pay the bill for NHI. The bill is really a calculated payment rate per person since all people will be in a single pool. Rate setting for NHI will need intersections with care protocols (e.g., diagnostic codes), rationing (e.g., queuing, emergency), standards, and other components of the cost of health care. But while NHI is bound to have reciprocal influence on the components of cost, NHI does not (necessarily) drive those components.
Mr. Chowka is opposed to national single-payer health insurance because he believes it's a gateway to totalitarianism - first it will stifle medicine, then us, citizens. He sees current technology as already enabling an overzealous level of constraints on privacy, innovation, and freedom and he fears conformity at the expense of quality. He doesn't address those of us who don't have the luxury of health care.
According to Chowka, reducing the many insurers down to a single payer means a single birdseye view into both demographic and utilization data which will boost the capabilities of the (evil) controllers. While I disagree with his conclusion, he's correct in the possible consequences of nationalized assets. How are his concerns allayed? Through a proper patient-centered architecture for care, regulatory and audit functions and reusing the best from Medicare, the VA, and other successful large scale providers.
Where Mr. Chowka sees showstoppers deserving alarm, I see a few mistakes in his logic plus a useful set of what I'll call, NHI implementation issues - known gotchas - to be aware of down the road. I think he's right to warn the public about nationalized data (e.g., emails, phone calls, and yes, health records) and its dependency on stricter privacy legislation and more importantly, public audits. But rather than use this information to arrest progress, accelerate it. Raise clinical information maturity levels in parallel with health insurance reform and to precede health care reform (i.e., first the insurers, then big pharma). Once physicians are in control of their own domain again, they can define the the parameters and participate in standards and oversight which should be welcomed components of infrastructure as they are today by honest brokers in health care vocations.
From "Medicine At Gunpoint - The Sicko Crowd's Deadly Rx For America" (my emphasis):
The disparate forces that have come together to make, promote, and use Michael Moore's film Sicko share an old and bankrupt collectivist agenda. But all of a sudden in 2007, their blueprint is hotter than ever and is being hyped as the final solution to the widely reported problems with American medicine.
In recent years, the dual operating systems for running health care delivery in the U.S.- an incompatible mix of the traditional for-profit private sector and the increasingly influential, federally-funded...have developed strategies and techniques that might serve to pave the road towards total government-run "universal health care" in the near future.
Well yeah, the out-of-control traditional for-profit sector rutted up the road so much people looked afresh at free market business alternatives like economies of scale, elimination of redundancies, and obsolete business processes. Yet, he paints the picture of a centralized structure intending to provoke a knee-jerk political objection to perceived Big Brother behavior and what he sees as the increasing pacification of the public. I'm kindly setting aside his misplaced socialized-medicine phobia. By the way, the author's use of inflammatory words (e.g., "final solution") is characteristic of his web site where you'll see Godwin's law violated and right wing hyperbole that belies his reputation in alternative medicine.
A technological imperative is helping to drive, and is providing the mechanisms that enable, increasingly intrusive public policies that favor maximum control of the population and the alarming loss of personal freedom....
the ultimate matrix of domination than in the brave new world of socialized medicine that many people like Moore are heralding. Two linchpins essential to the success of statist health care delivery are Electronic Medical Records (EMRs) and Evidence Based Medicine (EBM)...
A major stated purpose of Electronic Medical Records is to amass enough data to enable bureaucrat "experts" chosen by the government to measure "evidence" of medical "outcomes," and to determine which therapies, drugs, tests, and other procedures are supposedly the most effective, both clinically and in terms of cost, according to the current scientific fashions. The final step is to publish standards of practice that every doctor and health care professional in the country will have to follow. These clinical directives from on high constitute the EBM or Evidence Based Medicine part of the "E"-quation. Also part of the plan is to monitor much more closely-and to modify and control-an individual's behavior (eating, drinking, exercising, smoking, and other "lifestyle factors," and even whether or not a person takes his medication exactly as prescribed) with improved health status as the promised outcome.
Now I'm really interested because health information technology (HIT) is an area of my expertise. As one who values alternative medicine, I share his concerns for the stifling of innovation. But not enough to ignore the value of information and predictive medicine. Also, having had experience with promoting outcome measurements to physicians I can predict that physicians will be mighty guardians of this gate. Physicians do not like their performance, easily confused with "outcomes," measured.
Data, data quality, and measurement of aggregated data are the key gating features for EBM. Without the ability to measure something, it can be gamed, but it can't be managed. But to measure enables management - either mismanagement or managing for efficiencies and the common good.
As Mr. Chowka gives examples of the downside of EBM I start to understand the recommendation from my friend...Arguably (?), the influence of the pharmaceutical industry, in collusion with providers, has over-medicated America. Chowka looks at the use of statins as an example of EBM gone wrong. He covers the decision in England's NHS to test all citizens for cholesterol and prescribe statins virtually across the board to reduce cholesterol, regardless of other risk factors of heart disease, regardless of the ill effects of statins.
Without being expert, but an informed and interested patient, I agree. In fact, I have elevated cholesterol and have refused treatment with statins.
...the days when the practice of medicine was a highly individualized science and art of healing, with the doctor-patient relationship paramount, sacrosanct, and protected, are gone or going fast. From now on, especially if universal health care becomes the norm, there will be fewer unique treatments actually available to the patient, and instead more rigorous enforcement of the "approved" ones (à la the British model described above). If the doctor wants to get paid (or to stay out of jail), he will have to kowtow to the new official government cookbook of allowed and approved medical practices, and avoid the verboten ones. To ensure compliance, the government will be looking over the physician's shoulder as he electronically documents and communicates to the central databases everything he knows about and has done for his patients, down to the minutest details.
The author has a point here yet also has more faith in EMR than current technology has delivered. Also, the doctors are key stakeholders and while Chowka seems to assume that doctors are not making these decisions, I would suggest that they must and will under NHI.
Then Chowka goes off to make hyperbolic connections between "universal health care" proponents and a nefarious "nexus of competing agendas" on the far left, communists, socialists, and everyone who hates America. But his key concerns rise from a conflation (mistaken, ideological, or rhetorically mendacious) across his 3 villains: NHI, EMR, EBM. He sees NHI as a gateway to EMR and then, his worst case scenario, EBM. Remember, with EBM, alternative health strategies will have fewer, um, payers.
Electronic Medical Records (EMR)
EMRis a reality today in America and is independent of and (by law?) secured from the insurance and payment processes of health care. With or without national health insurance, Americans are coexisting with EMR in hospitals, clinics, and HMOs (e.g., Veterans Administration, Kaiser Permanente). Currently, EMRs are distributed by provider, meaning there is no known centralized national database (although seriously, the NSA can be assumed to the have access to all data in the universe on request by now). While there are national health care communication standards there is not sharing of data.
The collection of patients' various paper files, x-rays, and lab forms - all stores of health data - into a single, consolidated digital medical record available across a network can theoretically be accessible where ever the patient is. There are important privacy concerns - regardless of heath care reform - which were initially addressed in the Clinton administrations' HIPPA legislation. Is it enough? I doubt it. Should it influence rolling out NHI? Absolutely not.
EMR is a health record database, clinical, not administrative, not used by insurers. EMRs commonly link to administrative customer databases, may even share demographics, but clinical data is supposed to be strictly secured from non-clinical use such as administrative or insurance purposes. A firewall of separation exists to implement privacy and doctor-patient confidentiality and such security is an architectural critical success factor for EMRs. For instance, to my knowledge, Medicare today does not have direct access to patient records in electronic form or otherwise.
EMR provides sufficient political content to deserve a diary of its own...but the bottom line here is that opposing NHI for fear of EMR is simply not logical. For some hortatory subjunctive: charge forth and appreciate EMR technology, realize that while their cost is very high (EMR will NOT reduce YOUR cost of health care), the quality and portability of your health information is much more valuable to YOU, with you, wherever you are, and your doctor in a single cleaned electronic store. Look forward to less parochial more aggressive privacy and security oversight. But just like because your email can be easily stolen, you don't insist on snail mail forever and only, don't be afraid of EMR like Mr. Chowka suggests.
Evidence Based Medicine (EBM)
EBM is simply the concept of best practices, supported by data, or evidence. It's a practice built upon research of individual and patient population data, which enables optimization of methods and procedures. Best practices are re-formed into guidelines and protocols that will reliably result in predicted outcomes. The bigger the population, the better the evidence is and the better the guidelines can be (i.e., the more value in imposing standards). For some, predictive medicine provokes a fear that guidelines will be overly restrictive. Of course, like in other disciplines, the size, span, and quality of the frame of the viewer will also create predictive aspects. EBM has been used to deny coverage and limit physician choice. But do we toss the whole discipline out because it can be abused?
The fear here is basic - we know smoking kills, we modified our behavior to not smoke, and now there are laws preventing smoking. Therefore, predictive medicine results in reduced freedom. What's next...? <foreboding music>
Let's go back to the cholesterol example. Aggregated data shows that people who have heart disease also tend to have high cholesterol. Too much cholesterol is a bad thing. No data supports a causative relationship between cholesterol and heart attacks, and there are people with very high cholesterol who do not have cardiac disease. So, some use this as an example of EBM gone wild - if providers give statins, and lower cholesterol in the population, then there will be less heart attacks overall. OK, fine. I'm still not taking the statins until all of the other lifestyle issues are handled, and may regret that. As Chowka says, EMR enables such statistical analysis that leads to the trend in statins, a variety of EMB. So far, in the US we have the choice whether or not to accept treatment.
A better example of EBM is in prostate cancer. The more data available and aggregated from discrete, individual-level data in EMRs, the more cases professionals can readily review for trends, relatedness to other factors (e.g., age, treatments, nutrition), and the more robust and predictive the guidelines. So, if it is demonstrated that laparoscopic removal of prostates provides better outcomes than surgical removal, surgeons may be asked to retrain in the new procedure (or lose their jobs?), different equipment may be ordered (contracts lost?), the estimated number of inpatient nights will be reduced, new resident training is updated.
The term "outcome" is controversial itself. The surgeon can say that the only outcome to be measured is the cancer while the urologist may also include continence and erectile ability.
Here's an example of EBM used for rationing. Let's say that prostate specific antigen (PSA) blood test results of a certain number indicates a recommendation of surgery, or that PSA guidelines could be changed as a population is educated and data show positive outcomes with nutrition therapy. Since rationing is a necessary current reality, the large aggregates of data in EMR produce the knowledgebase that shows how much wait time each stage can withstand before surgery (i.e., the worst stage cases are treated the soonest while better stages don't degrade prior to treatment).
Another example currently in the news: the use of heart stents is being challenged now as a result of years of evidence that drug-lined stents can cause blood clots. With true EBM, data would show up long before pharmaceutical vendors would provide it. Mr. Chowka's point, if practices are demonstrated to be inferior, there probably will be pressure to conform. So? Professionals can manage a balance between innovation and best practices.
The fear Mr. Chowka shares with an unknown number of doctors is that their choices will ultimately be impeded by evidence, or the lack of it. Valid concern, invalid reason to slam NHI.
Imo, reactionary fear of information will stifle the whole civilization faster than too much information will stifle a profession. Just because we can do something wrong is not a reason for not doing it right. Most of the time, at least. Inaction is illogical to me, regressive, and more akin to the RW aspect to the author than his alt med side.
Summary
No government access to my health record. That's what I demand. An individual's medical record is exclusively for clinicians to use and NHI should not change that rule.
Electronic medical records can provide improvements in health care, portability and medical reform but EMRs are not insurance reform and do not address the issues of afford ability and junk insurance. A national single insurer should have NO physical access to patient data and we must legislate such provisions.
So, when politicians say they're dealing with Universal Health Care and digress right into electronic medical records note that they're changing the subject away from the issue of affordable health care for all, and maybe even hijacking the conversation to lobby for more corporate welfare to subsidize EMR at taxpayers expense. You see, we know EMR are a good thing because enterprises not driven by profit have demonstrated it. So, the for profit companies want the tax payer to cover their investments. Ha!
As for Mr. Chowka's review of SiCKO, his preference for flying below the radar is noted, but I say that his conflation of health insurance reform with all things evil is bad science, bad politics,and not supported by the facts. Remember, he is a complimentary alternative cancer therapies specialist. Who or what is he complimenting is the question.
Thanks for stopping by and reading this far; I hope it's helpful. There are plenty of items for discussion and argument here and that's the great thing about threads, put 'em all together and you get something material!
