Monday, December 31, 2018

Dander Up, Down, and All Around

Today's topics: VA health care politics; a clear-eyed and sane report from a bastion of managerialism, with related observations on innovators trying to create real bottom-up value.

It's the last day of the year, so let's get this done. Owing to various largely unforeseen challenges, happily now largely behind us, this "Dander" series was interrupted for some time. Apologies to anyone who noticed. In any case, to refresh: as Chief Blogger and FIRM president Dr. Poses has indicated often enough in these pages, health care developments raising our dander are still everywhere, all the time, and on the increase. Nothing particularly new here. Certainly not new since the 2016 election.

Except that in our current situation--inter-woven social (read: inequality) and political (read: everything inside the Beltway morphing from mere swamp to crazed greased pig trough)--the health sector is triply hard-hit. Really, it gets old to keep on playing nay-saying Cassandra. It's not normal.

Thus today in America the patient can't catch a break. It's probably true here more than in any other first world country. Others' budgets are as overstretched as ours, not to mention much lower as %GDP; their technology is just as uncooperative. Will yellow-vests to come out on the streets over it here, as they recently did over social engineering whence we got our Freedom Fries? (That may be up to just three guys: John Roberts and Trump's two new USSC nominees, as ACA makes its way to them yet again.)

No need to hyperlink the following examples. Everyone's immersed in them.
  • Obamacare imperiled by twisted politics and jurisprudence, even though its recent mild decline in enrollments probably means little or nothing and the body politic wants it.
  • Ultra-right wingnuts flexing muscle by urging the dismissal of the capable (and quite religious) head of the National Institutes of Health. Why? Stem cell research, a promising technology that's run afoul of some ideological right wing evangelical cant.
  • Net-net, IT's impact on health care, coming as much from the well meaning elitist left as from the elitist right, still negative. It enriches tech- and health-organizational CEOs while patient satisfaction, provider satisfaction and life expectancy all three tank. (I know, it's complicated--we also got that opiate crisis.)
  • Corruption in government, tech, hospitals and big pharma: can you spell "conflict of interest"? Read pretty much any recent posting in Health Care Renewal.
I could waffle on and on. But instead of that let me focus today on one thing that's got my dander up and another that's actually tamped it down a bit.

The VA, yet again. No doubt, forever. Or, Why's the VA Such a Punching Bag?

Dr. Poses has been feeding me troves of data and news about the VA. I'm happy now to report just a few highlights. Oh, wait: more like lowlights. Dreary as ever. Ever since the capable David Shulkin was fired, the question rings louder, "how bad can it get?" We now know the answer: bottomless pit.

Here are some of the lowlights. Bear in mind that, rightly or wrongly (we think mostly wrongly), Shulkin is now being blamed for all these deficiencies at the VA. Despite the facts that he was hamstrung from the get and that the VA was, like the EPA and others, one of the places where tge White House allowed chaotic privatization to run amok. We're in a fun-house mirror version of Ronald Reagan's "government is the problem."
  1. Suicide Watch. Under this administration, while suicality remains rampant among veterans of recent Forever Wars, the VA has fallen down grievously on the job of addressing it. Last month's report from the government's own GAO confirms this.
  2. Privatization Writ Large. Privatization initiatives, so dear to the hearts of cronies and lobbyists, are already in big trouble. Trump's own hand-picked successor to Shulkin recently had to admit to Contress the “The [VA] was taken advantage of because of the hasty nature that took place when the program was put together." Not budget dust, either: the agency paid out nearly $2B-with-a-'B' in unnecessary fees for these private booking "services."

    (In fairness let's put a little parenthetical note in here. As a former employee I know the VA itself causes unnecessary care delays. Service-connected disability ratings impede scheduling, as do salaried physicians' myriad ploys for putting the brakes on their own performance.)
  3. Privatization Writ Small. Still, this privatization thing is a great example of two-wrongs-don't- make-a-right. ProPublica informs us that what's "actually happened in the four years since the government began sending more veterans to private care: longer waits for appointments and, a new analysis of VA claims data by ProPublica and PolitiFact shows, higher costs for taxpayers." Can the VA claim better outcomes using any parameter at all? I think not.
  4. Mar-A-Lago. Lots more VA stories are leaking out. None are especially edifying. But in some ways the most alarming and tawdry among them is that surrounding the troika of unelected Florida golfing buddies. For months or more now they've been calling a lot of that agency's shots. Direct line to the White House, demonstrable responsiveness on the part of VA apparat. Maybe the crowning glory in this administration's reputation for cronyism, this group--comics mogul Ike Perlmutter (you can't make this stuff up), Palm Beach MD Bruce Moskowitz and lawyer Marc Sherman, collectively known as the "shadow rulers"--have pushed a lot of policies and expenditures for the VA with zero expertise.

    Unless a lousy golf handicap counts as expertise. Democrats have vowed a response in the new Congress, and we can only hope Speaker Pelosi prioritizes that. I think when it comes to Pelosi versus Ike's Marvel Avengers, the lady wins hands down. The conservative (and probably still somewhat Moonie) Washington Times reports this will happen in the first half of 2019--both from the GAO and the House Oversight Committee. These guys are super bad COI news, having weighed in with their scant expertise on way too much down to VA job candidates.
  5. The worst-of-the-worst for this poor agency is how the Shadow Rulers have gummed up its use of technology, especially IT. A little background: the VA was the one organization within the entire US Government that developed, back in the day with its VISTA technology, a fairly creditable in-house electronic medical record. VISTA, along with DOD's AHLTA (get it?) were supposed to play nice together but, despite billions in earlier expenditures, never did. VISTA might have survived but, starting with Shulkin (and probably predecessors) got deep-sixed by the bogus attractiveness of private-side EMRs.

    GE had its hands in there for a while: it deserves what it got (with AHLTA). Now since ~2015, thus pre-dating the current White House, it's Cerner. The main vendor rival to the privately-held Wisconsin cult vendor Epic, Cerner got the inside track to craft a workable EMR for the VA and DOD. But the Boys from Mar-A-Lago want to micro-manage this? Why? Earlier this month ProPublica disclosed part of the reason based upon FOIA-obtained emails. The doc among the troika has his own mobile app. Here's how it went down.
[N]ewly released emails also detail Moskowitz’s effort to get the VA and Apple to adapt his app. As a VA IT official described it in a May 2017 email, 'We are utilizing the native iOS mobile app, Emergency Medical Center Tracker, that Dr. Moskowitz developed.' VA health officials offered their own ideas for how a collaboration with Apple could benefit veterans, such as working on credentialing, data exchange and analytics, and suicide prevention research. But Moskowitz rejected the VA doctors’ ideas in favor of his own. 'These are good areas but not the emergency ones which my group of experts have identified,' he said in a May 2017 email. 'I sent an email to outline the recommendations.'
 'Nuff said. As someone who cared for thousands of veterans, I can't begin to describe how galling this is, even if the new guy, Wilkie, says he's trying to right the ship. While blaming his predecessors.

If these gentlemen from Florida--that bastion of fair elections and cost effective medicine--were instead gumming up Medicare, threatening the health of parents and grand-parents of business leaders, dot-commers, millennials and trust-funders, we'd have heard a lot more hue and cry about the VA and its shadow rulers.

Now I Pat Down my Dander. Soothing Words from Unlikely Places. 

Oddly enough, the worlds of IT--absent the shameful events described above in connection with the VA--and management are beginning to pull themselves out of their torpor. Under the dual impact of the HITECH and ACA enactments, the IT and management communities strove for years to accommodate to this brave new world of individual mandates and EMR meaningful use.

The result was rather anechoic. Unless you were right down there in the trenches, you heard little complaining about the baleful effects of the IT pall dropped into the doctor-patient relationship. Typical statement from EMR vendor CEOs: "my job is change management." (Ram it down their throats.) Typical statement from provider CMOs and CMIOs: "I only get to play with the Lego Blocks they give me."

That's changing now, and the signs are everywhere, though sometimes hard to parse. Nailing down the how and why of this change can be difficult, but the effects of "unusability" are emerging into a vocal majority consensus. Folks known as "thought leaders," such as Robert Wachter and Donald Berwick, have exerted part of this impulse to call a spade a spade in the interest of QI, citing, among other things, generational change. Smartphone users and tech-savvy students and house staff are much less likely to tolerate the

Some of those properly impatient young innovators--and I don't mean the septuagenarian Moskowitz--went on to found start-up companies that are starting to move tecnology out of its old, enormously dreary meaningful-use rut. They're bringing patients--"engagement" the new meme--back into the narrative.

What is this new narrative? The rather staid and managerialist health IT society, HIMSS, has this to say, couched in classic bureau-speak jargon, in its 2019 conference agenda, "6 Health Information and Technology Topics to Immerse Yourself in at HIMSS19." Translations into English follow each bullet.
  • Strategic Patient Experience Improvement (help the doctor with her workflow)
  • Aim for Secure Accessibility (make everything more secure)
  • Mapping a Vision to the New Consumer Landscape (improve revenue cycles)
  • Moving Precision Medicine into Primary Care (make "precision" medicine, whatever that is, or at least AI, work better--maybe with smart guidelines--for primary care providers)
  • Contextualizing AI for Healthcare (ok, we know that AI is really important)
  • Exploring the Pharma-Provider-Payer Relationship: the Last Step to True Value-Based Care (get everybody working together better now that fee-for-service care is giving way to bundling)
Stripping away the cant, however, these are actually pretty lofty goals. They show HIMSS coming into its own. Charge capture, upcoding, and dashboards for managers watching 30-day readmission tallies begin to sound so 20th century. Care coordination from the bottom up, not just the top down, begins to appear more attractive as studies start to show that top down doesn't always work all that well. (Caveat: find a way to read the whole JAMA piece, not just the online abstract. The journal's behind a paywall.) Leadership for such shifts is coming in many cases from outside classic health IT vendor-land, notably in innovation centers cropping up among many providers and payers.

Meanwhile, on just about a daily basis I learn about a new start-up addressing these issues, often based on newer concepts and approaches to workflow as ecological reflection of a unified community-wide integrated health care system.

Let's now move from specific health care realities and IT start-ups to the more general and philosophical matter of why it's taken so long to get to this place. Let me conclude by drawing the reader's attention to some recently emerging, and highly salutary, public intolerance to bullshit. (Can this be a result more broadly speaking of an emerging disgust toward insufferable politicians ?)

The recognition of obfuscation through bullshit goes well back into the mid-20th century. It was perhaps most famously addressed well over a decade ago in the elegant short book On Bullshit by emeritus Princeton philosopher Harry Frankfurt. But a much more recent vocal objection to nonsense in health care comes from a source that some might've considered heretofore unlikely: a couple of senior Wharton management professors. Though Lawton Burns and Mark Pauly barely mention their Princeton forebear in a secondary footnote, they nonetheless deserve an enormous shout-out for bringing attention to Detecting BS in Health Care. No paywall: use the link and download it now.

Burns and Pauly bring out all the other B's: to start with, buzzwords, bullets (silver), best (practices) and bandwidth. Lots of others. There's one B, however, that they espouse: bottom-up. Hard to know how firmly the Burns and Pauly tongues were planted in the Burns and Pauly cheeks, but for heaven's sake they know they're right about this. Common sense solutions so clearly and frequently give way to self-dealing and managerialist me-tooism in health care. Those who benefit from such nonsense have been called out often in this blog. But we can hope they now know not only are a few doctors now on to them, but some clear-headed individuals from the management establishment as well.

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