Danny Lieberman, the founder of Pathcare – talks about why we should be spending less money on healthcare and more on collaboration.

The root cause of big failures is always hubris.

Think about hubris in healthcare when you read this article.

The most highly publicized software failure in history, officially abandoned in January 2005, was the US FBI Virtual Case File IT project, where $170 million in software development was written off with no government accountability. VCF was supposed to automate the FBI’s paper-based work environment and allow agents and intelligence analysts to share vital investigative information. Sounds  lot like the goals of modern EMR systems – paper reduction and data sharing – doesn’t it?

In the software engineering industry, adding more resources to a project that is late and expensive will only make it even later and more expensive. This is the analogy of how the US is trying to “fix” their “broken” health-care system.

Obesity – cause or chance?

Read the following statement:

In the McAllen Texas metropolitan area, 38.8 percent of the residents are considered obese according to a Gallup study from 2011, ranking McAllen TX the most obese Metro area in the US.”

What do you make of this?

Your mind has been very active for a few seconds – some effort was involved, your heart rate increased, your pupils dilated.

Very likely, you ended up focusing on the fact that McAllen is in Texas, with a lifestyle where people drink more and exercise less.

Now read the following statement:

In the Boulder Colorado metropolitan area, only 12 percent of the residents are considered obese according to the same Gallup study from 2011, ranking Boulder CO as the least obese Metro area in the US.”

What do you make of this?

Very likely, you ended up focusing on the fact that Colorado is located in the Rockies with a rural population and a recreational and sports-oriented lifestyle where people eat healthier and spend more jogging and biking.

Is a rural, sports-oriented lifestyle an indicator for reduced obesity?

Maybe. Maybe not.

Consider the number of state parks and visitors as a proxy for a recreational and sports-oriented lifestyle. Courtesy of the US National Park Service we see the following:

Colorado has 13 national parks and 5,805,431 visitors to national parks (in 2011). Texas has 13 national parks and 4,373,534 visitors to national parks (in 2011). Colorado has 49 people/square mile and is ranked 37th in the US in population density and Texas has 98 people /square mile and is ranked 2d in the US in population density.

Since Colorado has 50% more visitors to national parks and only half the population density, we may assume that most of the visitors to Colorado’s state parks are from out of state.

The number of national parks visitors in a particular state, therefore does not look like a good indicator for a healthy sports-oriented life style that would reduce obesity in a particular geography.

Is population density is a good indicator for obesity?

Boulder CO (population 98,000 in the US 2006 Census) has 30% less people than McAllen TX (population 133,000).

Living in a smaller city in a more rural area might be healthier since the air is cleaner and there are less fast-food opportunities for Tex-Mex cuisine, cheeseburgers, cherry-cola and fries.  However, public-health statistics show that cardiovascular-disease and asthma rates in McAllen TX are lower than in the US national average.

So something else is going on besides lifestyle and density of greasy spoons.

McAllen is  one of the most expensive health-care markets in the country.

In 2006, Medicare spent fifteen thousand dollars per enrollee in McAllen, almost twice the national average.

El Paso TX has similar public-health statistics and demographics of non-English speakers, illegal immigrants, and unemployed. El Paso health-care costs are half those of McAllen.

And by the way, the income per capita in McAllen is only twelve thousand dollars.

McAllen’s health-care costs are so high because doctors, are maximizing revenue with extra tests, services, and procedures even though higher costs (which are higher revenues for physicians), do not translate into higher quality-of-care in McAllen.

On Medicare quality metrics, McAllen’s five largest hospitals perform worse than El Paso.

Not only are extra procedures and tests not as cost-effective as simple means such as exercise but they also create more risk which in turn pushes up the cost of health-care and reduces quality-of-care even more.

Focus on continuous quality improvement and teamwork

Grand Junction, Colorado, has Medicare’s highest quality-of-care scores and lowest cost of health-care in the US.

Years ago doctors in Grand Junction setup a system that paid them a similar fee whether they saw Medicare, Medicaid, or private-insurance patients, so that there would be little incentive to cherry-pick patients. At the initiative of the local HMO, physicians also meet regularly on small peer-review committees to go over their patient charts together. They focus fixing root causes of problems like poor prevention practices, unnecessary procedures, and unusual hospital-complication rates.

Problems went down, quality went up and costs ended up lower than just about anywhere else in the United States.

See  article by Atul Gawande – The New Yorker in 2009 The Cost Conundrum for the full story of McAllen TX.

Confusing profit with patient

The Affordable Care Act adopted in 2010 will allow employers to charge obese workers 30 percent to 50 percent more for health insurance premiums if they decline to participate in a qualified wellness program.

If you live in the US and you are obese you will pay 3 times: pay for damaging your health, pay more for health-care insurance and pay a third time for a qualified wellness program.

Some folks think that it’s better for the government to pay for health-care and others think it’s better for private insurance companies to pay. Others think, patients should have some skin in the game and pay a premium out of their own pocket as a sort of governor on the demand-side of healthcare.

The problem with all of these models is that they turn the patient (the obese person) into a profit center. The employers reduce their costs on participation in health-care coverage, the insurance companies increase their revenues and the qualified wellness program providers create new revenue streams from people who live off fried snickers, cheeseburgers and cherry cola.

In order to improve the quality-of-care, we need to take medicine back to basics – good patient-physician relationships – caring about patient health and doing so with the best evidence-based medicine and with the best technologies for a physician to reduce his stress and speed up decision making instead of enslaving highly trained physicians into data entry with CPOE




Danny Lieberman is the authority in applying threat analysis to Governance, Risk, and Compliance (GRC) in healthcare. He is a sought-after speaker, prolific blogger on healthcare technology, and advisor on software security and privacy compliance issues to healthcare and medical device vendors. He is passionate about Pathcare: the private social network for a doctor and her patients. Danny is a solid-state physicist by training, professional programmer by vocation and avid amateur saxophonist and biker.

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