OP-ED

The Patient and the Snake Oil Salesman

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On June 11, 2016, James Madara, MD., addressed the American Medical Association’s Annual Meeting with some wonderful hyperbole. Dr. Madara is the CEO of the AMA, and he likely felt some pressure to rally the troops (a/k/a physicians) and show that the AMA is advocating for their “side.” And it got attention, with articles trumpeting that Dr. Madara called digital products “modern-day ‘snake oil’.” He indeed did.

We do need to give Dr. Madara a little leeway here.  The role of the AMA is to represent physicians, and he’s the CEO.  That being said, consider for the moment that one of the major points Dr. Madara made was to tout how the AMA’s predecessors over 100 years ago outed snake oil for the fraud it was, thereby protecting the consuming public.  While it was a while ago, the AMA should be rightly proud of that accomplishment.

However, what Dr. Madara did at the June AMA meeting, entertaining as it was, does not deserve equal accolades.

 Let’s first look at the good parts.  What he was calling digital health snake oil were not ALL digital health products.  There are products in the market that are either vaporware or that can do outright harm, and he was referring to producers and literature that have oversold what digital products alone can do.  For better or worse, it is a largely unregulated arena, and use of such products does not mean never seeing a doctor again.  Duly warned.

Dr. Madara continued:  “The future is not about eliminating physicians, it’s about leveraging physicians.”  I could not agree more.  We must get them to the sweet spot where they practice at the top of their license, unlike today.  Doing less with better results.  Moving away from volume production to patient outcomes.  But his focus on leveraging physicians brings me to my issue.

The medical profession by and large has ignored the convenience of patients.  We all know this.  The entire process of just seeing a physician is highly inconvenient.  There are, of course, exceptions, and they shine out as such.  But the center of the universe in our current system is…them.  Physicians might not actually realize that given the enormous pressures they are under.

But from the standpoint of an outside observer, it sure seems that way.  Everything about physician care revolves around maximizing what the physician can do in the extraordinarily limited amount of time he or she sees a patient.  That world circles around the physician rather than the patient.

That’s not entirely the fault of physicians.  Our care delivery model and its financing (how payors pay for care) have ensured a model that is anything but patient-centric.

But back to the AMA speech.  The digital products Dr. Madara refers to, both good and bad, are attempts by the “market” to benefit patients–namely us.  They are efforts to educate us, empower us, and make our health care more convenient…for us.  We patients feel anything but empowered with our healthcare.  Thus, these digital products are the natural consumer response to a highly inconvenient, largely poor quality medical service in America today.

This should be, after all, about the patient’s’ convenience and outcomes.  From the AMA CEO’s comments, it is very unclear whether he appreciates that, because his few nods to technology are limited to technology that advances the physician’s convenience. For example:  “…digital tools that would simplify and better organize our lives…”  He’s referring to physicians’ lives–not ours.  He never mentions the convenience of patients.

Dr. Madara goes on to tout the “Steps Forward” digital modules which are made available via the AMA website.  Their purpose?  To “…address pain points highlighted by physicians….”  Not by patients.

The medical profession is light years behind virtually every other profession when it comes to customer convenience and interaction, much less the use of customer/patient-facing technology.  So it’s unsurprising that the “customers” are taking matters into their own hands, and at least the digital world is reacting to supply the consumer demand.

Given physician uninvolvement, of course there will be some snake oil.  But up to now, most physicians have wanted nothing to do with this sort of technology. It’s simply not a focus of the medical profession, and that is my point.  That must change, or the digital consumer revolution, which IS coming, will do it without their involvement, diminishing the truly important role physicians play.

Last but not least.  Dr. Madara takes shots at electronic medical records, lumping them in with digital snake oil remarks.  Here I take great issue on a number of levels.

 

  • Physicians could have been more involved in their design.  For whatever reason, they were not.  Where was the AMA when EMRs were being designed and introduced?  The result is predictable.
  • Physicians seem to accept the lack of interoperability as an inevitable part of the treatment landscape.  If ATMs can do it, so can EMRs (I’m told it’s a bit more difficult in healthcare than in finance, but…).  It’s outrageous that there’s not more of an outcry on our lack of interoperability.
  • The inordinate amount of time MDs spend on their computer, albeit apparently true, is a tired red herring.  Rather than make EMRs the whipping boy, design better EMRs and focus on better office workflows and business models.  Seasoned professionals in other areas (law, accounting, etc.) are not thusly hamstrung.  They find ways to make it work.  It’s a sign of a broken business model if MDs are spending as much time entering data as treating patients.

The truth is that almost every physician cares deeply about patients.  But the AMA’s comments might lead one to conclude to the contrary.  This could be seen as just one more instance where the profession continues to unilaterally dictate care paternalistically rather than collaboratively design it based upon greater patient and family input, and perhaps welcoming apps that do just that.

It would be a very healthy development indeed if the AMA were to focus more on facilitating patient convenience and outcomes and be a tad more receptive to the consumerized digital medical revolution that will soon be upon us, like or not.

Jim Purcell was the CEO of BCBSRI. Prior to that, he was a trial lawyer in healthcare, and today he mediates and arbitrates complex business disputes and is focused on workplace wellbeing. jamesepurcell.com (healthcare) and jimpurcelladr.com(mediation/arbitration).

 

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Steven FindlayBobbyGvegasPerryHayward_ZwerlingJonathan Halvorson Recent comment authors
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Steven Findlay
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Steven Findlay

This is a terrific dialogue. As a consumer/patient advocate, I agree with and support Jim’s main contention: that doctors–individually and collectively–ought to be more open to and involved in reengineering the system so it works better for patients. Trade groups like the AMA pay copious lip service to that but spend most of their time and money focused on making the system work better for doctors. That said, it’s true that docs are overly burdened right now with a poorly designed system of accountability and quality measurement. The debate over MACRA is warranted…but MACRA is an opportunity as well. One… Read more »

Perry
Member
Perry

Groups like the AMA really aren’t making it better for doctors. That being said, that is really their job, after all they are the doctor’s association, not the patient’s association. On the other hand, doctors are trying to do their best within the system to make it better for their patients, but let’s face it, an unhappy, overworked, stressed out doctor who is working with a very convoluted, overblown system is not going to be able to consistently focus on how to make their patient’s lives better. In other words, if doctors aren’t happy, patients are not going to be… Read more »

Paul @ Pivot ConsultingLLC
Member

Economist John Cochrane of Stanford made some comments about the history of success of the approaches our health policy experts rely on: ” The ACA and the health-policy industry are betting that additional layers of new regulation, price controls, effectiveness panels, “accountable care” organizations, and so on will force efficiency from the top down. And they plan to do this while maintaining the current regulatory structure and its protection for incumbent businesses, management, and employees. Well, let’s look at the historical record of this approach, the great examples in which industries, especially ones combining mass-market personal service and technology, have… Read more »

Allan
Member
Allan

Steven Findlay says: “ I agree with and support Jim’s main contention: that doctors–individually and collectively–ought to be more open to and involved in reengineering the system so it works better for patients. ” You really don’t want that because you always seem to rely on a more collectivist approach. If you desired the system to work for the patients you would be providing the patients with money and power. The AMA’s major support at least since 1983 has been against physician interests. Think of CPT codes being owned by the AMA which provides them with a lot of profit… Read more »

Allan
Member
Allan

Perry, the video you sent @ http://www.kevinmd.com/blog/2016/06/doctor-endures-pre-authorization-hell-recorded.html#comments was extremely informative and I hope Jim takes a listen to all 21 minutes. 3.5 minutes of wasted physician time just in an attempt to confirm the physician is who he stated he is while the insurer uses electronic voices. AMEX seems to be able to do most of this electronically without any time consumed. IT is so valuable that some believe we require mandates and fines against physicians. Where is the IT provided by the insurance company to end this waste of the first 3.5 minutes of time? An electronic message containing… Read more »

Perry
Member
Perry

Excellent points Allan. Oh yeah, that pesky fee for service where the poor schlep ordering the test doesn’t make any money for it, but also has to waste 20 valuable minutes when he could have been seeing another patient. Oh, that 20″ could also have been spent getting involved in the politics of health care, but unfortunately the patient came first.

jamesepurcell
Member

I was traveling but will look at the video and all the other links that were sent and comment. This IS the dialogue we must have. I am a huge supporter of physicians and mourn what their professional lives have become. See some of my earlier blogs. But we have to work through the outrage and make this work as best we can given some inevitabilities such as CMS and, yes, commercial insurers.

Allan
Member
Allan

Jim, as I have said over and over again there is nothing wrong with commercial insurers. They are the good guys until they get into bed with a few other powers and suddenly disdain the free marketplace.

jamesepurcell
Member

Yeah, I listened to it. Ughhh. I instituted a pre auth for high end imaging because usage was increasing above 20% per year and quite frankly didn’t know what else to do. Clearly too many were being taken, and dangerous levels of radiation from the CTs were getting almost commonplace. I didn’t do it because I thought ordering physicians were getting rich off it, or even made ANYTHING from it. There are laws dealing with self referrals. I did it to put a rein on usage, and it did work albeit with much pushback from both the physicians and labor… Read more »

Allan
Member
Allan

Jim, I am not in favor of over-utilization. There are doctors that over-utilize and there are insurers who deny medical treatment to increase their profits. Such denials seem to be an A class danger. As you say, 1) physicians didn’t do it to make a profit and 2) there were laws dealing with self-referral. Since the insurer stands to benefit monetarily off denial of treatment should the insurer be in such a position? Does the insurer have the right to make the process so heinous just because the insurer is paying the bill? Certainly, most physicians are for the most… Read more »

Perry
Member
Perry

Why do docs order tests? Well, if they can’t by law make money or kickbacks, that’s not the reason. They could be CYA, but then, how do you know that and maybe the doc is just being cautious and ruling something out. The doc feels the test is truly needed to determine the course of treatment. The patient wants it just to make them feel better. If this is the case, these days with huge deductibles, the patient is likely to forego it, especially if we emphasize they don’t really need it because it won’t change the treatment. Therefore, is… Read more »

Allan
Member
Allan

“This IS the dialogue we must have.” Jim, I was hoping you would respond to my questions which were made in the hope of reasonable dialogue. Maybe you are still travelling or haven’t yet had the time. I believe that you don’t want abusive insurers and hope that you believe that I don’t like overutilization. It has been said dialogue is what is needed to resolve these issues so that all of us can better serve the patient. I hope you get the time to answer the questions I raised for the sole purpose of opening the dialogue with real… Read more »

BobbyGvegas
Member

Tweeted “Convergence.” Cure for physician burnout, or will it just make things worse? http://regionalextensioncenter.blogspot.com/2016/06/convergence-future-of-health.html … @AmerMedicalAssn @aafp #MoonshotSummit

Allan
Member
Allan

Jonathan Halvorson, everyone owns a portion of the blame for the problems we face in healthcare. That, however, is true in virtually every portion of our lives so the problem facing health care isn’t all that different. Unfortunately, the usual problems were not worked out in the marketplace, rather decisions were made behind closed doors and those decisions were backed up by the rule of law where government was involved in picking winners and losers. Physicians could have done better, but, for the most part, they are not political actors. They are busy taking care of patients. Instead, we have… Read more »

William Palmer MD
Member
William Palmer MD

Good, Allan.
I just learned the other day that patients are not asked if they want to belong to an Accountable Care Organization. They are assigned by the CMS! The patients don’t even know they have been put into a club whose purpose it is to try to skimp on their care. [sic!]. How would you like it if, when you went to a dentist, you were assigned by the government to a dentist group that was trying to skimp on the care of your teeth?

Outrageous.

Hayward Zwerling
Member

“The patients don’t even know they have been put into a club whose purpose it is to try to skimp on their care.”

I am a practicing physician in MA. I know of no ACOs to whom the above statement applies. All the ACOs/physicians here in MA (that I am aware of) sincerely want to improve patient care.

I would appreciate it if you could provide a reference supporting your statement.

Thank you.

William Palmer MD
Member
William Palmer MD

I’m try to find this citation, Hayward. I also think that physicians want to improve on care, but if your payer leans on you forever–like a worn heel on your shoe–eventually some of the weaker humans (all of us) will tilt to the skimp. Honestly, the payers want skimping too, late at night, when they are confiding to their wives.

William Palmer MD
Member
William Palmer MD

Am. Journal of Preventative Health 2012 June 42(6Suppl2):S180-S183.

It’s easier to google: Scholarly articles on Patient Attribution….you’,ll find several articles.

Attribution is the word they use to describe a patient’s assignment to an ACO.

Hayward Zwerling
Member

I believe most medical societies have been complicit wrt MU, MACRA and ONC Certified EHRs by making encouraging public statements about the evolution of MU into MACRA, and refusing to advocate for the abolishment of the legal mandates which are the legal underpinnings of MU, MACRA and ONC Certified EHRs. It is my opinion that these organizations were fearful of antagonizing the Federal Government and concerned that if they did such advocacy work, they would be excluded from influencing ONC’s evolution of the HITECT mandates. I believe these organizations should advocate to promote innovation in the health care realm and… Read more »

Paul @ Pivot ConsultingLLC
Member

Fantastic!!!.the end of mandates is a necessary precondition for technology/EHR’s to get to the point they add value and don’t interfere with patient care. Ending mandates/coercion will force the IT vendors to make their products a compelling investment on their own merits. I just wish some state and federal politicians would get on this …..if Ben Carson stays close to Trump perhaps it will happen!?…probably the only hope.

LeoHolmMD
Member
LeoHolmMD

The AMA is hardly a membership organization and is not representative of physicians at large…not even close. They laid back on this issue waiting to see how it could be leveraged for personal gain, much like they did the MOC issue. EMRs are plagued with patient uncentered design. And now they want to bark about it? The EMR is a data mining tool for “managing” lives as designated by CMS, the ultimate purchaser and designer of these systems. Sure, it could have been something else, like a communication tool for physicians and patients, but CMS had no intention of designing… Read more »

William Palmer MD
Member
William Palmer MD

Jim, help us work for the patient–have the money go through the patient (as in indemnity)–and you will see kind, considerate, gentle professionals who will make medicine a truly ethical calling and give great prices. We are less than St. Francis of Assisi because we work for bureaucracies and by their rules. We can’t be intimate with the Department of Homeland Security, et al. Send all your invoices to the Department of Agriculture for inservice training on this.

jamesepurcell
Member

William (or Bill): It’s an interesting idea about returning to indemnity. Personally, I think health insurers should stop “managing” care altogether and focus on the patient side (i.e., compliance). Giving the patients the money would be a scary proposition for providers though. Their unpaid service would skyrocket I’d think. But somewhere in there is an idea worth exploring. Payments that only could be used for providers?

Margalit Gur-Arie
Member

Well, if the CEO of the AMA is problematic, wait ’till you see the new President. Dr. Gurman practices on paper in his own clinic and has no plans to go digital. That said, I am not sure why calling digital products snake oil is problematic. They don’t work, they don’t fix any problems, they cost lots of money, they make the sellers (and other incidental profiteers) rich and the buyers poor and miserable, they are falsely advertised all day every day from every soap box across the land. Is that not the definition of snake oil? Is it possible… Read more »

Allan
Member
Allan

“Unfortunately, the digital health industry is infested with snakes and snake feeders. We need to clean that up first.”

Margalit, you have a way with words. Thank you.

Long ago, against their will, physicians stopped treating patients and started treating code numbers and guess who promoted that? “He who pays the piper calls the tune”.

jamesepurcell
Member

It is likely unfortunate that healthcare is financed at all by insurance. That was/is a historical anomalie that has its roots in the 40’s and 50’s. The criticisms of course make a point, but that does not obviate the need for digitalizing that which can be digitalized, safely. Of course the last word is key. And look at my article on THCB last week on what insurers are doing wrong.

Allan
Member
Allan

There is nothing wrong with insurance until it is mandated, becomes a monopoly, etc. You seem to look at the EHR as a tool of the healthcare industry and government looks at it as its tool. Health insurance doesn’t require digitalization. It requires an individual to work with insurers so that both their needs are met.

Jonathan Halvorson
Editor

Margalit, what you say is quite misleading. Yes, some lawyers are paid by the hour. But some are paid a salary. Some are paid a flat fee, which is similar to a bundled payment for an episode of care. And some are paid a contingency fee, which is an extreme form of performance-based payment with shared upside and downside risk. More generally, a large majority of professionals are paid a salary, not on an hourly basis, and there are good reasons for that both for the job holder (like income security and not having to hustle) and those they serve.… Read more »

Steven Findlay
Member
Steven Findlay

Completely agree with Jonathan’s response to Margalit.

Perry
Member
Perry

I completely agree with Margalit’s response to Jonathon’s response.

Margalit Gur-Arie
Member

🙂

Allan
Member
Allan

I completely agree with Margalit on this subject as well.

Margalit brought up an important point: “the bar association does not allow law firms to be owned by non-attorneys. Why? Because there is an ethical obligation that lawyers accept and “investors” do not. Unfortunately, health care doesn’t work this way.”

One can provide loud applause to another at will, but can one respond to what Margalit is saying?

jamesepurcell
Member

Most states have a Corporate Practice of Medicine statute that, with some variation, prohibits the ownership of IPAs and other organizations that provide care through physicians by non-physicians. Hospitals are exceptions. The idea was and is that non doctor business people might pressure physicians to compromise care in favor of the almighty dollar, or some such. So, that’s already here and has been for a while.

Allan
Member
Allan

As you say, most states, but not all states and those that have that statute do not enforce it in the same manner. To my understanding , the statute is relatively weak and does not match up to what we see from the Bar.

Remember, Jim, the physician acts as a type of agent to the patient yet in many cases the insurer is trying to force the physician to act for them leaving the patient alone without much protection when he needs it most.

Margalit Gur-Arie
Member

Hospitals, or rather health systems, are the biggest employers of physicians (inpatient and outpatient), so that is not really an exception. In addition to that, insurance plans also own physician practices and there are venture capital firms that invest in physician practices (primary care chains are a prime example and so are the mushrooming “telehealth” companies). It seems to me that physicians owning their own practices is quickly becoming the real exception. So no, that is not already here.

Margalit Gur-Arie
Member

Fair enough. Let’s look at these things a bit closer then. Yes, lawyers are paid in different ways, but the bar association does not allow law firms to be owned by non-attorneys. Why? Because there is an ethical obligation that lawyers accept and “investors” do not. Unfortunately health care doesn’t work this way. For attorneys there is a clear understanding of who the customer is, except maybe government attorneys who are overworked, underpaid and burned out much more than doctors. In our current system, doctors supposedly serve at least two masters and sometimes three, if they are employed by a… Read more »

Adrian Gropper, MD
Member
Adrian Gropper, MD

I’m not a practicing physician because I work full-time on the technology policy issues raised in this post. I work hard to hear and amplify the sentiments of my colleagues in my medical society, including helping to bring about the resolution described in this recent post https://thehealthcareblog.com/blog/2016/05/23/seven-principles-for-better-information-technology/ I am hopeful but I am also frustrated by how late the AMA and medical education are to admit to the problems. Jim Purcell’s post gets it mostly right. Physicians have ceded control of their essential patient engagement tools to business interests. The AMA and activist specialty societies like the Family Physicians have… Read more »

William Palmer MD
Member
William Palmer MD

Market power is the ability to affect prices. You don’t want us to regain this, do you?

Allan
Member
Allan

I don’t like the tone of this piece. “That world circles around the physician rather than the patient.” Foolish me, …and I always thought the world circled around the CEO’s and their henchmen that sit in a distant place far away from the patient while they manipulate both the patient and the physician for their own needs. I don’t have anything against CEO’s, but to listen to some of this stuff sort of makes me want to change my mind. Go ahead and blame physicians, the one’s that actually care for patients 24/7 under the most stressful life and death… Read more »

Jonathan Halvorson
Editor

I think this piece says things that need to be said. However, some things could have been said less contentiously, with more sticking to empirical facts rather than apportioning responsibility for how the facts came to be. There are many causes of our current state, across payers, providers, the public, and government. The finger of blame can’t point in just one direction, which I believe Jim recognizes but it doesn’t always come across in the post. That said, to adopt the attitude that physicians are blameless, or can be blamed only for working too hard and not playing the political… Read more »

Allan
Member
Allan

Reply above.

RogueRad
Member

“It’s the doctor’s fault.”

Mr. Purcell reveals the limits of his imagination. His banality (contrived, not natural, I hope) is all the more inexcusable as he is from the insurance industry – thus aware that insurance distorts the relationship between the consumer and the product, as costs are diffused and benefits are not concentrated either.

To blame doctors for the lack of success of digital health is to acknowledge in doctors the omnipotence that digital health wishes to refute.

Perhaps doctors are to blame for Theranos, too

https://thehealthcareblog.com/blog/2015/10/21/disruptive-idiots-from-silicon-valley-part-ii/

jamesepurcell
Member

What I wrote is that physicians were and are missing in action when it comes to design, or even significant interest in, digital assistance. Not that they are to blame for the lack of success. That jury is still out. What I criticize is the lack of apparent willingness to work to advance self-help and convenience of patients, who I sometimes call “consumers.” As to your comment regarding insurers, for sure we share the blame. I’ve already admitted as much many times. That doesn’t mean I don’t call ’em as I see ’em.

Allan
Member
Allan

“physicians were and are missing in action”

Where were you in the 80’s when I was creating my own prehistoric electronic medical record? Where was the government (aside from inhibiting its creation)?

You want input from physicians? Skip the mandates. ,Let the medical record be what it was initially meant to be, physician notes. Let the process expand organically even if it doesn’t meet your personal needs, the needs of bean counters, lawyers and government. Then get out of the way for physicians have been involved in changing technology forever.

jamesepurcell
Member

Allan, we have a market that’s reacting to a broken system. All the participants share blame for that. To blame insurers and the feds and continue to mope won’t cut it. Just sayin.

Allan
Member
Allan

Jim the system was broken by those that wish to involve themselves in the buyer / seller agreement. Think of third-party payer (the employer tax deduction). How has that panned out?

Paul @ Pivot ConsultingLLC
Member

So wrong in so many ways…..physicians were the victim of the “reformers” as much as patients were. It is especially ironic to see this from an ex insurance executive and lawyer.
Here is my piece “Reform the Reformers”
http://www.newsobserver.com/opinion/op-ed/article32658552.html
Oops…I wanted to post the THCB link….here it is:
https://thehealthcareblog.com/blog/2015/09/01/reforming-the-reformers/

meltoots
Member
meltoots

Well Jim, lets start with your list: 1. Physicians WERE involved in EHRs, until CMS and ONC made a policy market, allowing only “certified” EHRs to be used. This completely killed innovation as they ladled on complex regulations that only large EHR vendors could try to achieve. And in the beginning they BARELY achieved them, or said they did, and they are completely useless, unusable, and inefficient. The EHR market was moving, albeit slowly, but it would have popped without the massive policy market with HITECH. I would argue that MU and HITECH has done more irreparable damage to medicine… Read more »

jamesepurcell
Member

I do believe I have empathy. I said as much several times in the article. I realize that my former life creates a lovely target, but my point is that the AMA appears from the Doctor’s comments to look at this only from the standpoint of physician convenience, and not patient convenience. There has to be a balance here. I will reread my article (again), but I do not believe that I was being critical of physicians. Incidentally, you could ask any primary care doc in RI whether I was negative toward physicians, but this isn’t about me. It’s about… Read more »

Perry
Member
Perry

But the center of the universe in our current system is…them.

No the center of the universe in our system is neither the physician nor the patient. It is the BS regulated documentation.

Perry
Member
Perry

By the way, here’s just a small piece of what us “doctor-centric” doctors deal with to help patients and do our jobs:

http://www.kevinmd.com/blog/2016/06/doctor-endures-pre-authorization-hell-recorded.html#comments

LeoHolmMD
Member
LeoHolmMD

A quick test to see how uninteroperable you are: How many passwords do you have to keep up with?
Point #1 is right on.