The One Way the Trump Administration Can Drive Competition Without Regulation

There is one way the Trump HHS and VA can thread the needle between provider economic self-interest and burdensome regulation and it’s based on Federal health IT policy.

This past week has seen a number of high-profile announcements from the Trump HHS including Secretary Azar and CMS Administrator Verma  about patient empowerment and enhanced transparency as a strategy to breathe life into healthcare reform. Meanwhile, VA Secretary Shulkin is under immense pressure to make their privatized Cerner EHR interoperable.

It’s pretty clear that the Trump HHS wants to do something about the frustrating and ineffective health IT policies that led to the 21st Century Cures Act information blocking provisions and that they’re hoping to leverage the $1 Trillion of federal spending in healthcare as an alternative to heavy-handed regulation.  This is all good but what can they actually do?

Most of Secretary Azar’s talk is about disruption:

“In fact, it will require some degree of federal intervention — perhaps even an uncomfortable degree. That may sound surprising coming from an administration that deeply believes in the power of markets and competition. But the status quo is far from a competitive free market in the economic sense of the term, and healthcare is such a complex system, that facilitating a competitive, value-based marketplace is going to be disruptive to existing actors.”

And most of Administrator Verma’s talk is about patient control as essential to disruption:

“To this end, the administration is launching the MyHealthEData Initiative. MyHealthEData is a government-wide initiative that will break down the barriers that contribute to preventing patients from being able to access and control their medical records.”

Patient control can, and should, be mandated through regulation such as TEFCA  but it might work even better if CMS and VA used their purchasing power in the market for health services and health IT. Medicare and Medicaid can set an example for how patients can direct access to their specific benefits to patient-centered service providers that will provide decision support and other services. The VA can set an example in how their new Cerner EHR implements patient-directed exchange as the foundation of interoperability with Department of Defense as well as private-sector providers of services to our veterans. The Federal health system does not need regulation, just discipline.

But there’s also one piece of regulatory temptation that HHS and our federal health system must avoid and it’s evident in this confusing quote from Administrator Verma’s speech:

“In addition, to help beneficiaries make good decisions about whom they share their data with; CMS will require that App Developers go through an approval process based on industry best practices before they are granted access to beneficiary data.”

An “app approval process” is regulation by a different name and must be shunned by the Trump HHS. Who would decide to approve an app or not? Why should electronic access to patient data be subject to censorship when paper-based access through the typical “Release of Information” form allowed patients to send data directly from the hospital to *anywhere*?

HHS and the VA must not be allowed to censor a patient’s decision to share our own medical data. The bureaucracy required to approve the patient’s choice does not exist today and does not need to be created tomorrow. This one issue was central to the 2016 API Task Force Recommendations and the discussions around this isssue dominated the debate prior to acceptance by the predecessor of today’s HHS technology advisory group (HITAC).

Patient control over the FHIR interfaces being implemented by Medicare Blue Button 2.0 and VA’s Cerner EHR must truly be under patient control if we’re to avoid burdensome regulation. It might be as simple as that.

Adrian Gropper is CTO of Patient Privacy Rights.

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  1. Each citizen likely fits into one of three categories as they seek to achieve stable health during their life time. One group identifies a Primary Physician to manage their healthcare needs. Usually, these citizens keep good care of themselves and benefit from a trusting relationship to negotiate their episodic healthcare needs. This group is populated by young families and Medicare-Eligible citizens with stable health.
    The second group tends to find physicians or physician groups based on their healthcare needs, usually going to urgent care centers or a hospital’s Emergency Department for any new HEALTH Condition and any subsequent referral. If they encounter trouble, they will use a random specialist to direct their referral processes. The Medicaid folks populate this category, with high levels of social adversity.
    The third category tends to have citizens with high needs, especially with quality of life issues. They often have a constellation of specialists to pick and choose from for their daily health needs. This group has very unstable health.
    The first group is about 45% of the citizens, the second group 35%, and the third 20%. Its likely that only the 45% group might take ownership of this proposal. For the other two groups, no level of behavioral economics would likely change their health. The presence of multiple chronic illnesses often complicate any attempts to bring about continuity of care. This group suffers the most from the lack of enhanced Primary Healthcare and the absence of incentives for Specialists and Hospitals to support that role. The the Power Law Distribution curve at the high cost end is commonly populated by the 20% group. They are often joined by citizens from the 35% group, with a sudden aggravation of their multiple evolving health problems.

    A conversation with any disparate group of Primary Physician who had separately been in practice in the same community for more than 30 years would likely describe a similar set of groupings. They might be slightly different based on their urban, suburban or rural geographic setting. The level of poverty would greatly skew the analysis for any physician’s Primary Healthcare setting.

    So, the BOTTOM-LINE: the continuing use of the electronic data processing model to solve the cost and quality problems of our nation’s healthcare should come to a HALT, unless there is a controlled study for 5 years to demonstrate its benefit. We have traditionally stuck with this mantra. Why are we abandoning it now? If its because of the institutional codependency between the payers and providers of Complex Healthcare having caused each other to lose their own AUTONOMY, because of the market-share growth model, then lets own up and move to the Design Principles for Successfully Managing a Common-Pool-Resource that are already known and vetted. The well recognized concept of Paradigm paralysis applies and continues to strangle the high level of excellence that we all know exists deep inside our healthcare industry.
    So, out of all this, what can we expect as physicians leave post-graduate medical education with a $200,000 debt to work in an institutional environment that is unable to offer them a stable professional career as a basis for a life-time of professional achievement and family stability???

  2. Thanks Adrian. We’ve all noted this rhetoric coming from the Trump/HHS health folks. It’s not unexpected, and it’s also not inconsistent with what the three previous presidents were trying to accomplish in terms of transparency, consumer access to information, and more competition. All well and good and I’m glad they have decided to march to this beat. But with this administration, beware of diversionary tactics! There’s a lot they are doing that will not in any way benefit consumers and patients. That said, if Azar gets serious about interoperability, more power to him

  3. There is NO way individual patients will be able (or want) to go out for bids on their medical needs. An Amazon marketplace just isn’t realistic. A large part of medicine is developing trusted relationships with doctors – you don’t negotiate with your friends.

    Let big players like Medicare, VA, and hopefully, in a land far far away, Medicare for all negotiate. True disruption would be government price regulated health care.

  4. It will have to be very disruptive. There is no model of first world quality medicine coupled with market based pricing that exists and provides care at lower cost than does ours. There are lots of examples of quality care and more government intervention. I think pt control will work very well for the 50% of the population that doesn’t use much medical care. For everyone else? Count me skeptical. (To be sure, great if it works as it would be simpler.)


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