Technology and the power to say no is real health reform

The technology at this week's HIMSS show is aimed at reducing the need for intravenous permission, and limiting that permission to what is most likely to deliver value.

Health costs are skyrocketing because doctors have what marketing guru Seth Godin 10 years ago called "intravenous permission."

When the ambulance comes, or you arrive at the emergency room, docs can sell you whatever they want, at whatever price they want, and you have no say in the matter. The needle in the arm is your permission.

The technology at this week's HIMSS show is aimed at addressing this power imbalance. It's about reducing the need for intravenous permission, and limiting that permission to what is most likely to deliver value.

(Shown are Microsoft executive Peter Neupert and the Cleveland Clinic's Martin Harris, at HIMSS this week.)

There are two main ways this is done:

  1. Combining electronic medical records (EMRs) with practical knowledge, as with GE's Qualibria, can put best practices, the most cost-effective procedures, at the patient's bedside.
  2. Combining these records with a patient portal, as with Microsoft's HealthVault, can empower people to do their own medical tests, see the practical advantage of following the doctor's advice, and get better care with fewer office visits.

Both of these are important. So is the EMR's ability to avoid mistakes, as NCHIT David Blumenthal described in his HIMSS keynote on Tuesday. Technology can automate checklists, which also reduces mistakes.

But none of this will really work unless we first understand the power of the word no.

As in, "no, we won't pay for that expensive test." As in, "no, we won't cover you at that price if you keep smoking, or drinking like a fish, or turn yourself into a beached whale."

This is the essential difference between the American system, which covers only four in five of us for 17% of our gross domestic product, and the health systems in other countries, which cover everyone for around 10-12% of GDP.

Other countries regulate what can be done with medical dollars. They have formularies, and don't accept new procedures until they're proven, not just to work, but to deliver value for money.

Once you're in the American system, whether you're poor on Medicaid, or old on Medicare, or a VA hero, or lucky enough to have good health insurance, the mission is always to take care of you. Doctors have intravenous permission not only from you, but from the people paying the bills.

Attempts were made in the 1990s to cut this out, through what was called "managed care." It didn't work. Hospitals won back their pricing power. The power to price is also the power to grow. When you're selling and not buying -- as most hospitals are -- selling more is the route to profit.

Systems like Intermountain Health, which sell insurance as well as care, have different incentives. So they practice evidence-based care. They have best practices, based on data from their computer systems, to  inform doctors and nurses on what they should do for each patient at every stage of the process.

This is what comparative effectiveness is all about. Gather the data, see what works, and do that first. Yet that was the first thing tossed out of health reform, even before the stimulus passed, because of conservative claims it would "kill grandma."

The second leg of health reform is convincing you to change your nasty habits. The idea is to move care down the permission ladder, so you are subscribing to wellness services or transacting for them. This gives buyers more power than they have with a drip line.

The idea is that health services get a per-patient fee for wellness. They use this to give patients data on themselves, helping them collect the data, get them eating better and exercising and taking responsibility for their own health. An ounce of prevention over a pound of cure.

But this interferes with freedom, we're told. Smoking is legal, liquor is legal, McDonald's is legal, exercise is a choice. You're Communists, Nazis, trying to tell me what to do.

I argue that's not freedom, it's license.

But rather than have an argument, I suggest, sign here. Go in peace. You and Ayn Rand have a grand old time. But when you get cancer, or heart disease, or diabetes, I think that contract should say that when the drip line goes into your vein you pay cash. Or accept responsibility for your choices and drop dead.

Those are the two legs of real health reform. Data tells us what to do, so we can say no and stand our ground. Data tells us as individuals what to do, so the system can be protected from your fat ass demanding a quadruple bypass when we told you and told you to stop stuffing your stupid face with cheeseburgers.

It doesn't matter who pays. That's the focus of the current health care debate, who pays. And that's the wrong focus.

We should ask, instead, how much, and what we're willing to do, as patients and as people, to cut that cost. Ask not what our health system can do for you, ask what you can do for our health system.

This post was originally published on


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