King Canute’s Court

Source: http://bitaboutbritain.com/bosham-cnut-the-kings-daughter-and-harold

As the story goes, Canute, king of England and Denmark around 1035 AD, had a sizeable court. Now, that wasn’t unusual. Court functionaries were the bureaucrats of medieval kingdoms, and actually ran the place while the king did… well, kingly things. But Canute’s courtiers, in the manner of government functionaries hangers-on today, thought that the king could do virtually anything. And of course, each courtier wished to have that supposedly vast power used to benefit his particular concerns. Tiring of their flattery and demands, Canute moved his throne to the edge of the sea, and commanded the tide to hold where it was, and not to advance. Of course, his shoes were shortly very wet. He then pointed out that he had no power over nature, that only God was all powerful. It is not recorded whether this silenced his courtiers.

The story was told by Henry of Huntingdon, a 12^th century historian of Anglo-Saxon-Danish England. It may even be true. But true or apocryphal, it contains a lesson for today.

For the last ten years, we have been engaged in a national effort to re-configure the health care system. We are now entering a new phase of that effort. Let me say that the effort has achieved some worthy goals, particularly by decreasing the numbers of uninsured citizens. But nobody seems very happy. Rural hospitals are closing in large numbers, doctors are discouraged, medical practices are snarled in red tape, and costs are continuing to rise. Patients are covered, but the premiums and co-pays continue to rise. The public seems to be ambivalent at best, and hostile at worst.

The health care system isn’t precisely like the tide coming in, though. It is, after all, a human system. One can certainly argue that if people put the thing together, other people can take it apart and fix it. Really? Let’s see. During the Progressive Era, Prohibition was the Right Thing to do. Recall how well that worked? It was a disaster. Other than giving secure employment to a brigade of FBI agents, of course. More recently, remember the War on Poverty? Well-intentioned, perhaps even helpful. But poverty remains stubbornly with us. Just because people can create a problem is no reason to assume that people can un-create it, or even change it.

Indeed, once a system becomes sufficiently complex, changing it may be akin to changing the tides. For the last 50 years or so, the march of globalization has promised to make nation-states irrelevant. But recent events here, and in Britain, and across Europe, express a contrary opinion. Human institutions are constantly in a dynamic balance among many forces, pulling them in differing directions. Changing that balance is not carried out by the wave of a pen, whether the pen is wielded by a king, or a President, or even (gasp!) Congress.

So, the relevant question is, just how much power does the government have over the practice of health care? The assumption has been that by providing insurance coverage and tweaking the rules, we can re-order the health care system to our liking. But… are we really accomplishing something, or are we just watching the tide come in?

Health care is a bit large for a short essay. So, let’s focus on one aspect. Take the Electronic Health Record. (Please!) We have all been subject to Meaningful Use requirements to incorporate the EHR into our practice. And we now know from a number of surveys, notably one by the Rand Corporation, that the EHR is a major source of dissatisfaction for physicians.¹ How did we get here?

Between 10 and 20 years ago, a number of people, inside and outside of health care, began a major push to bring information technology into health care. Advocates saw no downsides. Other than initial expense and maintenance, putting patient information into electronic form would streamline health care, cut costs, improve quality, and provide portability and transparency of health records. The Leapfrog Group, a consortium of major companies, was especially vocal. It may be worth noting that of the 150 members of the Leapfrog Group at that time, about 50 were information technology companies. Anyway, based on the hope that IT would improve health care, the Health Information Technology for Economic and Clinical Health Act (HITECH), was passed by Congress as part of the American Recovery and Reinvestment Act in 2009. The CMS created rules, and thus we wound up with Meaningful Use.² It was supposed to be introduced in three phases starting in 2011, leading to greatly improved outcomes by 2016.

Now, it’s 2017. Meaningful Use has been abandoned. More precisely, it is now folded into MACRA and MIPS. MACRA is the Medicare Access and CHIP Reauthorization Act (MACRA) of 2016.³ The idea was to manipulate reimbursement rates for Medicare patients, in order to encourage the use of EHRs. MIPS, or Medicare Incentive Payment System, is supposed to do the manipulation, financially rewarding good physicians, and penalizing bad physicians. And of course, the insurance companies are expected to line up behind the Center for Medicaid and Medicare Services (CMS).

What about all of those objectives? Well, most of them are pretty much abandoned, as well. CMS is now just into penalizing physicians if they don’t meet a laundry list of requirements, without much regard for whether those requirements will improve outcomes or not. We should give credit here to the AMA, whose negotiations with CMS have considerably moderated the requirements and reduced the penalties. But the requirements and penalties still exist, and our government is counting on them to change our practices.

Meanwhile, EHRs have become a major problem for physicians. The Rand survey of 2013 showed that the EHR was a major source of dissatisfaction, entirely aside from the other aspects of increased paperwork and surging bureaucracy. The Physician Foundation’s biennial Physician Survey of 2016 noted that the EHR was number three on the list of things that physicians found least satisfying about practicing medicine. (In case you were wondering, number one was regulatory and paperwork burdens.) That same survey showed that 52% of physicians were pessimistic about the current state of health care, and 63% about its future. Personally, 47% planned to accelerate their retirements.⁴

The Federally-mandated drive to bring the wonders of information technology to health care has resulted in widespread dissatisfaction and disillusion among physicians. More physicians than ever are planning to retire early, and more of them limiting their practices. Granted, we do have a lot of EHRs available. But they haven’t produced the wonders that were anticipated.

Managing information in the health care system is difficult, and simply cannot be reduced to computer-friendly algorithms. We can track inventory, do accounting, and generate bills. Past those, we’re into territory that is considerably more hostile than was ever dreamed by the Leap Frog Group. The same treatment doesn’t produce the same result in a different patient. Or, often, in the same patient at a different time. An abnormal lab test may be important, unimportant, irrelevant, or wrong, depending on circumstances. Many things are time-sensitive, many are not. Some systems promote transparency, some advertise their proprietary nature as enhancing security. For that matter, we can’t even agree on whether we want transparency or security of our data. Requiring the use of computer systems in this environment has become an exercise in futility. Except, of course, inside the Beltway and in most state legislative chambers.

It’s safe to say that the king’s shoes are pretty well soaked, the hem of his robe is sopping, and his throne is becoming waterlogged. King Canute was wise enough to know his limitations, and to stop ordering the tide to halt. Our present leaders, evidently, are not. Canute is dead, but the descendants of his couriers are alive and well today.

Biography

Charles W. Van Way, III, MD FACS, FCCP, FCCM, MSMA member since 1989, Missouri/AMA Delegate, and Missouri Medicine Contributing Editor, is Director of the UMKC Shock Trauma Research Center.

Contact: cvanway@kc.rr.com

Reprinted with permission, Kansas City Medicine