As we move past the one-month mark of dealing with COVID19 in the United States, it’s important to document the lessons we are learning and inventory obstacles we’re facing in fighting this invisible enemy. When the pandemic passes, and it will pass, we need to be able to assess root causes and adjust to ensure future success. It is true that COVID19 took many by surprise, especially in the magnitude of its impact. Upon investigation, it becomes apparent that many pre-COVID decisions made by policymakers, politicians, businesses, and others have hampered our ability to respond to the pandemic.
No doubt many healthcare policies were well-intentioned, but short-sighted. Many other times, government, often complicit with self-interested businesses (including not-for profit hospitals) and professional class groups (such as physicians and other health professionals), has created barriers to competition and other protections that exacerbate gaps in access to health services and care delivery. Finally, we must understand that the Centers for Medicare and Medicaid (CMS), largely in the manifestation of payment policies by Medicare, has been the regulator of the healthcare industry in the US, not the market. [When one uses the term market, others may vilify it as some abstraction, but it really means making planned economic decisions in the absence of really understanding what customers want and need. At minimum, it seems that COVID19 has proven that trying to manage health-related supply and demand by government agency results in delay, disjoint, and confusion. Payment for anything other than results, as decided by those who gain the benefit and bear the cost of the consumption, is foolish.]
Some examples of such regulations and policies include:
- The ability for practitioners to engage patients via video, or what we call “telehealth,” has been hampered by a lack of legitimacy by CMS — i.e. a lack of formal payment for services provided via telehealth until very recently. This makes no sense in our digital world.
- Gains from the use of information technology in healthcare has lagged the massive impacts we’ve enjoyed in all other aspects of our lives. Why is this? A good bit is related to antiquated payment decisions and core decisions related to which technologies get reimbursed and which don’t. Government, either directly or influenced by independent self-interest, has put its finger on the scales of what’s approved and what’s not. Recall the HITECH act, which drove the adoption of clinical decision support technology (EHRs) from single-digits in the early part of 21st century to near ubiquity, but to what end? What many would characterize as a boon for the EHR industry became a further entrenchment of the siloed nature of health information.
- The licensing of health professionals has been a contentious issue for some time. States have argued that it’s their responsibility to ensure the safety of their residents. States have also used that argument to enforce state-by-state licensing requirements — requiring credentialed practitioners to be licensed in every state in which they wish to practice, and, yes, pay a fee. I am all for states’ rights, as an appropriate foil to federalism, but when a qualified professional that happens to live in and be licensed in one state can’t come to the aid of patients of an adjacent state, it requires a solution.
Even during the crisis, with such a massive push for access to telehealth, there was no uniform state response to relaxation by emergency action or otherwise to remove the licensing barrier. Issues of licensing also impact the availability of skills and competencies. For example, specialty lobbies that have fought for years for protection from substitutes, such as physicians trying to block nurses from performing certain activities, and even physicians blocking other physicians from the same, have been found mostly to protect the salaries of those with the more powerful lobby, not the lives of consumers.
- Certificate of Need laws for everything from new hospital construction, retrofitting, bed expansion, and a variety of other health services have been shown repeatedly to not benefit consumers. Often under the guise of some central authority’s wisdom as to what consumers really need, a group of appointed “experts” decide what institutions win and lose approval to deliver certain facilities and services. While it’s easy to focus on government mistakes during the crisis — and there certainly have been some — let’s not lose sight of the impact that prior decisions have had on our current conundrum.
All of this is less about assigning blame, and more about reinforcing systemic changes that need to be addressed. There will be time for a postmortem, but as we fight through, it’s important to be collecting information and prompting questions. Now is not the time for shackling industry or entrepreneurs; it’s time to be placing bets.