Dan Munro is the author of the book Casino Healthcare: The Health of a Nation: America’s Biggest Gamble. Though the book was published in 2016, not much has changed. Travis Good interviewed Munro for Datica’s Healthcare Innovators Podcast on September 29, 2017. A few highlights of that enlightening conversation follow below, but make sure to listen to the recorded podcast to hear it all.
The U.S. health system is like a casino
The US healthcare is like a casino because no one really knows the cost, the diagnosis, the outcome. Munroe says,
There is clinical evidence that many of the most expensive conditions to treat, ones like cancer, are the ones that are the result of totally random cell mutations. That happens about 66% of the time.”
And there are other ways the healthcare system is a gamble, according to Munro. He notes that where you live matters almost more than your genetic code when it comes to your health in terms of quality of care and outcomes.
Universal patient identifiers are overdue and inevitable
Although social security numbers are not at all secure, the public fears the idea of a universal patient identifier. Munro believes that fear is based in ignorance of the risks of continuing to use social security numbers or name and birthdate combinations and that consumer education could help.
Munro says that about 10-14% of medical errors are the result of mismatched patient identification — a situation that could be remedied by adopting a system that included a universal patient identifier. The government mandates things such as vehicle identification numbers, AC power outlets, and the gauge of train tracks because there is a safety component to those things, and Munro suggests a similar safety issue exists in healthcare IT.
Patient matching is especially bad in light of the need for interoperability
Within any given hospital system, patient matching is correct about 90% of the time. But, when patient data is shared outside a hospital system the accuracy rate drops to somewhere between 50 and 60%. It seems like there should be a correlation to when financial institutions adopted standards for ATMs.
“In fact,” says Munro, “the competing commercial interests are using the lack of interoperability to keep patients locked into their system.” Banks were losing customers by not having compatible ATMs; healthcare organizations are retaining them.
HIPAA originally mandated the creation of a universal patient identifier
There are a couple of components of the original iteration of HIPAA that are often forgotten, according to Munro. HIPAA requires portability of patient information, which in practicality requires a national patient identifier. He says HIPAA was “designed to create a national provider identifier and it was also tasked to create a national patient identifier.”
The national provider identifier part worked and is still in use today. “So we have a national provider identifier but for political and financial reasons, it was deemed to be too sensitive to create a national patient identifier,” says Munro.
Universal coverage and single pricing would work better in healthcare than tiered pricing
Munro wrote an article for Forbes titled “Single payer isn’t necessary but single pricing is.” There are distinctions between single payer, single pricing, universal coverage. He says “We tend to lump the phrase in with medicare for all, single payer and universal healthcare. The reality is it is distinctly separate.”
Universal coverage is the correct phrase as opposed to universal healthcare. The World Health Organization defines that as being a situation in which, “All people have access to preventive, curative, and rehabilitative health services of sufficient quality to be effective while also ensuring that people do not suffer financial hardship when paying for these services.”
The debate is how that is paid for. He says universal coverage is the system being used in many other countries successfully and the one we need because it would move us from a system of tiered pricing to single pricing.
Currently, the US has a system of tiered coverage; it’s tiered for age, twice — once at the age of 26 and once again at 65 — as well as by military service, heritage, and income. Even with all that tiering, plus more within those tiers, there is still 10% of the population without coverage.
“The only reason that we do tiering in the sense of coverage is to support tiered pricing. The tiered pricing is really at the heart of a system that has been optimized for revenue and profits and not safety and quality,” says Munro.
Tiered pricing works in other industries, but that doesn’t mean it works for healthcare.
Munro describes how tiered pricing works in several other industries: if you purchase a mattress, you’ll find different prices at different retail outlets, when and where you purchase an airline ticket determines the price rather than your destination, and hotel rooms are priced differently by season or when events occur.
So we have tiered pricing in every industry and the assumption has always been that that’s the way it should work and that’s the way it can work in healthcare. It really can’t.”
Electronic health records were originally billing engines, but things have changed
Most people in the industry tend to think of EHRs as one big monolithic market with Epic at the top, but the reality is that small practices have different needs than the big health systems. Smaller organizations are more likely to choose a cloud-based application. The market is more diverse than many people think.
“EHRs were originally billing engines,” says Munro, “and we’ve tried to include clinical data.” He says that is another reason for the current interoperability problems in the industry.
Patient access leads to increased risk
There are issues with allowing patients access to their own data through patient portals. If a patient accesses their data from organization A then sends it to organization B, how can organization B know that the patient didn’t somehow corrupt the data and somehow increase their liability?
There’s a desire to give patients access to their data and certainly some patients want more participation in the data process, but we still have to work through the elements of the risk associated to that data on whose part.”