Here, he discusses his book and his passion for reform.
[Editor’s note: Interview has been edited for length and clarity.]
Question: As an advocate for rural healthcare, you argue changes in physician training and lifestyle expectations have particularly hurt rural areas. Why? And, how could rural care be made more attractive?
Dr. Earl Ferguson: As I discuss in my book, physician training has gotten longer, less intensive and much more expensive. Physicians now must focus on the business of medicine to pay their medical school and other training debts. It is much easier and simpler with less uncertainty to join larger group practices in urban environments. One solution might be more medical training debt repayment programs for service in rural, underserved areas.
In addition, medicine does not seem to be the satisfying service profession that it was decades ago. Increasing administrative and regulatory complexity over the last few decades have made healthcare much less efficient and more difficult. That evolution must be reversed if physicians and other healthcare providers are to maintain the professional healthcare service that patients deserve.
Q: Your book has some great stories on some of the strange administrative burdens on hospitals, such as a regulatory requirement that a payphone be located near a CT scanner. Why is it so hard to change/minimize the burden of regulations on healthcare providers?
EF: The biggest problem is government bureaucracies and regulatory requirements are developed and sustained by people who are not involved in actually providing healthcare. Those bureaucracies don’t simplify and streamline themselves and they don’t focus on what is really important for cost-effective healthcare delivery. Their complexity and regulations grow without adequate input from providers and patients who deserve and require much better service than is currently being delivered by those bureaucracies.
Q: ACOs and bundled payments are potential solutions to healthcare problems in this country. Do you believe these models will get the job done, so to speak?
EF: Accountable care organizations, coordinated care organizations and bundled payment programs have the potential to increase the coordination of care, appropriateness of care, and efficiency of care and to decrease costs to a limited extent — particularly by better coordination of care for the most difficult and expensive patients to manage, wellness and health promotion programs, focus on evidence-based medicine, more appropriate utilization of drugs and expensive technologies and decreasing the wide variations in cost and quality of healthcare, etc. They do not, however, address the high administrative costs of excessively restrictive laws, rules, regulations and reporting requirements that must be appropriately simplified if we are to decrease those costs and inefficiencies.
Q: You argue that one of the intended benefits of the Patient Protection and Affordable Care Act — more data on cost and quality to help inform healthcare decisions — hasn’t been realized. Why is that the case?
EF: The Health Information Technology for Economic and Community Health Act and the ACA elevated health information technology implementation and the need for healthcare reform to a more prominent position on America’s agenda. We’ve needed that for decades, and some of us have been early adopters of electronic health records and other health information technologies to improve access to healthcare data, long before the HITECH Act and the ACA. Those Acts have pushed HIT forward more rapidly with a significantly positive vision, but with increasingly negative consequences in their implementation.
First, the Office of the National Coordinator for Health Information Technologies pushed automation of overly complicated and excessive governmental and insurance company administrative and reporting requirements without fully examining, understanding, simplifying and standardizing those requirements. Second, the ONC pushed providers (hospitals and physician offices) to adopt EHR systems before they were certified and when those systems were certified they were not certified for usability and interoperability. Well over four hundred EHRs certified by the ONC are on the market after being certified only for minimal functionality (audit logs, e-prescribing, physician quality reporting systems, etc.). The most commonly implemented EHR products (those with 1 percent or more of the EHR market have failed to meet usability and interoperability expectations). Seamless health information exchange is essential for making informed decisions on healthcare costs and quality, but the problem is not just the HIE vendor, but the lack of standards and the unwillingness of EHR vendors to provide timely, cost-effective interfaces to exchange data.
We do not have current EHR, HIT and HIE systems adequate to meet our needs for data on cost and quality to support truly informed evidence-based healthcare decision-making. Despite the optimism of the new National Health IT Coordinator Karen DeSalvo, we are a long way from that goal. I predict major disruptions in EHR, HIT and HIE system implementation with certified EHRs decreasing from more than 400 to less than 40 within the next two years and major problems with true interoperability. We should not be surprised by continued changes and delays in ONC implementation of requirements and standards. We must keep in mind that EHR vendors make their money from extensive training (because their products are so difficult to use), frequent upgrades on hardware and software, and lack of interoperability that requires expensive charges for development of interfaces for their products. EHR vendors will resist simplification and seamless portability of data, as this will threaten the foundations of their businesses. However, I predict that in the not too distant future the EHR market will markedly change with software as a service systems, with more intuitive EHRs (easy to use without extensive training — like iPhones, iPads, Tablet PCs and similar devices) and cloud computing (for EHRs, HIE, data banks, data analytics, etc.). Those systems will bring costs down to a fraction of the costs of current EHR systems and will not require purchasing servers or expensive upgrades of hardware and software.
Q: Lastly, one of your concluding recommendations is more individual freedom of choice in healthcare coverage along with more universal healthcare coverage. Aren’t these two ideas counterintuitive? How do you see them fitting together under your proposed recommendations?
EF: Everyone should be required to have at least basic insurance for unexpected, catastrophic, expensive health issues (accidents, cancer, etc.) with variable deductibles, according to their choice. This would be relatively inexpensive if everyone was required to have that coverage.
People should then have other options for routine, non-emergent and not catastrophic healthcare, including personal pay or self-insurance through Medical Savings Accounts. They should also have options from a limited number of standardized healthcare insurance plans with choices for coverage and deductibles. People should not be required to buy plans with coverage that they do not need or want.
Children, pregnant mothers, those with significant disabilities and others who cannot afford healthcare insurance should be provided a basic level of care, as well as catastrophic care insurance. We did this fairly well before the ACA, but it is still far from optimal.
However, one of the biggest problems in our country has been people that have the means to purchase health insurance, but chose not to do so. People who chose not to get insurance, should be required to pay up front for care (except for catastrophic and true emergency care). They should not have the option to go to emergency departments for minor issues without being required to pay for that service.
The bottom line is that we should promote individual responsibility for personal health and healthcare decisions and we should build more cost-effective systems that incentivize appropriate behaviors, through significant cost sharing, for example. However, we should provide appropriate care for those that are unable to adequately care for themselves.
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