“Our national healthcare system can no longer beguile itself with the myth that quality care involves only one doctor and one patient alone in a room where confessions are made and promises are kept…. A visit with a physician may be the point of entry into the system for a given episode of illness, but it contorts the process and potentially undermines the quality of care to pretend that an institution can be reduced to a personification of the secret-protecting family doctor.”
This chilling testimony was delivered not by Darth Vader, as you might think, but by a lawyer for the American Hospital Association at a hearing of the National Committee on Vital and Health Statistics, Subcommittee on Privacy and Confidentiality, in Chicago on Wednesday, March 30, 2005. Industry representatives went on to agree that a national electronic health information system (a) should not permit patients to have any control over the information that goes into the system, (b) should pre-empt stronger state privacy laws, (c) should not be required to inform patients of non-routine disclosures of their personal health information as currently mandated by HIPAA (Health Insurance Portability and Accounting Act), and (d) should eliminate the “minimum necessary” standards currently required by HIPAA (these limit the amount of information that is permitted to be disclosed).
Jim Pyles and Prudy Gourguechon testified for the American Psychoanalytic Association and the contrast between APsaA's representatives and the industry spokespeople could hardly have been starker. The Association testified that any national health information system should be solidly grounded in traditional standards of medical and professional ethics and constitutional law. They quoted the Department of Health and Human Services themselves as noting, “The entire healthcare system is built on the willingness of individuals to share the most intimate details of their lives with their healthcare providers…. More than anything else, the relationship between a patient and a clinician is based on trust.”
This meeting in Chicago was followed by a meeting in Washington, D.C., between representatives from the Association (Jon Meyer, Jim Pyles, and me) and top ranking representatives from the office of David Brailer, President Bush's new czar for electronic medical records. We stressed the need for privacy safeguards to be built into any national electronic medical records system. This should include patient consent, patient control over “levels of confidentiality,” and accountability to the patient from those who would access information. Although we received a thorough hearing, it is difficult to know what the ultimate effect will be. Kathleen Fyffe of Brailer's office observed ruefully that over 50 percent of large computer systems fail (other articles say 75 percent) and the ability to protect such systems from hackers is severely limited. With this in mind, we suggested that only minimal core information, such as that which might be needed in an emergency room, be entered into such a system. We suggested that “minimum necessary” core information agreed on between Oxford Health Plan and us could be used as a template. Fyffe was extremely interested, and asked for the relevant documents.
It is a world where insurance companies and HMOs increasingly insinuate themselves between us and our patients. Their goal is to erase the boundary between the role of the healthcare professional and that of the payer, and ultimately, to control all aspects of health care.
We also met with Congressman Patrick Kennedy's (D-RI) staff on April 29. On May 10, the congressman introduced the 21st Century Health Information Act of 2005 (HR 2234). The final version of the bill contains numerous privacy provisions based on recommendations we made to the congressman's staff. Although the bill does not go as far as we would like to protect privacy (for example, there is no provision for patient consent), it is much improved over earlier versions. A Senate version of this bill is likely to be introduced in the future by Senator Hillary Rodham Clinton (D-NY) with Republican co-sponsorship. The purpose of the bill is to provide federal grants and loans to develop “interoperable regional health information networks,” i.e. electronic medical records. This bill, if passed, will go a long way toward creating the tightly controlled and totally inclusive managed care network that failed when the original Clinton Health Plan was defeated in 1994.
It is easy to see where all of this is going. Unfettered access to health information will allow managed care companies to institute even more widespread healthcare rationing than is now the case. It is an open secret, and hardly one even apologized for, that Congress, the Administration, the insurance companies, and managed care companies are working together to develop a system in which healthcare professionals and patients will have very
Robert Pyles, M.D., is chair of the Committee on Government Relations and Insurance, and a former president of APsaA.
little control over health care. Increasingly decisions will be economically based, and made by companies whose profit margins depend upon limiting care. Independent practice is the enemy of such a system; there will be increasing pressure to eliminate it.
We have all taken solace in the fact that private practice has remained a refuge for our ability to deliver quality care to our patients. It is highly likely that, once electronic health information systems are in place, pressure will increase on all healthcare practitioners to be included within the managed system. It is not inconceivable that the ability to have a healthcare license will depend on participation in the healthcare system. At the same time, the new doctrine of “pay for performance” will put further pressure on healthcare professionals to be included in the system or to suffer economically. The ability of any individual practitioner to function will be “graded,” according to what degree he conforms to standardized “guidelines.”
This is the “brave new world” we are facing. It is a world where insurance companies and HMOs increasingly insinuate themselves between us and our patients. Their goal is to erase the boundary between the role of the healthcare professional and that of the payer, and ultimately, to control all aspects of health care. This is why our Association must continue to “fight the good fight.” Our profession and our patients depend on it.