Eyeworld

16 January 2018 EW NEWS & OPINION by J.C. Noreika, MD, MBA Insights A clinician's take on the status of our nation's healthcare transformation and innovations that hold promise for its future J anus, the uniquely Roman deity who faces forward in anticipation and back in reflection, ushers in a new year that augurs challenge and opportunity. This essay marks the begin- ning of Insight's seventh year. The support of ASCRS, EyeWorld, and its readership is gratifying. Below is the final installment of a themat- ic triptych that incorporates the November column's contemplation of "Medicare for all" and December's divination of lessons from inter- national healthcare models. The Affordable Care Act ran 1,990 pages. The Washington Post estimated that an additional 20,000 pages of regu- lations were issued by 2013. Trigger warning! The next 823 words are not meant to solve but to provoke. Provocation #1: Not as elegant as "liberté, egalité, fraternité," "Medi- care for all" is a brilliant rallying cry. It won't happen in the U.S. as long as only 55% of the populace pays federal income taxes and 28% remit no payroll tax. The conundrum of universal coverage and tax equity remains unresolved. The cost to merely administer the program will explode. Organizationally, CMS' 4,100 employees can't manage the needs of another 200 million claim- ants. Politically, America's dialectic between big and small government proscribes collaborative effort. Fur- thermore, "Medicare for all" doesn't address the twin root hazards of the economic riddle, aging and chronic disease. The solution lies elsewhere. Provocation #2: Capitalism or socialism, some patients will pay for more, newer, and quicker. Health- care can be egalitarian or universal but not both. Recently, Gullapalli N. Rao, MD, founder of India's L.V. Prasad Eye Institute, intimated that has skyrocketed. There are more than 65 programs offering combined MD/MBA degrees. Medical schools are incorporating liberal arts courses such as design and architecture into their curricula. Thomas Jefferson University's Sidney Kimmel Medical College supports a student-managed Professional Executive Leadership (PEL) initiative. The program en- courages future clinicians to re-en- gineer patient care. Through their effort, the reviled EHR will become today's ARPANET. Could today's secularists invent Janus? Romans created and honored the god as their guide through tran- sitions, passages, even time itself. His symbolism resonates with physi- cians. Standing among the fragrant apricot trees of a long-gone orchard, no prophet could have anticipated the innovations wrought in its place by Silicon Valley's visionaries. I hope the same will one day be true of our exam rooms. As always, I wish you the best in the New Year. EW Reference 1. Al-Lamee R, et al. Percutaneous coronary intervention in stable angina (ORBITA): a dou- ble-blind, randomised controlled trial. Lancet. 2017 Nov 1. Epub ahead of print. Editors' note: Dr. Noreika has practiced ophthalmology since 1981. He has been a member of ASCRS for more than 35 years. Join the discussion on this article and others on the EyeWorld blog at blog.eyeworld.org. Contact information Noreika: JCNMD@meditrends.net this not-for-profit organization's mission serving millions of patients who pay little or nothing would be impossible if not for an economi- cally tiered system. The affluent pay for amenities so that the destitute can receive necessities. In America, the debate about whether universal insurance guarantees better health and longevity remains unresolved. Outcome studies have found little impact on the management of diabetes, obesity, and hypertension, three principal cost drivers. But Medicare coverage seems to impact the lifespan of seniors. At its adop- tion in 1965, an American's life expectancy was 70.22 years. Today, on your 70th birthday, you can expect 15 more celebrations. The overall cost for this augmentation is astronomical. Provocation #3: Gene therapy is here today much in the same way the ARPANET, the forerun- ner of the internet, was in 1969. Spark Therapeutics grew out of a Children's Hospital of Philadelphia skunkworks to become the darling of Wall Street speculators; its market cap is $2.5 billion. In October, it received an FDA's advisory commit- tee's unanimous approval to treat RPE65 mutation associated retinal dystrophy. The company has been coy in discussing the therapy's cost. Reports estimate prices as high as $1 million dollars per treatment. Like ARPANET, it will take years and bil- lions more to realize gene therapy's potential to prevent chronic debility and rationalize its price. Still, it has the aura of inevitability. Provocation #4: Big Data is not an economic game-changer. It is a robust tool that aggregates treatment results of rarely encountered pathol- ogies to unmask hidden patterns and improve therapeutic algorithms. Judged "unbelievable," an article in the Lancet reported the ineffective- ness of coronary stenting for chronic angina. 1 More than 500,000 costly procedures are performed annually worldwide. The study did not rely on Big Data. It compared results of actual stenting with a sophisticated sham procedure. Big Data is only as good as its inputs; it would have missed the placebo effect of the procedure itself. Provocation #5: Is there a doctor shortage? Is the political empow- erment of physician extenders justified? It depends. Philadelphia does not have a doctor shortage. Winnemucca, Nevada? Perhaps. There are two problems: (1) the geo- graphic distribution of physicians especially specialists and (2) the inef- ficiencies of work flow belabored by regulatory overload. Maldistribution might be addressed if medical school graduates were permitted as part of their post-grad training to barter ser- vice time, for example, in the Veter- ans Health Administration or Indian Health Service for educational debt amnesty. Also, technology can be used to enhance geographic reach. Telemedicine has revamped the identification and triage of diabetic eye disease on northern Canada's tundra. Government pays doctors for their virtual presence. Costs will come down; innovators are chasing the holy grail of harnessing telemed- icine to artificial intelligence and machine learning to better identify pathology. Provocation #6: Troublemakers: Silicon Valley's Coming of Age by Stanford historian Leslie Berlin is a fascinating recapitulation of the invention of the digital world as we know it. Less publicized players— Mark Markkula, Bob Taylor, Robert Swanson, and Niels Reimers— worked with Jobs, Wozniak, Ellison, and Noyce to usher in the digital transformation of the globe. The story concludes it wasn't govern- ment bureaucracy but a small cadre of resolute, indefatigable entre- preneurs that sparked the Fourth Industrial Revolution. Since I earned an MBA in 1988, the number of doctors receiving business degrees Provocations of a new year J.C. Noreika, MD, MBA

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