CHARLESTON, W.Va. -- A Nov. 11 National Journal article noted that "the U.S. is on the cusp of turning telemedicine and mobile technology into daily health practice" but "challenges" remain that could undermine implementation. These include payment for the services, privacy and security concerns, and little evidence these services result in improved health status and outcomes.
These challenges have not deterred advocates form moving ahead and saturating the market with "APPS," assuring us they will greatly improve the access, quality, effectiveness and efficiency of health care, i.e., better outcomes at lower cost. Sound familiar? It should, since the rhetoric mirrors that used by proponents of the ACA.
As with certain new apps, certain ACA components have great promise for improving health access and quality. But claims of reduced costs and improved outcomes remain suspect and unproven. One must ignore significant realities to make such claims.
It starts with the fact that "people," not "physicians," are the major factor influencing health status outcomes. Clinical care contributes to less than 20 percent of outcomes. Genetic, environmental, demographic and behavioral influences contribute 80 percent.
Occasionally technology produces advances, e.g., immunizations, water purification, certain medicines, preventive promotional practices, that can "cheaply" prevent costly "down stream" disease and disability resulting in savings. More often, it produces desirable, but costly, interventions to contribute to the longevity and quality of life.
A few recent examples include bariatric surgery for obese children, hepatitis C drug therapy and cochlear implants for seniors, to add to an ever expanding list of wonderful -- but costly -- advances such as hip and knee replacements, artificial lenses, organ transplant, dialysis, and genetic and biologic therapies.
The situation is made worse by the fact that the segment of the population, i.e. seniors, that often benefits most, is rising as a percentage of the population, increasing demand and Medicare expenditures.
Behavioral factors, not insurance coverage, mainly contribute to the poor utilization of "cheap" technologies that could save money in the long run. A recent Boston Globe article highlights the ongoing problem of parents resisting immunizing their children. Immunization rates in adults are suboptimal. Even for those insured with an established source of primary care, adherence with behavioral and therapeutic prescriptions, such as stop smoking, lose weight, exercise, and take medications, often hovers around 50 percent or lower, contributing to chronic, costly heart and kidney disease, cancer and other maladies.
From a cost and health status perspective, topping the list of behavioral influences, are violence, mental health, and substance abuse. The federal Department of Health and Human Services recently issued mental health parity regulations to allegedly address this problem through policy directives to insurance companies, who are raising serious concerns (The young "physically" healthy adults who were to keep ACA costs down could consume considerable mental health resources.) No one has addressed where the money to develop qualified professionals, facilities and programs is to come to make a dent in this enormous morbidity, mortality and social upheaval problem.
Insurance coverage without a functioning local delivery system is close to worthless. ACA architects believe they will save millions by stimulating the development of new "value" delivery and reimbursement models, which doctor and patients will love. Doctors and patients are not sure they agree.
Low cost (less than $50 to $150 a month) concierge practices are growing, and retail clinic use has tripled between 2007 and 2010. Insurance companies are offering catastrophic packages to supplement such models that many claim can operate for 40 percent less by eliminating insurance processing and other administrative overhead.
In rural areas it is especially difficult to initiate certain models. What the final outcome will be of stripping patients of their trusted physicians remains to be seen. The situation is made worse by the fact that the latest projections for 2025 show an increasing physician shortage because of the growing aging population and effects of the ACA.
Promoting improved health status and controlling costs is a complex endeavor influenced by many interdependent factors. Pushing ahead based upon hope and ideology -- ignoring the interplay of all these factors -- will help certain individuals gain improved access to health care but also produce chaos, serious system dysfunction and increased costs. Changing behavior and setting limits, i.e., rationing, is the major way to improve health status and control costs. It is just a matter of who and how.
Felsen is a retired public health physician in Great Cacapon.