Executive Memo: The Door to Reform is Wide Open

EXECUTIVE MEMO Conrad Amenta, SFMMS Executive Director

THE DOOR TO REFORM IS WIDE OPEN

The most esoteric area of health policy in which I’ve been involved has been the digitization of health records. Most agreed that it needed to happen, but nobody wanted to expend political capital, let alone actual capital, to make it happen. It was complicated, difficult, expensive, unsexy, and impossible to claim victory (and credit) with certainty. Then, in 2008, the world’s financial system melted down, and the United States commandeered what would turn out to be $831 billion via the American Recovery and Reinvestment Act (ARRA) to stave off a recession. A component of the ARRA was the Health Information Technology for Economic and Clinical Health Act, which spurred a “meaningful use” framework designed to motivate the implementation of electronic health records (EHR) by physicians and hospitals in the United States. Adoption of EHRs surged. Today, EHRs, though much-maligned by some, are a fixture in physician offices both ambulatory and hospital-based. What does a financial crisis caused by subprime mortgage lending and derivatives have to do with the digitization of healthcare? Almost nothing. But the crisis they created swung the door to reform wide open: legislators usually reticent to sign off on investments in the arcana of medical workflow and data management were induced to do so by conditions beyond their control. Receptivity to bold ideas increased.

The COVID-19 pandemic has already produced similar conditions. For most of my career, there’s been a debate about whether services provided by a physician over the telephone or by video should be paid for at the same rate as services provided in person. It’s a debate that’s become paralyzed by the ‘what-ifs’: if we pay physicians to provide telemedicine, will it increase access, or will physicians stop providing in-person visits? What price will we pay when it comes to our privacy? Perfect becomes the enemy of good and we wait as, state-by-state, initiatives are piloted, tested, and studied.

In the past months, however, federal and state entities have broadly authorized telemedicine to ensure patients stay at home when seeking medical services. New regulations have established that physicians will be paid for almost all services, at parity with in-person service, on any platform, including privately owned messaging platforms that are not always compliant with federal privacy laws. Penalties for lax privacy practices have been waived. Telemedicine has existed since the 1960s, but the system-wide reforms speculated about for decades took place in mere days.

What’s becoming clearer to us every day is that we are in the moment-of-moments, a truly worldwide imposition of perspective. The word crisis comes from the Greek “to separate, decide, judge,” meaning “to keep only what is worthwhile.” And our perception of what is worthwhile tends to change in times of crisis.

If it’s true that the scope of the COVID-19 pandemic will reorder the daily lives of hundreds of millions of people for months or years, that also signifies conditions for change that dwarfs the conditions produced by the financial crisis of 2008, a crisis that nudged medicine toward digitization.

In times of crisis, the incentives and disincentives to which legislators usually respond are outweighed by much larger incentives and disincentives. Risk aversion and economic anxiety are relegated to status as second-order concerns. A government united in purpose, be it of one party or both, should aspire to forge pacts on a societal scale to provide jobs to Americans at a time when they require both work and a renewed sense of mission.

It’s a time for the physicians of the San Francisco Marin Medical Society to lean into our values: to be bold, imaginative, and fearless when working with our local legislators in service to our communities and patients. Throughout these pages, you will find examples of the dedication of physicians in San Francisco and Marin. Let’s be inspired by them to recognize and respond to this moment – to walk through the door to reform. Gratefully, Conrad Amenta