Hammering the final imaging interoperability nail.

  While the rest of the medical world suffers a lack of EMR interoperability because there is no standard for the export of complete patient information (!), we, in imaging, are hampered by more mundane matters. As has been true for the past 30-odd years, Medical Imaging is way ahead in the development of interoperability standards (DICOM) and technical frameworks (IHE).

  Intraoperability of imaging within an enterprise is very mature. Transferring images between providers and enterprises via a patient transported CDROM and its subsequent importation into the destination system has been available for decades. Technical frameworks for the direct, electronic interoperability of imaging studies across enterprises have existed for many years. There are ongoing, multi-institution, multi-vendor demonstrations of this interoperability.

  BUT, in the real world, outside the demonstration, commercial, direct, electronic image sharing across enterprises does not occur. None of the commercial medical image sharing vendors, large or small, federate with each other despite the fact that they may do so as part of the demonstration project. Shame on them. When we write checks to one another or otherwise transfer money, our individual banks are federated to each other and through clearing houses to make the transaction work. Similarly, when EMR systems place e-prescriptions, these transactions go through clearing houses to reach the pharmacy of your choice. If these institutions have identified the business model that facilitates these exchanges, then why haven't our vendors done similarly? As I have written before, this is because of market driven engineering. Vendors will only implement that for which their customers demand. So when you go out to subscribe to an image sharing vendor's service, insist on federated (IHE XDS-i.b) exchange. If only there were a national office to coordinate health care IT that could coordinate this nail into place.

Have we arrived at a single payer fork in the road?

    The recent articles about the DOJ's efforts to block the "merga-mergers" of Anthem / Cigna and Aetna / Humana prompt me to believe that the battle for a national, single payer is (almost) over and we (who support that notion) have won, and lost. Sort of. 

    The insurance companies have long realized that their endgame is a monopoly, toward which we hurl despite DOJ brakes. They know that they only need one room full of math geeks, math geeks, math geeks, and math geeks (who knew they had so many professional societies!) and one computer to compute actuarial risk for what is, from a health risk perspective, one pool, Americans. The rest of the differences in the thousand points of darkness that are individual health plans, wellness benefits and other meaningless fluff, used as bright shiny objects to confuse politicians, are artifacts of revenue optimization that are unnecessary in monopoly-hood.

    So, we will arrive at a single payer and it is here that we have two choices: Medicare-for-all (I know that, together, we can Kumbaya a better name) and ACAH-Megacorp (only because I heard from John Oliver that "Tronc" is taken). There are only two important differences between the two: salaries of the executives/bureaucrats that run them and what gets done with the 'revenues in excess of expenses' (since everyone thinks they're a non-profit these days). Anthem has cash reserves of $1.5B, Cigna $2.5B, Humana $2.5B, and Aetna $17B (who's gonna win that game?).

    Interestingly, the drug companies are well versed in the writing on the wall. They have long ago won the battle against Medicare since, by law, Medicare is the black knight in any drug related battle. They are now at war with ACAH-Megacorp.

    Now the AHA and AMA (doctors, not motorcyclists or model aircraft enthusiasts) find themselves in a pickle. AMA opposes the mergers (and presumably monopoly-dom), AMA opposes Medicare-for-all, AHA opposes mergers, AHA opposes Medicare-for-all. Who will be a harsher taskmaster? The cold cutting whip of  jackwelchian capitalism or the all measuring, all knowing, Earth mother? Better Medicare-for-all then Medicaid-for-all.

    And so, we come to the ultimate paradox. Unstoppable force meets immovable object. Capitalism versus Socialism. Do we want this single payer to be run by the capitalists or the socialists. I, for one, have frequently ranted that we want this payer to be run by the Socialists. Capitalism is great for many things such as cars, cell phones, computers and the like. We understand that not everyone can drive a Tesla Model S or pocket an iPhone[n+1]. Our society even tolerates that some people eat filet mignon, some eat pizza and fast food, some eat Ramen, some eat dog food and some children eat only once every day or two. That's a sad commentary on our society but true nonetheless (We still have a huge number of food pantries in the USA!). No one, however, is (nor should they be) willing to settle for anything but the Cadillac (so to speak) of health care. If everybody with Hep C wants Hervoni, to survive, isn't everyone with aging going to want the anti-aging pill when it is available? The young must subsidize the old, the healthy the ill and the wealthy the poor. There is no other way.  By its very nature, providing health care service is a human and humane effort, social by its very fabric. We, Americans, humans all, take care of each other. Who wouldn't bring some soup and medicine to a sick neighbor. Why do we shy away from institutionalizing this humanity? Solely because its name is Socialism.
   So, I vote, let's cut the crap and red tape and just go for the Medicare-for-all option. The quicker we get to this single payer, the quicker we can simplify the system. Let the Department of Health and Human Services  (read that name again, aloud) manage the program.

Sidebar: What was wrong with the Department of Health, Education and Welfare that I grew up with? What better things upon which to spend the wealth of a nation than on the health, education, and welfare of its people. For welfare is not an evil word. Welfare means, "the good fortune, health, happiness, prosperity, etc., of a person, group, or organization; well-being". Even in it's other sense, it still only means, "financial or other assistance to an individual or family from a city, state, or national government". Are we not about to enter a discussion about 'basic income' in light of the successful automation of our industries?

    Every one in health care would have to survive on Medicare rates: Providers, hospitals, medical device vendors, and the drug dealers. We would have to re-arm the black night (all puns intended). The socialist Medicare-for-all will still have to compete with touch points in the capitalist world. If we want the best and brightest to be our providers then we will have to value and compensate them appropriately, perhaps make medical school free.  If we want the best scanners and technology, the best drugs then we have to value them appropriately, but not without bounds. It is not a free market.
    But wait, with all those health insurance people displaced to sell life, auto and home insurance, the law of supply and demand will mean that the cost of those insurances will fall, too! (Oh, wait, I forgot, capitalism doesn't work there, either).  To abuse Ben Franklin's words, "We must all hang together or most assuredly, we shall all hang separately". Sure seems to apply to this crazy thing we call the American health care system.