And Now for Something Completely Different

The most interesting story I read in the past week doesn’t come from the more usual worlds of health and/or technology, but from sports. It’s not even really news, since it was announced last fall; it’s just that it wasn’t until last week that a U.S. publication (The New York Times) reported on it. In a nutshell, a Paris football (a.k.a. soccer) club is not charging its fans admission during the current season.

Translation: It's Priceless. Credit: Paris FC

Since last week I wrote about medical debt in the U.S. healthcare system, you might guess where this is going.

The club is Paris FC. Last November it announced:

For the first time in history, Paris FC is offering free tickets for all home matches at the Stade Charléty, starting from the 11 November until the end of the 2023-2024 season from its Bastia reception, in a bid to offer a new and innovative vision of football by welcoming as many people as possible.

The policy includes the men’s second division team and the woman’s first division team. The NYT article clarifies that fans supporting the visiting team might be charged a “nominal” fee, and that hospitality suites still pay market rates.

Pierre Ferracci, Chairman of Paris FC, said: “We are proud to support this ambitious and pioneering project, which goes beyond the simple framework of sport in terms of the values it conveys. We want to bring people together around our club and our teams, while committing ourselves with strength and conviction. In a context of difficult purchasing power, we are confident that a club can be an ideal tool for bringing together people of goodwill and engage with societal issues.”

Fabrice Herrault, Paris FC’s general manager told NYT: “It was a kind of marketing strategy. We have to be different to stand out in Greater Paris. It was a good opportunity to talk about Paris F.C.” The club estimates it might cost them $1 million.

No wonder they're cheering. Credit: Paris FC

It seems to be working. The NYT reports:

Months later, most metrics suggest the gambit has worked. Crowds are up by more than a third. Games held at times appealing for school-age children have been the best attended, indicating that the club is succeeding in attracting a younger demographic.

The idea is not entirely de novo; last spring Fortuna Düsseldorf, a German second division football club, announced it would offer free admission for at least three matches this season, with the intent that eventually all home matches. “We open up football for all. We will have free entry for league games in this stadium,” Alexander Jobst, the club’s chief executive, said at the time. “We call it ‘Fortuna for all’ which can and will lead us to a successful future.”

In a NYT interview last spring, Mr. Jobst added: “We think it is completely new. We were trying to think about how we could do the soccer business completely different from before.”

I’m always a sucker for efforts to think about a business completely different than before.

Fortuna has now had two of its three free matches, and Mr. Jobst told NYT last week: “Our average attendance has gone from 27,000 to 33,000. Our merchandise sales are up by 50 percent. Our sponsorship revenue is up 50 percent. We have reached a record number of club members.”

Sure sounds like a success.

Keep in mind that for most professional sports, ticket and concession revenues are gravy; the real money is from TV deals, as well as sponsorships. The NFL, for example, only gets 17% of its revenue from fans, the NBA 26%, and MLB 31%, while MLS and NHL need over 40% (not such good TV deals!). Fortuna, in case you’re interested, only gets 20% of its revenue from tickets, even though it is only in the second division.

Meanwhile, Paris FC only gets 4% of its budget from ticket sales. “We're not taking a big risk, and we won't lose out," Mr. Feracci told Le Monde. "The balance will be positive, thanks to new sponsorship income and the arrival of new shareholders who have shown themselves to be keen on our vision.

Spectators matter, not just as a revenue source. We all remember American professional sports during the early days of the pandemic. The NBA finished its 2019-2020 season in a bubble, with players, staff, and media quarantined, playing in empty arenas. Most of the NFL and MLB games that year were also without fans. Players and television viewers hated the experience; it just didn’t seem real without actual fans in attendance.

“Since the pandemic, there has been a growing awareness of the role of spectators in the ‘production’ of sporting events,” Luc Arrondel, a professor at the Paris School of Economics, told NYT. “The presence of supporters in the stadium increases the desirability of the television product, and therefore, possibly, the value of television rights,” 

Professor Arrondel has even made the case in a paper (“Faut-il payer les supporters?”) that it might actually make sense for professional teams to pay the most ardent fans to attend in-person.

Yes, all that is thinking about the business completely differently.

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Meanwhile, there’s the U.S. healthcare system, which treats its “fans” – i.e., patients – as revenue from whom every dollar should be squeezed. E.g., ever pay a facility fee for a doctor’s visit, or pay the inflated U.S. prices for prescription drugs? It’s not surprising that we end up with all that medical debt. As I wrote last week: “why are so many charges so high, why aren’t people better protected against them, and why don’t more Americans have enough resources to pay their bills, especially unpredictable ones like from health care services?”

So here’s a thought” out-of-pocket spending is “only” 11% of national health expenditures. What if we just abolished it? Healthcare’s version of not making fans pay to attend football matches.

Now you might say - that’s crazy, how would the health care system make up that 10%? I’d say two things: first, we all know that there’s 10% of savings to be had in our bloated system; what better to use them for than this?  Second, and more importantly, we need to admit that the current business model in the U.S. healthcare system does not work.

It’s time to think of ways to do the business of healthcare “completely different than before.”

Not making patients pay out-of-pocket might not be the “right” way to do that, although we could do worse, but, in any event, we better think of something completely different before the system crashes.

Healthcare's Debt Problem

 

Among the many things that infuriate me about the U.S. healthcare system, health systems sending their patients to collections – or even suing them – is pretty high on the list (especially when they are “non-profit” and./or faith-based organizations, which we should expect to behave better).

Credit: Kenneth Fowler/CNN

There’s no doubt medical debt in the U.S. is a huge problem. Studies have found that more than 100 million people have medical debt, many of whom don’t think they’ll ever be able to pay it off. Kaiser Family Foundation estimates Americans owe some $220b in medical debt, with 3 million people owing more than $10,000. It’s oft cited that medical debts are the leading cause of bankruptcy, although it’s quite not clear that is actually true.

So you’d think that helping pay off that debt would be a good thing. But it turns out, it’s not that simple.

A new study from the National Bureau of Economic Research (NBER) by Raymond Kluender, et. alia, found that, whoops, paying off people’s medical debt didn’t improve their credit score or financial distress, made them less likely to pay future medical bills, and didn’t improve their mental health.

“We were disappointed,” said Professor Kluender told Sarah Kliff in The New York Times. “We don’t want to sugarcoat it.”

The researchers worked with R.I.P. Medical Debt, a non-profit that buys up medical debt “at pennies on the dollar,” to identify people with such debt, and then compared people whom R.I.P. Medical Debt had helped versus those it had not. One set of people had hospital debts that were at the point of being sold to a collection agency, and another had debts that had already been sent to collection. And, perhaps to highlight how little we understand our healthcare system, they asked experts in medical debt what their expectations for the experiment were.

Credit: Kluender, et. alia

Much to everyone's surprise, having debt paid off made no difference between control and debt-relief groups. I.e.,

• “We find no average effects of medical debt relief on the financial outcomes in credit bureau data in either of our experiments.
• We similarly estimate economically small and statistically insignificant effects on other measures of financial distress, credit access, and credit utilization.
• We find that debt relief causes a statistically significant and economically meaningful reduction in payment of existing medical bills.
• We estimate statistically insignificant average effects of medical debt relief on measures of mental and physical health, healthcare utilization, and financial wellness, with “opposite-signed” point estimates for the mental health outcomes relative to our prior.”

In short:  

Our findings contrast with evidence on the effects of non-medical debt relief and evidence on the benefits of upstream relief of medical bills through hospital financial assistance programs. Our results are similarly at odds with views of the experts we surveyed, pronouncements by policymakers funding medical debt relief, and self-reported assessments of recipients of medical debt relief.

 Amy Finkelstein, a health economist at the MIT and a co-director of J-PAL North America, a nonprofit group that provided some funding for the study, told Ms. Kliff: “The idea that maybe we could get rid of medical debt, and it wouldn’t cost that much money but it would make a big difference, was appealing. What we learned, unfortunately, is that it doesn’t look like it has much of an impact.”

If only it was that easy.

To be clear, there were three key statistically significant effects:

1. “small improvements in credit access for the subset of persons whose medical debt would have otherwise been reported to the credit bureaus,
2. modest reduction in payments of future medical bills, and
3. worsened mental health outcomes, concentrated among those who had the largest amount of debt relieved and those who received phone calls to raise awareness and salience of the intervention.”

The authors admitted they had not expected the mental health results and had no good explanation, but their “preferred interpretation is that recipients of the cash payments viewed the transfers as insufficient to close the gap between their resources and needs, raising the salience of their financial distress and harming their mental health.”

As Neale Mahoney, an economist at Stanford and a co-author of the study, told Ms. Kliff: “Many of these people have lots of other financial issues. Removing one red flag just doesn’t make them suddenly turn into a good risk, from a lending perspective.”

The authors concluded:

Nonetheless, our results are sobering; they demonstrate no improvements in financial well-being or mental health from medical debt relief, reduced repayment of medical bills, and, if anything, a perverse worsening of mental health. Moreover, other than modest impacts on credit access for those whose medical debt is reported, we are unable to identify ways to target relief to subpopulations who stand to experience meaningful benefits.

On the other hand, Allison Sesso, R.I.P. Medical Debt’s executive director, told Ms. Kliff that study was at odds with what the group had regularly heard from those it had helped. “We’re hearing back from people who are thrilled,” she said.

As statisticians would say, anecdotes are not data.

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Removing medical debt seems like a can’t-lose idea. A number of states and local governments have passed programs to pay off medical debt (most working with R.I.P. Medical Debt) and a number of others are considering it.

Credit: Juweek Adolphe/Alyson Hurt for KHN and NPR 

Last fall the Consumer Financial Protection Bureau initiated rulemaking that would remove medical bills from credit reports. It has also, according to NPR, “penalized medical debt collectors, issued stern warnings to health care providers and lenders that target patients, and published reams of reports on how the health care system is undermining the financial security of Americans.”

Director Chopra admits: "Of course, there are broader things that we would probably want to fix about our health care system, but this is having a direct financial impact on so many Americans."

If nothing else, the new study should remind us that our health system is best at putting band-aids on problems rather than solving them. The problems we should be addressing include: why are so many charges so high, why aren’t people better protected against them, and why don’t more Americans have enough resources to pay their bills, especially unpredictable ones like from health care services?

I’m glad R.I.P. Medical Debt is doing what it is doing, but let’s not kid ourselves that it is solving the problem.

Where's Our Infrastructure Plan B?

I’ve been thinking a lot about infrastructure. In particular, what to do when it fails.

There was, of course, the tragic collapse of Baltimore’s Francis Scott Key Bridge. Watching the video – and, honestly, what were the odds there’d be video? -- is like watching a disaster movie, the bridge crumbling slowly but unstoppably. The bridge had been around for almost fifty years, withstanding over 11 million vehicles crossing it each year. All it took to knock it down was one container ship.

Container ships passed under it every day of its existence; the Port of Baltimore is one of the busiest in the country. In retrospect, it seems almost inevitable that the bridge would collapse; certainly one of those ships had to hit it eventually. The thing is, it wasn’t inevitable; it was a reflection of the fact that the world the bridge was designed for is not our world.

Transportation Secretary Pete Buttigieg noted: “What we do know is a bridge like this one, completed in the 1970s, was simply not made to withstand a direct impact on a critical support pier from a vessel that weighs about 200 million pounds—orders of magnitude bigger than cargo ships that were in service in that region at the time that the bridge was first built,” 

When the bridge was designed in the early 1970’s, container ships had a capacity of around 3000 TEUs (20-foot equivalent foot units, a measure of shipping containers). The ship that hit the bridge was carrying nearly three times that amount – and there are container ships that can carry over 20,000 TEUs. The New York Times estimated that the force of the ship hitting the bridge was equivalent to a rocket launch.

“It’s at a scale of more energy than you can really get your mind around,” Ben Schafer, a professor of civil and systems engineering at Johns Hopkins, told NYT.

Nii Attoh-Okine, a professor of engineering at the University of Maryland, added: “Depending on the size of the container ship, the bridge doesn't have any chance,” but Sherif El-Tawil, an engineering professor at the University of Michigan, disagreed, claiming: “If this bridge had been designed to current standards, it would have survived.” The key feature missing were protective systems built around the bases of the bridge, as have been installed on some other bridges.

Credit: The Geography of Transport Systems

We shouldn’t expect that this was a freak occurrence, unlikely to be repeated. An analysis by The Wall Street Journal identified at least eight similar bridges also at risk, but pointed out what is always the problem with infrastructure: “The upgrades are expensive.”

Lest anyone forget, America’s latest infrastructure report card rated our overall infrastructure a “C-,” with bridges getting a “C” (in other words, other infrastructure is even worse).

What's the plan?

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Then here’s an infrastructure story that threw me even more. The New York Times profiled the vulnerability of our satellite-based GPS system, upon which much of our modern society depends. NYT warned: “But those services are increasingly vulnerable as space is rapidly militarized and satellite signals are attacked on Earth. Yet, unlike China, the United States does not have a Plan B for civilians should those signals get knocked out in space or on land.”

Huh?

At least in Baltimore drivers can take another bridge or container ships can use another port, but if cyberattacks or satellite killers took out our GPS capabilities, well, I know many people who couldn’t get home from work. “It’s like oxygen, you don’t know that you have it until it’s gone,” Adm. Thad W. Allen, who leads a national advisory board for space-based positioning, navigation and timing, said last year.

“The Chinese did what we in America said we would do,” Dana Goward, the president of the Resilient Navigation and Timing Foundation in Virginia, told NYT. “They are resolutely on a path to be independent of space.” Still, NYT reports: “Despite recognizing the risks, the United States is years from having a reliable alternative source for time and navigation for civilian use if GPS signals are out or interrupted.”

The economic and societal impacts of such a loss are almost unfathomable.

Credit: War Room/Army War College

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And, if you assume, well, the odds of satellite killers taking out all of the GPS satellites is unlikely – Elon can just send more up! – then think about the underseas cables that carry most of the world’s internet traffic. According to Robin Chataut, writing in The Conversation, there are some 485 such cables, with over 900,000 miles of cable, and they carry 95% of internet data.

What you don’t realize, though, as Professor Cataut points out, is: “Each year, an estimated 100 to 150 undersea cables are cut, primarily accidentally by fishing equipment or anchors. However, the potential for sabotage, particularly by nation-states, is a growing concern.”

The cables, he notes, “often lie in isolated but publicly known locations, making them easy targets for hostile actions.” He recommends more use of satellites, so I guess he’s not as worried about satellite killers. 

We’ve recently seen suspicious outages in West Africa and in the Baltic Sea, and cables near Taiwan have been cut 27 times in the last five years, “which is considered a lot by global standards,” according to ABC Pacific; accordingly, “it has been happening so frequently that authorities in Taiwan have started war-gaming what it would look like to lose their communications with the outside world altogether and what it would mean for domestic security and national defence systems.”

It's not just Taiwan that should be war-gaming about infrastructure failures.

Credit: Visual Capitalist

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If all this seems far afield from healthcare, I have two words for you: Change Healthcare.

Until six weeks ago, most of us had never heard of Change Healthcare, and even among those who had, few realized just how much the U.S. healthcare system relied on its claims clearinghouses. With those frozen due to a cyberattack, physician practices, pharmacies, even hospitals weren’t getting paid, creating a huge crisis.

Infrastructure matters.

Think what would happen if, say, Epic went off-line everywhere.  Or have we forgotten one of the key lessons of 2020, when we realized that over half of our prescription drugs (or their active pharmaceutical ingredients – APIs) are imported?   

Healthcare, like every industry, relies on infrastructure.

Infrastructure is one of the many things Americans like to avoid thinking about, like climate change, the national deficit, or healthcare’s insane costs. I understand that we can’t fix everything at once, nor anything quickly, but at the very least we should be coming up with Plan Bs for when critical infrastructure does finally fail.

Gen Z's Mid-Life Crisis

These are not happy times in America.

Gen Z is not happy. Credit: Bing Image Creator

Now, I’m not thinking about the increasing cultural wars, the endless political bickering, the troubles in the Med-East or Ukraine, the looming threat of climate crisis, or the omnipresent campaigning for the November 2024 elections, although all those play a part. I’m talking about quantifiable data, from the latest World Happiness Report. It found that America has slipped out of the top 20 countries for the first time, falling to 23^rd – behind countries like Slovenia and the U.A.E. and barely ahead of Mexica or Uruguay.

Even worse, the fall in U.S. scores is primarily due to those under 30. They ranked 62^nd, versus Americans over 60, who ranked 10^th. A decade ago those were reversed.  Americans aged 30-44 were ranked 42nd for their age group globally, while Americans between the ages 45-59 ranked 17^th.

It’s not solely a U.S. phenomenon. Overall, young people are now the least happy, and the report comments: “This is a big change from 2006-10, when the young were happier than those in the midlife groups, and about as happy as those aged 60 and over. For the young, the happiness drop was about three-quarters of a point, and greater for females than males.”

“I have never seen such an extreme change,” John Helliwell, an economist and a co-author of the report, told The New York Times, referring to the drop in happiness among younger people. “This has all happened in the last 10 years, and it’s mainly in the English-language countries. There isn’t this drop in the world as a whole.”

Jan-Emmanuel De Neve, director of the University of Oxford’s Wellbeing Research Center and an editor of the report, said in an interview with The Washington Post that the findings are concerning “because youth well-being and mental health is highly predictive of a whole host of subjective and objective indicators of quality of life as people age and go through the course of life.”

As a result, he emphasized: “in North America, and the U.S. in particular, youth now start lower than the adults in terms of well-being. And that’s very disconcerting, because essentially it means that they’re at the level of their midlife crisis today and obviously begs the question of what’s next for them?”

Gen Z is having a mid-life crisis.

The researchers speculate that social media, political polarization, and economic inequality between generations contribute to the low scores for younger Americans. Jon Clifton, CEO of Gallup, believes: “Young people have more social interactions, but feel more lonely,” and that they aren’t as connected to their job, churches, or other institutions.

“One factor, which we’re all thinking about, is social media,” Dr. Robert Waldinger, the director of the Harvard Study of Adult Development, said in a NYT interview,. “Because there’s been some research that shows that depending on how we use social media, it lowers well-being, it increases rates of depression and anxiety, particularly among young girls and women, teenage girls.”

Others note the impact of the pandemic. Professor De Neve said: “general negative trend for youth well-being in the United States [was] exacerbated during covid, and youth in the U.S. have not recovered from the drop.” Similarly, Lorenzo Norris, an associate professor of psychiatry at George Washington University, who was not part of the World Happiness study, told NYT:

The literature is clear in practice — the effect that this had on socialization, pro-social behavior, if you will, and the ability for people to feel connected and have a community. Many of the things that would have normally taken place for people, particularly high school young adults, did not take place. And that is still occurring.

“It’s a very complex time for youth, with lots of pressures and a lot of demands for their attention,” Professor De Neve diplomatically observed.  It was not true in all countries that younger people were the unhappiest, and Professor De Neve suggests: “I think we can try and dig into why the U.S. is coming down in terms of wellbeing and mental health, but we should also try and learn from what, say, Lithuania is doing well.”

Did you ever expect Lithuania might be a role model for our young people?

Professor Helliwell told CNN that young people are reflecting what is going on around them: “Almost whatever institution you’re in, people in North America seem to be fighting over rights, responsibilities and who should be doing what to improve things and who is to blame for things not going well in the past.”

Amidst all the gloomy findings, the report did say: “The COVID crisis led to a worldwide increase in the proportion of people who have helped others in need. This increase in benevolence has been large for all generations, but especially so for those born since 1980, who are even more likely than earlier generations to help others in need.”  They may be less happy, but Gen Z and millennials aren’t less charitable.

 So there’s that.

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Honestly, if young people aren’t depressed, they’re not paying attention. Social media is dominating their lives, whether Instagram is making them feel depressed or TikTok is driving them to harmful mental health content. They can see the impacts of climate change but not any sign that their elders plan to do anything about it. Their jobs are neither satisfying nor economically viable enough to allow them to build wealth, especially when suffering from crushing student loans.  They don’t expect Social Security to help with their retirement, whenever that may be and whatever that might look like. They have no reason to think that the largely geriatric politicians understand them or their needs.

 And when it comes to health care, they can see the attacks on women’s health, the inadequate support for mental health, and the gap in technology versus in the rest of their lives.

 They have every reason not to be happy. 

 The thing about mid-life crises is that they’re supposed to happen, you know, mid-life. Youth is supposed to be a time of optimism and exploration, of wanting to change the world. If current youth is already unhappy, we can’t assume they will grow happier, like those of us over 60 seem to have.  This is the America we’re bequeathing them; the question is, are we OK with that?

 Maybe a trip to Lithuania isn’t a bad idea after all.

 

Microplastics, Major Problem

It’s been almost four years since I first wrote about microplastics; long story short, they’re everywhere. In the ground, in the oceans (even at the very bottom), in the atmosphere. More to the point, they’re in the air you breathe and in the food you eat. They’re in you, and no one thinks that is a good thing. But we’re only starting to understand the harm they cause.

Who knows what microplastics are doing in our body? Credit: Bing Image Creator

The Washington Post recently reported:

Scientists have found microplastics — or their tinier cousins, nanoplastics — embedded in the human placenta, in blood, in the heart and in the liver and bowels. In one recent study, microplastics were found in every single one of 62 placentas studied; in another, they were found in every artery studied.

One 2019 study estimated “annual microplastics consumption ranges from 39000 to 52000 particles depending on age and sex. These estimates increase to 74000 and 121000 when inhalation is considered.” A more recent study estimated that a single liter of bottled water may include 370,000 nanoplastic particles. “It’s sobering at the very least, if not very concerning,” Pankaj Pasricha, MD, MBBS, chair of the department of medicine at the Mayo Clinic, who was not involved with the new research, told Health. 

But we still don’t have a good sense of exactly what harm they cause. “I hate to say it, but we’re still at the beginning,” Phoebe Stapleton, a professor of pharmacology and toxicology at Rutgers University, told WaPo.

A new study sheds some light – and it is not good. It found that people with microplastics in their heart were at higher risk of heart attack, stroke, and death. The researchers looked at the carotid plaque from patients who were having it removed, and found 60% of them had microplastics and/or nanoplastics. They followed patients for three years to determine the impacts on patients’ health, and found higher morbidity/mortality.

“We are reasonably sure that the problem comes from a frailty of the plaque itself,” says Giuseppe Paolisso, a professor of internal medicine and geriatrics at the University of Campania Luigi Vanvitelli in Naples, Italy, and one of the study’s authors. “We suppose due to the fact that the plaques with microplastics and nanoplastics have a higher degree of inflammation, this kind of plaque can be broken more easily; and once they are broken, they can go into the blood streams.”

“This is pivotal,” Philip Landrigan, an epidemiologist and professor of biology at Boston College, who was not involved in the study, wrote in an accompanying opinion piece. “For so long, people have been saying these things are in our bodies, but we don’t know what they do.” He went on to add: “If they can get into the heart, why not into the brain, the nervous system? What about the impacts on dementia or other chronic neurological diseases?”

Scary stuff.

If that isn’t scary enough, an article last yar in PNAS found: “Indeed, it turns out that a host of potentially infectious disease agents can live on microplastics, including parasites, bacteria, fungi, and viruses.” Even worse: “Beyond their potential for direct delivery of infectious agents, there’s also growing evidence that microplastics can alter the conditions for disease transmission. That could mean exacerbating existing threats by fostering resistant pathogens and modifying immune responses to leave hosts more susceptible.”

However much you’re worrying about microplastics, it’s not enough.

Marine ecologist Randi Rotjan of Boston University is blunt: “Cleaning up microplastics is not a viable solution. They are ubiquitous in our environment. And macroplastics are going to break down to microplastics for millennia. What we can do is try to understand the risk” Francesco Prattichizzo, one of the researchers in the new study, agrees, warning: “Plastic production is steadily increasing and is projected to continue increasing, so we must know how [and] if any of these molecules affect our health.” 

That’s easier said than done. As WaPo notes:

Part of the problem is that there is no one type of microplastic. The tiny plastic particles that slough off things like water bottles and takeout containers can be made of polyethylene, or polypropylene, or the mouth-twisting polyethylene terephthalate. They might take the form of tiny spheres, fragments or fibers.

Sherri Mason, director of sustainability at Penn State Behrend in Erie, Pa. told WaPo that, when it comes to assigning cause and effect: “Cigarettes are definitely easier than microplastics.” In the good news/bad news category, she added: “Probably over the next decade we’ll get a lot of good data. But we’ll never have all of the answers.”

Unfortunately, the amount of microplastics just keeps growing. Professor Stapleton told WaPo: “It’s almost like a generational accumulation. Forty years ago we didn’t have as much plastic in the environment as we do now. What will that look like 20 years from now?”

We can’t even imagine.

None of this is good news. Figure from Borrelle et al. (2017)

“The first step is to recognize that the low cost and convenience of plastics are deceptive and that, in fact, they mask great harms,” Professor Landrigan pointed out. Similarly, Lukas Kenner, a professor of pathology at the Medical University of Vienna, suggested to WaPo: “I’m a doctor, and we have our principle: ‘Don’t harm anybody. If you just spill plastics everywhere, and you have no idea what you’re doing, you’re going exactly against this principle.”

Microplastics are similar to cigarettes in that the health risks of the latter were pointed out years before any action was taken, and even then many people still smoke. It’s even more similar to climate change, in that we’ve had plenty of warning, and the impacts are starting to be clear, but the dangers accumulate over such a long period of time that no one feels compelled to act.

It’s also like climate change in that the fossil fuel companies bear a significant amount of the blame. Dr. Londrigan charges: “They realize that their market for burning fossil fuels is going down, yet they’re sitting on vast stocks of oil and gas and they’ve got to do something with it. So they’re transitioning it to plastic.” 

Perhaps biology will save us, with bacteria eating the microplastics. Or maybe it be robotics,  with nanobots doing the work. But we’ve been talking about engineering our way out of climate change for thirty plus years, and yet here we are, in climate crisis. I’m not holding my breath (although I’d ingest fewer microplastics that way) about fixing microplastics anytime soon.

We’ve all got a long list of things to worry about, but if microplastics isn’t already on yours, you should add it.

Wait Till Healthcare Tries Dynamic Pricing

Nice try, Wendy’s. During an earnings call last month, President and CEO Kirk Tanner outlined the company’s plan to try a new form of pricing: “Beginning as early as 2025, we will begin testing more enhanced features like dynamic pricing and day-part offerings along with AI-enabled menu changes and suggestive selling.” 

Wait for the surge pricing. Credit: Bing Image Creator

None of the analysts on the call questioned the statement, but the backlash from the public was immediate -- and quite negative. As Reuters described it: “the burger chain was scorched on social media sites.”

Less than two weeks later Wendy’s backtracked – err, “clarified” – the statement. “This was misconstrued in some media reports as an intent to raise prices when demand is highest at our restaurants,” a company blog post explained. “We have no plans to do that and would not raise prices when our customers are visiting us most.”

The company was even firmer in an email to CNN: “Wendy’s will not implement surge pricing, which is the practice of raising prices when demand is highest. This was not a change in plans. It was never our plan to raise prices when customers are visiting us the most.”

OK, then. Apology accepted.

Credit: Bon Appetit

At this point it is worth explaining a distinction between dynamic pricing and the more familiar surge pricing. As Omar H. Fares writes in The Conversation: "Although surge pricing and dynamic pricing are often used interchangeably, they have slightly different definitions. Dynamic pricing refers to any pricing model that allows prices to fluctuate, while surge pricing refers to prices that are adjusted upward."

Uber and other ride sharing services are well known for their surge pricing, whereas airlines’ pricing is more dynamic, figuring out prices by seat by when purchased by who is purchasing, among other factors.

Wendy’s wouldn’t be the first company to use dynamic pricing and it won’t be the last. Drew Patterson, co-founder of restaurant dynamic pricing provider Juicer, told The Wall Street Journal that dozens of restaurant brands used his company’s software. The company’s website doesn’t publicize those brands, of course. Still, he emphasized: “You need to make it clear that prices go up and they go down.” 

Dave & Busters is public about its pricing strategy. “We’re going to have a dynamic pricing model, so we have the right price at the right time to match the peak demand,” Dave & Buster’s CEO Chris Morris said during an investor presentation last year.  On the other hand, Dine Brands (Applebee’s/IHOP) Chief Executive John Peyton said. “We don’t think it’s an appropriate tool to use for our guests at this time.”

The potential revenue benefits are obvious, but there are risks, as Wendy’s quickly found out. Mr. Fares says: “One of the biggest risks associated with dynamic pricing is the potential negative impact on customer perception and trust. If customers feel that prices are unfair or unpredictable, they may lose trust in the brand.”

What Wendy’s tried to announce is not ground-breaking. Catherine Rampell pointed this out in a Washington Post op-ed:

In other words, things will be cheaper when demand is low to draw in more customers when there’s otherwise idle capacity. Lots of restaurants do this, including other burger chains. It’s usually called “happy hour.” Or the “early-bird special.” Non-restaurants do it, too. Think the weekday matinee deals at your local movie theater or cheaper airfares on low-traffic travel days.

Indeed, The Wall Street Journal reported: “An estimated 61% of adults support variable pricing where a restaurant lowers or raises prices based on business, with younger consumers more in favor of the approach than older ones, according to an online survey of 1,000 people by the National Restaurant Association trade group.” 

I wonder what the support would have been if the question would have been about healthcare instead of restaurants.  

Like it or not, some form of dynamic pricing will come to healthcare. Want a private room instead of semi-private? Surge pricing. Willing to see a nurse practitioner instead of a physician? Dynamic pricing. Want to buy prescription drugs in the U.S. instead of in Europe? Surge pricing. Want a doctor’s appointment Monday morning instead of Tuesday? Surge pricing. Need an ER visit Saturday night instead of Sunday afternoon? Surge pricing.

Some of these healthcare has been doing for years. Others, and even more insidious ones, are coming.

We have to know that the private equity firms that have invested in healthcare have to be interested. Yashaswini Singh and Christopher Whaley wrote in The Hill: “Over the last decade, private equity firms have spent nearly $1 trillion on close to 8,000 health care deals, snapping up practices that provide care from cradle to grave: fertility clinics, neonatal care, primary care, cardiology, hospices, and everything in between.”

They go on to warn: “Although research remains mixed on how it affects quality of care, there is clear evidence that private equity ownership increases prices. These firms aim to secure high returns on their investments — upwards of 20 percent in just three to five years — which can conflict with the goal of delivering affordable, accessible, high-value health care.”

Dynamic pricing has to look good to these firms. Surge pricing would look even better.   

 But one doesn’t have to be owned by private equity to be rapacious in healthcare. Everyone is looking for margins, everyone is looking to maximize revenue, and consumers – A.K.A. patients – grumble about prices but pay them anyway, especially if their health insurance company is paying most of the cost. In today’s healthcare world, if you are a CEO or CFO and you’re not considering dynamic pricing, it’s close to malfeasance.

To me, the scariest part of Wendy’s plan wasn’t the dynamic pricing but the “AI-enabled menu changes and suggestive selling.” Upcoding has been a problem in healthcare for as long as there has been coding, but when we get an AI-enabled menu of treatment options and suggested selling (aka treatments), well, we haven’t seen anything yet.

Maximize away.  

Look, I’m not going to Wendy’s even if they pay me, but I take my wife out on Valentine’s Day even though I know the restaurant has surged the hell out of its prices. Some things you pay for, and, when it comes to healthcare pricing, every day is Valentine’s Day.

I’m resigned to the fact that dynamic pricing has a toehold in healthcare already, but I’m holding out hope that we can use AI to help us make those recommendations and set those prices to deliver the most effective, efficient care, not just to maximize profits.