Tuesday, January 16, 2018

How to Make Heath Care Great (Again?)

In How to Make Gadgets Great Again, Geoffrey Fowler had this takeaway from CES 2018: "Gadgets are broken."  He quoted the Consumer Technology Association's projection that Americans will buy 715 million connected tech products this year, but noted: "Too many of them create more problems than they solve."

Health care's response: hold my beer.

Mr. Fowler listed four suggestions for how to make gadgets great again, and they're worth repeating:

  1. Respect our time: we know tech companies can make gadgets addictive, but can they figure out "not how to fill more of our time, but rather help us spend our time better?"  Plus, he also offered this rule of thumb:  "Before making a product, ask yourself: What would the “Black Mirror” episode about this tech be?"  I.e., think about the unintended consequences. 
  2. Security is not our job: It seems everything can get hacked, and all of our personal information is at risk.  We try to come up with new passwords and apply security patches, but he points out: "When I buy a car, I don’t have to purchase seatbelts and bumpers on my own—I trust the automaker took care of making it safe."  Why isn't that true for other technology?
  3. Focus on the "Internet of Services," not the "Internet of Things."  Sure, tech can connect almost anything, but that isn't the goal.  At the end of the day, we don't care about the device, we care about what it can do for us.  
  4. Don't lock us in: We're increasing getting into tech silos. The more data you give one of the silos, the harder it is to switch.  You're either an Apple person or a Google person.  You either like Alexa or Google Home.  Mr. Fowler rightfully complains: "I’ve got four different talking assistants on various devices in my house, but unfortunately my virtual staff doesn’t communicate well with each other."
Let's apply these four suggestions to health care:

  1. Respect our time: Ever waited to see your doctor?  Ever had to wait for a test or procedure, or to fill a prescription?  Ever been on hold with your health plan?  Most of us would say "yes" to at least one, if not all, of those.  The health care industry does not respect our time; it values the time of the people working in it.  
  2. Security is not our job: Has your personal data -- perhaps including your most sensitive health data -- been hacked at your health plan or health care provider?  Has any of it been sold to third parties, probably without your explicit knowledge or consent?  Whether you like it or not, the answer to these is also probably "yes."  
  3. Focus on the "Internet of Services," not the "Internet of Things."  Almost all of us have smartphones, and more of us are getting wearables.  Those of us who need pacemakers or new knee joints will soon find them all connected.  We're even going to swallow pills that are connected.  It's all certainly cool from a technology standpoint, but we're definitely in "Black Mirror" territory here.  We're rushing into health IoT before we really know what we can or should do with all the information, or how to protect it.  
  4. Don't lock us in: Health care is consolidating like crazy, whether health systems acquiring more hospitals and doctors, health plans gobbling up other health plans, or new combinations like CVS buying Aetna or United Healthcare buying Davita, all while narrow networks keeping increasing and formularies getting more restrictive.  Oh, and if your health care information is in one silo, don't expect it to be shared with another.  We want choices in health care, but our choices are getting more restrictive.  
When it comes to the things it produces being broken, the tech industry has nothing on health care.


I've already covered things about health care I'm dying to redesign, as well as my thoughts on how a truly 21st century health system might work, but, while all of Mr. Fowler's suggestions also apply to health care, I'll offer four aimed specifically at making it great:

  1. Make it about us: We talk about our health care system being all about the patient, but that's not true.  It's about the doctor, the hospital, the health plans and the medical industry -- them, their incomes and their processes.  Hopefully those work to the benefit of us, but, as the saying goes, hope is not a strategy.  What health care organizations focus as intently on us and our health as Amazon does its customers?  The ones which do will be the ones to survive.  
  2. Make it about health, not care: There is an oft-cited statistic that 80% of the things that impact health are SDOH -- social determinants of health -- and only a small portion are due to the care we receive, but our spending is the exact opposite.  We need to move focus, and money, away from care and invest in SDOH, away from specialty care and into primary care, and stop trying to do expensive moonshots until/unless we get the basics of our system right.
  3. Make it about facts, not faith: Too much of health care doesn't really work, for too many people.  The placebo effect doesn't just apply to placebos, many doctors don't have or know empirical evidence of effectiveness for many of their treatments, and as a result too much of our treatment is wasted, unnecessary, even harmful.  We're supposedly moving into a Big Data fueled, AI-assisted world; we must use those to move to an empirical age of health.
  4. Make our data ours:  Our health care data is not ours.  It belongs to the professionals who treat us, to the companies who help us collect it, or to the third parties who buy it.  We may have access to some, although not all, of it, but no one -- no one -- has a compete picture of our health.  If we're going to be person-centered, health-oriented, and data-driven, it has to start with the explicit understanding that any data about our health belongs to us, and we can choose when and to whom we share which of it.
I'm not sure when the golden age of health care supposedly was (or tech's either, for that matter), but I know this: we finally have the tools and the technology to make this it.  The question is, do we have the will?

Tuesday, January 9, 2018

No Internet? No Problem

Most healthcare thought leaders seem to be at a conference these days, what with StartUp Health Festival, JP Morgan Healthcare Conference, and CES 18.  They're talking about or listening to others talk about the future of healthcare and/or technology. 

Me, I'm just sitting at home thinking about the future.  Specifically, the future of the internet.
The internet has been successful beyond anyone's possible expectations.  It have infiltrated virtually every part of most people's daily lives, to the point where pundits like John Nosta suggest that technology has become almost as important as food, water, and shelter. 

He quotes an Ipsos survey that found 82% of people in India said they couldn't imagine life without the internet.  In India.  The comparable percent in the U.S. was 73%. 
Now we're all excited about the Internet of Things (IoT).  Everything you have or encounter will soon become capable of monitoring and communicating everything you do, and that will include monitors inside us.  The options are limitless. 

But, let's be honest: we've made a mess of things. 

Earlier this year we learned that most of the world's microprocessors have security flaws that leave them vulnerable to hackers stealing essentially anything on them.  The manufacturers and others are rushing to address the problems, but there aren't going to be any easy answers.  We've put an emphasis on ever-faster, and have accomplished miraculous improvements, but the trade-offs are sometimes vulnerabilities like these.   

If your personal information hasn't been hacked yet, well, sorry to tell you, but at least some of your personal information has been hacked.  Moreover, your personal data is currency to an array of companies.  All those "free" services aren't really free, they're just a clever way to find out more things about you, to better target advertising to you or sell your data to some other organization. 

Many thought the internet was going to democratize everything: make more information available to more people -- which it undeniably has -- and move more power to individuals and small organizations -- which it undeniably hasn't.

Think of the concentrated power of Amazon, Apple, Facebook, or Google, any one of which would make John D. Rockefeller envious. 

The underlying problem is that the internet was designed some 40 years ago, the Web over 25 years, and those are ancient in technology years.  We can throw more band-aids on them, but clever people will figure out new vulnerabilities and exploit them -- and us. 

Zeynep Tufekci fears that we're facing a looming digital meltdown.  In her words: "Modern computing security is like a flimsy house that needs to be fundamentally rebuilt."

It's time for something new.   

Some think that blockchain is going to be the next internet, fundamentally changing how we store, use, and ensure the validity of data.  Others caution that it is, perhaps, more like a new Linux.  Blockchain does offer exciting new possibilities, but may not go far enough on its own.


DARPA, which funded the development of the original internet, is looking at something called Dispersed Computing.  It would take advantage of more localized computing resources, such as smartphones, tablets, or autonomous vehicles.  Jonathan Smith, the DARPA program manager, told Fast Company: "Melding computing into communication is a dramatic rethink of the models and architectures we have become accustomed to." 

As Fast Company describes it:
Imagine every cell phone, smart thermostat, fitness tracker, and game console in your house contributing their spare cycles to help process the video you're trying to upload, or educate the machine learning algorithm that runs your AI personal assistant.  When a dispersed computing network wants to borrow your phone, in other words, it's going to be doing a lot more than sending a text.  
Petros Mouchtaris, president one of DARPA's vendors on the project, believes dispersed computing will be "transformational", one that will provide "a much more advanced internet than today."

DARPA is not alone. Wired's  The Internet Is Broken and accompanying article on how to fix it profile several efforts.  For example, Aral Balkan of ind.ie and Tim Berners-Lee are pushing for a more decentralized web.  Mr. Balkan says: "Imagine a world where every citizen owns and controls their own place on the internet." 

Dr. Berners-Lee is leading Solid at MIT, which they hope will decouple data from the applications they produce.  You could choose what data you wanted stored where, and any application that wanted to use it would need your permission. 

Meanwhile, Interdigital's Dirk Trossen is pushing for an "information-centric network," instead of the existing one based on URLs (uniform resource locators).  ICNs would disclose what information is stored, and that information would carry an authentication code that would make anonymity harder, this reducing phishing and fake news. 

Healthcare should be leading these kinds of efforts, not just watching with polite interest.

Healthcare leading the charge to reinvent the internet?  Ridiculous!  This is the industry that still uses faxes!  This is the industry whose providers need to be bribed to install EHRs!  This is the industry that can't connect those EHRs!  This is the industry in which making appointments online, viewing prices, doing virtual visits with providers, or even accessing your records are still viewed skeptically. 

And this is the industry that is already selling your health data to drug companies and others, and this is the industry suffering from data breaches and ransomware attacks

All those are reasons healthcare should be pushing for the next internet.

There's no internet-based healthcare colossus.  There's no healthcare organization whose use of internet-technology is the envy of other industries.  Face it: healthcare is only grudgingly accepting the use of computers, and, aside from things like email and organizational websites, is barely taking advantage of what the Internet has to offer. 

Rather than healthcare trying to catch up on internet-based technologies, it should skip to its next iteration.  Instead of a healthcare internet-of-things, let's put those new types of connectivity on a more stable, extendable platform.

Peter Levine of Andreessen Horowitz says: "I'm waiting for the next entrepreneur to come in who blows us away with the idea that there's some next thing that needs to be done relative to [dispersed computing].  I don't know what it is yet, but when I see it I'll let you know,"

Why can't that be someone in healthcare?  After all, it's our lives, and our most personal data, at risk here. 

Tuesday, January 2, 2018

Of Moonshots and Priorities

I was planning to do a what-I-wish-for-in-2018 post, but I saw a headline that made me wish I'd written it.  It came from a Wall Street Journal story about the woeful state of the NASA moon program.  They headlined it: "If We Can Put a Man on the Moon, Why Can't We Put a Man on the Moon?

It immediately made me think of healthcare.

The U.S. takes the whole "if we can put a man on the moon..." thing as a point of pride.  President John Kennedy put the challenge out there in 1962, at a time the U.S. appeared to be lagging the U.S.S.R. badly in the space race.  It was audacious, it was implausible, it was daring -- the kind of thing that made people love J.F.K.

Not only did we meet that challenge, but we did so within the decade, as he'd demanded.  The effort forced us to take big leaps, invent new technologies, spend lots of money, and risk many lives, including the loss of several.  But we did it.

Since then we've used that precedent to say, gosh, we're so good at meeting challenges, certainly we can accomplish anything we put our minds to. 

So we read about "moonshots" in almost every walk of life, from self-driving cars to Big Data to neural networks to nanobots, not to mention NASA's own moonshot for aviation. Alphabet's X is trying to turn innovation into a "Moonshot Factory," with a long list of bold projects. 

In healthcare, we have Joe Biden's Cancer Moonshot, Startup Health's moonshot list, IBM Watson's health data moonshot efforts, GE's digital health moonshots, among many other calls for healthcare moonshots.  We have so many moonshots we'll need more moons.

It's all very inspirational, but, it turns out, maybe we're not very good at moonshots after all. 

We did land 6 Apollo missions on the moon, but the last of those was in 1972.  We haven't even attempted a manned moon mission since then, and neither has any other country.  A small but dedicated percentage of the population now even believe the moon landing was faked.   

The WSJ article covers a report that NASA commissioned that helps explain why we're not landing anyone on the moon.  Basically, NASA's bureaucracy and contracting makes everything take too long and cost too much, even if NASA had enough money, which it doesn't.  The report calls for more public-private partnerships, to take advantage of the burgeoning private sector space efforts. 

Even Alphabet's moonshot efforts are having a fair share of crashes

B.F. Skinner wondered about the difficulty of improving education versus putting a man on the moon, and we just as well could ask the same question about improving healthcare.

These are things we could do.  We just don't. 

We like to believe we have the best health care system, but we don't.  Its problems are well known.  The U.S. spends too much money, mostly because our prices are insanely high compared to other countries.  We waste too much money and have too much unnecessary care

Our outcomes are average or worse.  Our already mediocre longevity is getting worse.   Some 28 million people still don't have health coverage, which represents the lowest level in decades but which is soon expected to get worse.  Even coverage doesn't ensure affordability.   

We continue to invent new drugs, devices, and treatments, but usually at higher and often jaw-droppingly high prices, and without always offering much incremental benefit.  We allow physicians to get payoffs -- let's be honest about this -- from those drug companies and device manufacturers.  We tout competition but are allowing both hospital and health plan markets to consolidate at unprecedented levels, despite much evidence that such efforts are only most likely to further increase costs. 

It's as though our car is speeding towards a cliff, but, instead of braking or turning away, we're hitting the accelerator.  Or, perhaps, saying we want to get to the moon but aim for the ocean. 

So, spare me the moonshots.  Spare me the big goals.  Spare me the expensive innovations.  Let's get the basics right first. 

Too much of healthcare has become like NASA.  Its processes are too slow, its organizations too bureaucratic and too inwardly focused, and everything is much, much too expensive.  Its regulations are expressed designed to keep outsiders out, to make barriers to entry high, ostensibly in the name of patient safety but, in many ways, more to preserve turf

The analogy to the new NASA report, which recommended public-private partnerships, might be more partnerships with non-healthcare organizations.  Amazon is the one perhaps most expected, and feared, to shake up healthcare.  Jeff Bezos, after all, is famous for saying "Your margin is my opportunity." 

As if anyone can figure out what the margins really are in healthcare, with confabulated charges, "non-profits" that aren't, padded salaries and superfluous jobs, and an array of middlemen -- think PBMs -- who add costs but not much value.  It makes the defense industry look like a hyper-competitive, transparent industry. 

The thing that made the actual moonshot successful was that, from top to bottom, the goal was clear, and shared.  In healthcare, that's almost never true.  We say it's about the patient, always about the patient, but that's hypocritical.  There are lots of goals and lots of priorities, often conflicting. 

A healthcare system that was truly about the patient would not look or perform anything like ours does -- and a true system of health would look at health first, and care as a last resort, so "patient" would never be the center. 

We would be. 

One of the hidden secrets about healthcare is that when doctors become patients, they don't tend to choose much of the care they typically give to patients, such as with end-of-life decisions.   If all care was treated that way, well, it's hard to believe we'd keep doing things the way we do now. 

Want a moonshot?  How about this: everyone working in healthcare should treat every person they deal with -- directly or indirectly -- as though they were themselves, or their parent, or their child. 

It sounds like a slogan.  It sounds too simple, and too unlikely to accomplish anything.  But so was "I'm helping put a man on the moon."

It's not about the moonshot; it's about the priorities.  Let's make this one ours.

Tuesday, December 26, 2017

"Local" Healthcare Isn't What It Used To Be

We live in a world where bigger is better.  Our phones are getting bigger.  Our televisions are getting bigger.  Our biggest companies are getting bigger (at least if they are in tech).  Our cars, especially SUVs, are getting bigger.  Our houses are getting bigger.

And, in healthcare, our hospitals are getting bigger, our physician practices are getting bigger, our health insurers, pharmaceutical companies, and medical device manufacturers are all getting bigger. 

It's time to question whether any of this is good. 

We're seeing it happen with retail malls already.  As has been widely reported, all across the country malls are re-purposing, dying a slow death, or dead already.  With Amazon and other online shopping giving seemingly limitless choices, easy price comparisons, and insanely quick home delivery, why bother to fight the traffic and the crowds, only to trudge through the mall in hopes of finding what you're looking for?

But retail shopping is not quite dead.  We're already seeing the one-time anchor tenants of malls starting to resize, as well as "big box" stores.  They making their existing stores smaller and opening up new, smaller stores.  "Retailers are realizing that they have to downsize stores to save money,” one retail expert told The Washington Post.

Healthcare is finally starting to realize it is, in fact, a retail business, and there is a trend for healthcare to locate in malls, part of the many ways malls are reinventing themselves.  But, of course, healthcare may be too late on this curve too.

Another, and perhaps better, example of how retail is changing was outlined recently in The Wall Street Journal.  Despite the much-ballyhooed increase in urban living, it's not all downtown condos for millennials and empty-nesters.  Millennials, it turns out, like the advantages of urban living but still want homes in the suburbs.  So suburban real estate developers are starting to incorporate retail in alongside new homes. 

"The single biggest challenge is walkability," Steve Patterson of Related Development LLC told WSJ.  People want schools, shopping, restaurants close by.  Another developer, Mark Culwell of Transwestern Development Co., added: "The resident comes home, relaxes a bit and then goes to a store half a block away without having to get back in the car." 

Unless, of course, he/she has to go to the doctor or, even worse, a hospital. 

Along these lines, NEJM Catalyst just published an interesting article by Jennifer Wiley, Nir Harish, and Richard Zane, three physician leaders.  In it, they make the case for "decentralization of health care."  As they say:
The traditional delivery model of a hospital as the “hub” of care, with a single centralized facility providing every facet of disease management and treatment, from specialized surgical cancer care to routine eye exams and chronic blood pressure management, should be questioned
Their argument is based around two key premises.  One is that "in the not-too-distant" future, health care systems will get paid for keeping people healthy.  Procedures like surgeries will go from being "golden gooses" to being an expense.  Having a big building with high fixed costs will be big disadvantage.

The second premise, of course, is that we have so many technologies that allow for more at-home options.  As they describe it, "...an entire industry is increasingly leveraging the power of “mobile health” to connect patients with providers."  E.g., portable electrocardiograms, x-rays, and ultrasounds.

They cite the example of Johns Hopkins' Hospital at Home program that "admits" patients to their own homes, and "are linked to the hospital through remote monitoring technology and receive daily visits from a physician and other caregivers (e.g., nurses, respiratory therapists, and physical therapists)."

A key to this away-from-the-hospital future may be what the authors call "community paramedicine," highly trained paramedics and EMTs whose "ability to deliver specialized tertiary care virtually in a patients’ driveway is changing the landscape of traditional care delivery models."

Finally, they point out a trend towards "microhospitals," whose 20 - 30 beds "rely heavily on virtual consultation and protocol-driven care for patients with specific care needs."  Construction Dive says they have a "big future," noting their convenience factor (although, typically for health care, regulation may prove a barrier). 

A similar trend is happening with nursing homes, such as in the Green House Project, which The New York Times just profiled.  Instead of the big, institutional nursing homes many of us picture, Green House's facilities are smaller and try to suit themselves to residents' preferences rather than vice-versa.  Susan Ryan, senior director for the Green House project, told NYT: "We try very hard to say, ‘This is home for life.'" 

This is not to say that either microhospitals or Green House nursing homes are revolutionizing their industries yet, but they may be pointing the way. 

Imagine suburban housing developments with microhospitals, Green House-type nursing homes, retail clinics, and doctors' offices all located within walking distance, alongside those stores, restaurants, and schools, not to mention all the online options that are and will increasingly be available.  Wouldn't you want to live there?

As long as most of us can remember, people have said "all health care is local."  What that usually meant, though, was "come to us."  Come to our hospital, our office, our facility, mainly because it was the closest to where you lived, and never mind what was available at the next hospital or in the next city, state, or even country. 

Increasingly we're going to see that health care may, indeed, be local, but it's going to mean what we can do in our homes or, at least, within walking distance from our homes.  Health care institutions and professionals who can't adapt to that are going to go the way of malls, dying or having to reinvent themselves. 

"Patient-centered" is a nice slogan, but it can't just be a slogan and it can't just be something that is applied in the usual places of care.  To make it a realty, it means truly centering health care around, and integrating with, where and how people actually live.   

As long as people are local, which even Ray Kurzwell thinks may be at least another thirty years, healthcare will be as well.  But who is giving that care, how, and where: those don't have to be -- and won't be -- "local" in the way they have been. 

Tuesday, December 19, 2017

We Have Seen the Future, and It Is...Estonia?

Like me, you may not have been paying close attention to what has been going on in Estonia.  That's probably something many of us should change, at least anyone interested in our digital future(s). 

OK, I have to admit: I had to look Estonia up on a map.  I knew it was in northern Europe, and that it had been involved in the whole U.S.S.R. debacle.  As it turns out, Estonia sits just across the Gulf of Finland from -- that's right -- Finland, and across the Baltic Sea from Sweden.  Skype was invented there, if you're keeping score.

More to the point, over the last twenty years it has evolved into arguable the most advanced digital society in the world.
Estonia's new brand concept
Nathan Heller has done a deep dive into Estonia in the most recent The New Yorker.  I recommend that you read it, or check out Estonia's e-Estonia site.  Basically, in Estonia:

  • everyone has a digital identity, safeguarded by a chip-encoded ID card and two-factor authentication;
  • virtually all other government transactions are done online, including voting;
  • most public and even private records are accessible online, so that, for example, in applying for a loan or a marriage license all needed data is pre-populated;
  • patient medical records are all online (owned by the patients), and are shareable only as patients specify;
  • most public records are stored in blockchain, and use the X-Road open source data platform for both public and private data.
If it sounds like a heavy government presence, that would be wrong.  One Estonian told Mr. Heller: "In Estonia, we don’t have Big Brother; we have Little Brother.  You can tell him what to do and maybe also beat him up."

They believe their efforts have saved two percent of G.D.P., by reducing salaries, expenses, and hassles for citizens.  Think about that: 2% of G.D.P.  As Everett Dirksen once said, pretty soon you're talking about real money.

And they're not done.  Just today, for example, Estonia announced it was launching its own form of cryptocurrency, which it refers to as a crypto token and calls "estcoin."  It can't actually be used as currency because Estonia, as part of the European Union, must use euros, but they're trying to figure out what it could be used for. 

They have some ideas about that, and many revolve around further support for their e-Residency program.  They claim that program created "a borderless digital society for global citizens:" 
E-Residency is a transnational digital identity that anyone in the world can apply for to obtain access to a platform built on inclusion, legitimacy, and transparency.  E-residents then have access to the EU business environment and can use public e-services through their digital identity.  
Some 28,000 people from around the world have already applied for e-Residency.

They admit that estcoins may be a solution in search of a problem, and they're OK with that.  Their attitude is, "OK, here's a cool new tool: what problems can we help you solve with it?" 

That is not your typical governmental attitude. 

Amazon has revolutionized retail by constantly trying to reduce "friction" for consumers.  Estonia has done that for government services and, increasingly, other commercial services.  No wonder they rank high in international competitiveness and ease-of-doing business rankings. 

The man behind the e-Residency concept, Taavi Kotka, told Mr. Heller:
If countries are competing not only on physical talent moving to their country but also on how to get the best virtual talent connected to their country, it becomes a disruption like the one we have seen in the music industry.  And it’s basically a zero-cost project, because we already have this infrastructure for our own people.
Kaspar Korjus, who announced the estcoin, put it bluntly: "Our focus will remain on our overall objective to grow our new digital nation and democratise access to entrepreneurship globally."

That is competing in the Internet age.

In the U.S., of course, we're talking about strengthening our borders, not becoming borderless.  Most of us still vote in local polling places, often using analog machines or even paper ballots.  We joke about standing in line at the DMV (although we're not very amused) and complain about how hard it is to file our taxes.  "Good enough for government work" typifies how we've dumbed down our expectations for government services.

In our health care system it's not much better.  We continue to plod towards electronic health records, although with much less progress on those EHRs actually being able to share data and virtually no progress in patients actually owning their own data or even in preventing it from being sold to third parties.  Waiting at the DMV has nothing on waiting in a doctor's office or ER.  We're talking about blockchain in healthcare, but there are heavily entrenched interests in the status quo. 

We don't have universal coverage (as Estonia does), and even some of our recent gains in covering people are starting to slip away, with Republicans happy to trade tax cuts for 13 million people potentially losing coverage.

We're still struggling to figure out how to deal with state lines in health care, as telehealth has illustrated.  Importation of prescription drugs has similarly shown how we have the same problem with national borders. 

Guess what: data increasingly drives our economy, even in health care, and data doesn't recognize borders.

We're not going to be a digital nation anytime soon.  We don't have an e-United States initiative.  We're not going to lead the world with creating a blockchain-based health care system.  We have huge sunk costs of infrastructure limiting not only what we do but what we think we can do.   We are a big battleship that turns oh-so-slowly.
 
But perhaps we're going to see state or local technological leaps forward.  Andrew Keen suggests that states may lead the charge in adopting new technology, specially pointing out how Rhode Island is looking at Estonia's example.  Meanwhile, Delaware -- long a locus for companies to incorporate in -- has passed a law allowing companies to use blockchain for corporate records, including stock trades.

Maybe next we'll see a local community fully jumping into the 21st century, not just for government services but for local private sector ones.  Wouldn't it be great, for example, if the near duopolies in the health care systems of, say, Cleveland or Pittsburgh came together to implement shared technologies for a frictionless patient experience? 

So what I'm wondering is: who/where in the U.S. is going to be our Estonia?

Tuesday, December 12, 2017

Welcome, Comrade Patient

Capitalism is in big trouble, even in the U.S. and especially among millennials.  So reports Fast Company and The New York Times.  Even capitalism-friendly publications like The Wall Street Journal and Bloomberg warn about it. 

The oft-cited reasons include problems like increasing income/wealthy inequity and dimmer outlook for good jobs, but I have to wonder how much of a role our health care system plays in these kinds of attitudes.
After all, in a health system driven by capitalism you'd like to think we'd be continually improving our health, getting more choice and convenience, and all at lower costs.  None of that seems to describe how it is working in health care, which may help explain why more are becoming disillusioned with it.

The WSJ article cited a 2016 Harvard Institute of Politics survey, in which only 42% of younger Americans said they supported capitalism and only 19% identified themselves as capitalists.  One student explained: "socialism has gotten less spooky; it's no longer associated with communism the way it was.  Straight-up capitalism has a lot of potential to be really corrupt."

The 2017 version of the same survey found that two-thirds of those 18-29 are fearful about the future of our country, with only 14% believing we're on the right track.  No wonder; the World Economic Forum says millennials in the U.S., UK, and Japan are the first generation in recent history who are posed to be worse off than their parents. 

The WSJ also showed a 2016 Gallop poll in which capitalism and socialism were rated equally favorably (both just over 50%) by respondents ages 18 - 29, which was a stark contrast to every other age group (support for capitalism goes up by age, while support for socialism declines).  Similarly, a 2017 WSJ/NBC News survey found that the 18-29 age group was much more likely to say the government should do more to help people, again in contrast to other age groups. 

People like economist Richard Wolff or sociologist Wolfgang Streeck suggest that perhaps capitalism is coming to an end.  Professor Wolff thinks it may be replaced by worker cooperatives, but Dr. Streeck warns: "We’re going into a long period where we don’t know what is coming.”

That sounds like what our health care system may be facing.

In some ways, the U.S. health care system is a model of capitalism.  Lots of people are making lots of money, whether they be stockholders in health companiesdoctors and health care executives, or even supposedly non-profit parts of the system.  The sector's continued strong job growth is the envy of many other industries and the pride of many local communities.   

The problem is, though, unless you are one of the lucky ones doing well with our current system -- and maybe even then -- you're probably not too happy with it. 

It costs too much, whether we look at the cost of care or the cost of the health insurance that is supposed to pay for that care.  We get plenty of innovative new drugs and treatments, but at astronomical new prices.  We see waves of consolidation, whose main effect seems to be reduced choices and higher costs.  The data is too siloed.  Healthcare professionals report dangerous levels of burnout.

And, of course, not only do we spend more than any other country, our heath outcomes are worst than most developed countries.
Last year, Senator Bernie Sanders made unexpected headway in his race to be the Democratic candidate for President despite -- or perhaps because of -- his socialist leanings.  One of his key planks was for Medicare for all, an idea that has seen a strong resurgence generally.  Even more popular is the (admittedly vague) push for single payor.

A Harvard-Harris poll found that 52% of Americans supported a single payor system, with even 35% of Republicans supporting.  Young people were most supportive.  Politico found that 49% of Americans support a single payor health care system, even more popular than adding a public option to compete with private health plans (44%). 

The Kaiser Family Foundation tracking poll showed 53% supporting single payor, with similar support for both that and a Medicare-for-all approach.  Pew Research Center found "only" 33% favored single payor, but noted that support is increasing quickly, and that almost half of those 18-29 support it. 

Perhaps most astonishing is that a Merritt-Hawkins survey found that 56% of physicians now support single payor, a sharp reversal from prior surveys.  42% voiced strong support.

Now, Medicare-for-all isn't single payor -- not with about a third of Medicare beneficiaries enrolled in private, competing Medicare Advantage plans and with all Part D recipients in them -- and even single payor does not mean nationalized health, like Britain's National Heath Service.   But these many survey results are warning signs that our current approach to financing health care is pushing an increasing number of people to call for something else. 

Vermont actually passed single payor, but the plan floundered when taxpayers saw the cost.  Colorado tried to pass single payor through an initiative, which down in resounding defeat.  Yet keep in mind that we didn't like the Affordable Care Act until it started to look like we might have it taken away, and then support grew.

The moral of the story may be that, when it comes to financing our health care, we don't really know what we want, but we sure don't really like what we have.

Right now, millennials are not as engaged in health care as older age groups because they tend to need it less.  They don't have as many health problems and don't see health professionals as often.  That's why getting them to buy health insurance is a constant struggle, even when they have the lowest premiums.   

But as this radicalized generation, who are already frustrated with economic inequity and the prospects for their future, realize how much they will have to pay for older Americans' health needs as well as for their own, push will eventually come to shove. 

We have some hard thinking to do about how we finance health care, and for whom.  We have some hard thinking about what the role of profit, competition, and capitalism should be in our health care system.  We have some hard thinking to do about why our health care system is not serving more of us better.

It may not be socialized medicine.  It may not be single payor.  It may not even be Medicare-for-all.  But it for sure will not be what we have now. 

Tuesday, December 5, 2017

Health Disparities and Lost Einsteins

One of the most evocative phrases I've seen lately comes from a new study from The Equality of Opportunity Project on the inequality of becoming an inventor in the U.S..  The authors decry the "lost Einsteins" in our society, i.e., "people who would have had high impact inventions had they become inventors." 

The study doesn't specifically reference the impact health disparities has on producing these "lost Einsteins," but it could have. 
Source: New York Times
I won't recount the methodology the study used, but here are its three key learnings:

  1. There are large disparities in innovation rates by socioeconomic class, race, and gender
  2. Exposure to innovation substantially increases the chances that children become inventors.
  3. Star inventors earn more than $1 million per year, suggesting that further increasing financial incentives or reducing tax rates may have small impacts on innovation.
The problem is not ability. The authors say:
Differences in ability, as measured by test scores in early childhood, explain very little of these disparities. Children at the top of their 3rd grade math class are much more likely to become inventors, but only if they come from high-income families (Figure 2). High-scoring children from low-income or minority families are unlikely to become inventors. Put differently, becoming an inventor relies upon two things in America: excelling in math and science and having a rich family.
In his New York Times opinion piece about this study, David Leonhardt notes: "Low-income students who are among the very best math students — those who score in the top 5 percent of all third graders — are no more likely to become inventors than below-average math students from affluent families.  

It's worse than that.  Mr. Leonhardt's take on the data is as follows: 
Women, African-Americans, Latinos, Southerners, and low- and middle-income children are far less likely to grow up to become patent holders and inventors. Our society appears to be missing out on most potential inventors from these groups. And these groups together make up most of the American population.
Patents/1000 children (light to dark).  By The New York Times | Source: Equality of Opportunity Project
As Steve Case told Mr Leonhardt , "Creativity is broadly distributed. Opportunity is not." 

It is largely what happens in the childhood environment that drives the innovation gaps.  Better schools, improved nutrition, and healthier surroundings should all help, but another key seems to be being exposed to innovators who are like themselves.  E.g., being around male innovators is not as important to girls as being exposed to female innovators.  

Closing the innovation gaps -- finding these lost Einsteins -- could have a dramatic impact on innovation and thus economic growth.  The authors believe that: "If women, minorities, and children from low-income families were to invent at the same rate as white men from high-income (top 20%) families, the rate of innovation in America would quadruple."

I can't help wondering how many of these lost Einsteins are lost because of health issues.  

After all, the U.S. has some of the worst health disparities in the world.  Some of that is due to affordability of health care, some to availability of health services, some to living in "food deserts" or simply not having enough to eat (1-in-6 kids!), and some to living in unhealthy environments, such as being exposed to lead poisoning (1.2 million kids) or air pollution.  

Income matters.  Race matters.  Location matters.  Education matters. 

Look at the rates of, say, asthma, diabetes or obesity disparities across the U.S..  Or maybe homicide rates or opioid overdoses/deaths.  Or look at differences in infant mortality rates and think about the Einsteins that not only get lost, but are never even born.  
 
All those make it clearer why some of those potential Einsteins have things other than some new innovation to think about.

This is the "health care system" we've built, or allowed to be built.  These are the differences in health outcomes that we bemoan, but largely just wave at hands when it comes to actually trying to reduce them.  

For example, The Washington Post/Kaiser Health News recently reported on how it is more profitable for hospitals to treat children with asthma, usually through expensive ER visits, than to address the underlying reasons for the asthma.  And, of course, it is low-income, often minority residents that end up being victimized the most by this.

An executive at Johns Hopkins, speaking of the at-risk populations and some proposed at-home preventive interventions, conceded: "We know who these people are. . . . This is doable, and somebody should do it."

Somebody, indeed. Maybe one of those lost Einsteins could have figured out a way to do it.

Let's keep in mind that we're not just missing perhaps the next Steve Jobs or Sergey Brin.  We may be missing the next Louis Pasteur, the next Wilhelm Conrad Rontgen, the next Jonas Salk, the next William Greatbatch, or the next Craig Venter.  People who can help truly invent our way into the 21st century health care we should have.

If we only had, say, $30 billion to spend on health, we'd get the biggest bang for our buck investing all of it in public health infrastructure and initiatives.  It wouldn't look anything like our current health care system -- or, rather, our medical care system --  but it could go a long way towards reducing all those glaring health disparities.

If we managed to scrape up $300 billion, we could not only do a better job in public health but also could target some critical, high-impact medical care needs, such as enhanced prenatal care or targeted preventive screenings.   

With our current $3 trillion in health spending, though, we manage to ensure that the people who finance and/or deliver medical care, or make the drugs and devices involved in that care, do very well financially, but the rest of us, not so much -- either financially or in our health status.  

Even a lost Einstein can see that is perverse.  

Our economy can't afford to lose all those Einsteins.  Even more, our society can't afford to go on treating the health of any of us, Einsteins or not, as carelessly as we're doing now.