Strange Bedfellows

Strange days in health care: Amazon appears to be getting into the pharmacy business, CVS wants to buy Aetna, and Uber is bidding on Doctors on Demand.

OK, I made up that last one, but it doesn't seem so far-fetched anymore, does it?

Health care is seeing some strange bedfellows these days, and I, for one, hope we see more.  I'm going to list some of the intriguing combination I'd like to see, but first let's start with what's actually going on.

CNBC and others have been reporting on Amazon's interest in pharmacy for several months, and just last week the St. Louis Post-Gazette reported they'd acquired wholesale pharmacy licenses in several states (a move that may mean less than it suggests).  Pharmacy stocks immediately took a tumble (as had happened to grocery store stocks when they announced their acquisition of Whole Foods earlier this year).  

No sector wants to see Amazon enter its space, as Amazon is known for low margins and excellent customer service.  Health care is an appealing target, with pharmacy considered one of Amazon's most natural first targets, given high prices and convoluted supply chain.

Almost as if in response to the Amazon rumors, CVS surprised almost everyone with their bid to acquire Aetna.  A drugstore getting into the health insurance business -- what sense does that make? 

More than one might think.  CVS is already a large PBM (pharmacy benefit manager), including for Aetna, and owns SilverScript, one of the largest Part D plans.  They should understand this business, and they would increase their potential engagement with tens of millions of people.

CVS has apparently been preparing for this for some time, having also reportedly talked to Anthem and UnitedHealth before agreeing to the Aetna acquisition.  It's a bold move, and could end up the largest health deal to date, at an estimated $66b price tag. 

At this point, intra-industry health care mergers, like last year's Aetna-Humana or Anthem-Cigna mergers -- both of which ultimately failed -- seem positively old-fashioned.

With tongue only slightly in cheek, here, in alphabetical order of acquirer, are some potential, perhaps unexpected mergers/acquisitions that might make sense:

1. Alphabet-WebMD: Private equity firm KKR is in the process of acquiring WebMD, in a deal worth some $2.8b, but Alphabet's Google would make a better home.  After all, health is one of the leading search topics on Google, and WebMD is one of the top destinations for those searches.  Google could figure out what to do with that content and further monetize those searches.
2. Amazon-Medibid: Amazon can certainly shake up the pharmacy world, but how about if they get into medical tourism instead/in addition to?  Not just for overseas medical tourism, which is booming, but interstate, intra-state, even intra-city "tourism" as well.  Amazon could create a market by having providers list fixed prices for bundled services, then letting consumers compare and "buy" those services on Amazon's marketplace.  There are not many companies in this space, but MediBid would be a start. 
3. Apple-Medtronic: Apple makes great consumer devices, focusing on delighting the users.  Medtronic is a leader in consumer devices too, only with focus on medical and often not visible to (or delighting) consumers.  With medical devices becoming more IoT, and with more focus on DIY health and patient satisfaction, Apple could raise the bar in medical devices significantly -- and further lock in their developing health ecosystem.  Their interest in primary care may have to wait.
4. Disney-Humana: Humana has long prided itself on being member-focused.  They recently announced a partnership with Oscar Health to boost their consumer focus, but nothing would make the leap to improving the member experience than by joining up with the guru of all customer experience, Disney.  Why would Disney want to get into health?  Well, maybe because there's a lot more money in health than in vacations.  
5. Facebook-PatientsLikeMe: Perhaps not a blockbuster deal, but Facebook's acquisition of PatientsLikeMe, one of the leading health "social networks," would further solidify Facebook's reach -- and give them access to much more data.
6. Microsoft-Practice Fusion: Microsoft has tried hard to be a leader in health, just like it has struggled to be a leader in anything other than PC operating systems.  One thing it is good at -- although still not the leader -- are cloud services, so why not buy Practice Fusion, which touts itself as the largest cloud-based EHR platform?   Better yet, snap up both it and athenahealth., another leading cloud-based EHR.  Both athenahealth and Practice Fusion are reportedly struggling.
7. Uber-Doctors on Demand: That opening sentence may not have been so far-fetched after all.  People have speculated about who would be the "Uber of health care," and Uber itself is trying with Uber Health.  Matching up patients with on-demand telehealth providers would seem within Uber's sweet spot, with Doctors on Demand on of the leaders in that space.  And if they could figure out how to add house calls, such as through Heal, they might really be onto something.
8. UnitedHealth-Epic: UnitedHealth has long seen itself as a health company, especially through its Optum lines of business.  They love data and analytics, and Epic's data would be a treasure trove.  Moreover, Epic has connections with huge numbers of doctors, hospitals, and other health care providers, which could strengthen United's ties to them.  And who knows: United's health information exchange expertise might even spur Epic's much criticized interoperability.
9. Walmart-Cardinal Health: Walmart is one of the best consumer retailers, while most consumers have never heard of Cardinal Health.  But most hospitals and other health care institutions have, relying on them to supply medical supplies and pharmaceuticals.  Walmart has low prices in large part because it is superb at supply chain and logistics, so it is a natural fit.
10. Walmart-Centene: If Walmart wants to stick to retail, it could do worse than to scoop up Centene, one of the leading Medicaid managed plans (and now exchange plans too).  Walmart has long been known for appealing to lower income customers (although they have been trying to broaden), so Centene's Medicaid and near-Medicaid populations would make sense.  The insurance could help push even more business to Walmart's huge pharmacy business, vision centers and retail clinics.

Surprised (or amused) by any of the above?  I sure hope so.

I'm tired of the (very dangerous) vertical and horizontal consolidation we continue to see in health care.  I want to see more surprises. 

Some of these suggestions may seem unlikely, but I'm more worried that they are not surprising enough.

AI Docs Won't Be Like Human Docs. Good

The 21st century is going to be a world of artificial intelligence (AI), whether we’re ready for it or not. And we’re probably not, especially not when it comes to health care.

Let's start with two tweets:

Chrissy Farr: "My favorite Friday quote: @Farzad_MD citing a peer at Mass General: "Any doctor that can be replaced by a computer should be.""

Trisha Greenhalgh: "I predict the very last doctor to be replaced by a robot will be the GP.  Almost none of our work is algorithmic."

These sentiments are widely shared by physicians. They view what they do as uniquely human, and are pretty proud of it — although some now allow that AI might be able to augment them. Someday.

However, feeling that their job is not likely to be replaced by AI (or other automation) is not unique to physicians. Consider the following from a Pew Research Center survey:

In other words: too bad for those fast food workers or those overpaid software engineers, my job is safe. And not just this year or next year, but for the rest of my life. There likely is some wishful thinking going on here, and that may apply to physicians as well.

Still, 79% of respondents believed that within 20 years doctors will rely on computers to diagnose and treat most diseases. The real question is the extent to which a human doctor will still be involved. 

This is hard for physicians to accept. Caroline Poplin, MD, JD, FACP, argues “Medicine is Not Manufacturing.” She laments that: “Even as Western medicine has become more scientific over the centuries, the central role of the physician-patient relationship, with the interest of the patient being paramount, has remained the same — until recently.”

In recent years, she believes, health care has become more of a business, and concludes that the the unique thing about medicine is its soul, “the essential element that has given patients comfort and relief for thousands of years and does so even today.” 

Take that, computers. 

The fact is, like it or not, that health care is a business, in which lots of people and organizations make a lot of money. It’s hard to walk into a hospital, or a surgery center, or even a doctor’s office, and not see that they are manufacturing operations. 

They’re often not very efficient, mind you, and as much as they say they are all about the patient, that is often hard to believe.  

That is not to say that there are not very empathetic, caring people in health care — many of them physicians — but let’s not confuse that with the practice of medicine. Not anymore. 

When physicians had little idea of underlying disease states and even less ability to do anything about them, that confident bedside manner helped many patients, but as we apply more science to diagnosing and treating patients, we should need it less.

What is it, exactly, that we’re trying to preserve? Physicians treat patients based on their experience with previous patients, the training they got, the research they remember, the imperfect and intermittent data they have, and their vaunted intuition. Those are a lot of variables, potentially leaving wide gaps in what they can bring to bear upon the care for a specific patient.

Human doctors do the best they can, in most cases, but they do make mistakes, they do order care that is unnecessary at best and inappropriate or dangerous at worst, and they don’t always agree with other doctors about patients. 

An AI, on the other hand, can bring to bear analysis of huge datasets, the depth and breadth of all existing research, and an infallible memory. Plus, it doesn’t have bad days, isn’t going to be tired, and doesn’t go on vacations.

It might even develop a bedside manner. 

The odds are that your human doctor is almost certainly not the “best” in the world, if we could ever figure out who that was, but the best AI doc could treat an unlimited number of patients.  

One of the most interesting recent AI developments comes from a game. Google’s Deepmind program AlphaGo Zero learned the fiendish difficult game Go — in three days, without any human instruction. It didn’t look at games played by humans, it didn’t have human Go experts programming it, it didn’t even play humans.

Instead, it was fed the rules, then played itself. Endlessly. Millions of games. It made stupid mistakes initially, but when all was said and done after the three days it was at a level no human ever has been. It learned many of the intricate strategies that humans have figured out over the centuries, as well as ones that Go experts called “amazing, strange, alien.”

“They’re how I imagine games from far in the future,” Shi Yue, a top Go player from China said, or, more colorfully, which Go enthusiast Jonathan Hop describes as “Go from an alternate dimension.”

Imagine this for health care.

We’ll start with more data. A lot more data. Not just finally breaking down all those ridiculous silos, but from more ongoing monitoring through wearables and other devices, helping establish our base health and giving more early warning of when things are getting off track.

AI will come up with ways of diagnosing and treating that we’ve already discovered — along with ones that are “from far in the future.” That’s a good thing, and we should welcome it.

Dr. Bryan Vartabedian, for one, thinks that AI will force doctors to rethink what they do. Computers make information widely available, imaging more precise, pattern recognition more possible. He points out:

The end result is a paradox: We want the precision and specificity of the machine yet we want to believe that we can still do it all with our hands and eyes and ears.

We probably can’t. So we need to start redefining what the human doctor of the 21st century will do.

Dr. Vartabedian thinks the key question may boil down to “What can a human do that a machine can’t?” That is a question whose answer will be continually evolving — as will the role of physicians.

In a separate article, Dr. Vartabedian hints at an answer:

My work is about translation and connection… I help them negotiate the transition between life with a chronic condition and the healthy development that can create some semblance of a normal life… It’s a far cry from the work of a scientist. And I’m good with that.

The goal of AI in health care isn’t to get rid of human doctors, but it shouldn’t be to preserve them either. The goal should be to do what is best for patients, for us.

There will be a role for physicians in the future. Probably. But there will also be one for AI. It won’t be the same as human doctors, and that’s OK. 

Elon, Do We Have a Disaster for You!

One of the most interesting twists resulting from Hurricane Maria striking Puerto Rico was Elon Musk's offer that Tesla could help Puerto Rico solve its energy crisis, with a long-term, 21st century fix.  After all, its electrical grid was devastated, with almost all the power wiped out.  It didn't help that even prior to this disaster its system was antiquated and badly in need of repairs.

It is telling that we don't have similar offers to rebuild the Puerto Rico's health care system, which is similarly devastated.  Or, for that matter, our system, which is its own kind of disaster.

Mr. Musk was asked on Twitter if Tesla could help Puerto Rico using solar and battery power, and he responded in the affirmative, saying it had done so on smaller islands but faced no scalablity issues.  Next thing we knew the Governor of Puerto Rico and he were talking.  Now Tesla is starting to deliver their battery systems to the island, so we'll see.

The appeal is obvious.  The island has a perfect climate for solar power.  Rebuilding the power plants and power lines is a daunting task, especially for an island that is essentially bankrupt.  Solar is renewable, oil and coal are not.  And, being a tropical island, Maria is not the last strong storm that will strike Puerto Rico, so future outages are inevitable.  Solar/battery at least decentralizes the grid, lessening how wildspread such outages might be.

Maybe it is a marketing stunt on Mr. Musk's part -- if so, you have to give him credit for it -- but the idea has merit.  A disaster like Maria is a once-in-a-lifetime opportunity to try bold new ideas instead of blithely rebuilding what was there before (let's hope Houston does the same with its zoning and floodplain issues).

Meanwhile, Kaiser Health News reports on the toll Maria has taken on the island's health system and residents' health, both now and for some time to come.  Relief workers are doing the best they can, but there's no easy fix for the underlying problems the system was already facing, like high prevalence of chronic conditions, funding shortfalls, and an ongoing brain drain of health professionals, all exacerbated now by lack of clean water, adequate supplies, and shelter.

Still, even Elon Musk isn't bold enough to offer to rebuild their health care system, much less ours.

Sometimes disasters do make us rethink our health care system.  Katrina, for example, has often been credited with creating the impetus for electronic health records (EHRs), since it destroyed countless paper records, wrecking havoc on care for thousands of patients.

But we didn't pay enough attention to even that very visible crisis.  We do have a lot more EHRs now, but less than 30% of hospitals self-report being interoperable, and half of physicians' time is supposedly spent on their documentation efforts.

The records themselves remain largely physician-centered and exclusively medical, although Epic, the nation's largest EHR vendor, is finally saying they will move to a "comprehensive health record" (CHR).  "Because healthcare is now focusing on keeping people well rather than reacting to illness, we are focusing on factors outside the traditional walls, Epic's CEO told HealthIT News.  Rivals say they are doing the same.

I'm glad that in 2017 EHRs vendors are finally realizing there is health outside a medical facility.

It shouldn't take a hurricane -- or an earthquake, or a bickering Congress -- to realize that we have an in-progress disaster with our health care system.  Sure, health care hiring is booming and hospital/medical construction is everywhere, but those are signs of the disaster, not of the robustness of the system.

We spend way too much on medical care, we get too much unnecessary care, we are subject to too many medical errors (including deaths), and we suffer from too many lifestyle diseases, such obesity and diabetes.  Our longevity is embarrassing -- and declining.

We give tax breaks to "non-profit" hospitals regardless of how they use those breaks, and to employer health plans, which end up disproportionately benefiting the middle and upper class.

We finally managed to give health coverage to millions of previously uninsured Americans, but now those gains are under attack, while half of the poor and near-poor remain uninsured.

We bounce from one new dietary finding and/or fad to another, while eating too many processed foods and not nearly enough healthy foods.  Meanwhile, few of us get enough exercise, and we spend too much time on our various screens.  Our social networks are increasingly online rather than in-person.

There is not nearly enough "health" in our health care system, just ever-more "medical."

If all that isn't a disaster, I don't know what is.

Let's say we were starting from scratch.  Let's reset what our health care system could be.  Let's say we didn't have all these hospitals, hadn't trained any physicians, hadn't deployed any medical devices or used any prescription drugs, although we could start with the knowledge of what each of those could accomplish.

Would we remake the system as it is, or would we design something new?

In a previous post I enumerated several things about our health care system I was dying to redesign, and in another I gave some specifics about how a re-engineered system might work.  Even those, though, didn't start from entirely scratch, still focusing more on the medical than on the broader health perspective.

We should be spending more on our health needs -- broadly defined -- than on our medical care.  We should be more worried about if people are going to the park than if they are going to the doctor's office.  And when we do get medical care, we should make sure it is care that has solid evidence of working, rather than too often accepting care that might work.

Elon Musk has his hands full saving humanity, not to mention helping Puerto Rico, so we probably can't count on him to offer to reinvent our health care system too.  So who will it be?

Let's Hope This Bores You

I think I know what is wrong with health care: not enough people are bored. 

These are stressful times for health care.  There's a never-ending stream of innovation, constant pressures about costs, concerns about the quality of care, conflicting research findings, ongoing uncertainty about how we should finance what coverage for which people, and new business models and organizational structures. 

There's too much to take in, and everyone in health care is working too hard, too long.  Honestly, who has time to be bored?

But that's a problem. 

We usually think of being bored as a bad thing.  You don't often find people saying they're looking to be bored.  You don't find many activities that bill themselves as being boring.  In our always connected, 24/7 culture, being bored is seen as some kind of a failure: isn't there another notification on your phone, another email you could read, another update you could post, another task on the to-do list that you could try to cross off? 

But being bored, as it turns out, is closely connected to being creative.  Psychology Scott Barry Kaufman writes:   "In recent years, neuroscientists have discovered that we tend to get our best ideas when our attention is not fully engaged in our immediate environment or the task at hand."  He was writing about executives needing more alone time, but the point is to distract the brain in order to allow those creative juices to flow.

Earlier this year Wired reported on two studies relating to boredom.  One found that subjects who had just been doing boring tasks like copying numbers from a phone book did better on creative thinking tests than a control group.  The second found that subjects who had to watch a dull screensaver did better on an associative word test. 

"Boredom becomes a seeking state," said one of the lead researchers.  Another of the researchers worries that: "We try to extinguish every moment of boredom in our lives with mobile devices," thus eliminating "useful, productive monotony." 

Similar, a 2014 study found that bored people are more likely to have "divergent thinking styles...Thus, boredom may encourage people to approach rewards and spark associative thought." 

We're even so scared that our children will become bored that we hyper-schedule them, give them interactive devices, and structure their free time.  Dr. Helen Street says: "A child’s school life is more structured than ever and from an earlier age than ever before....As a result we are seeing a massive creativity deficit in kids."

Imagine what is happening to even-busier adults.

Albert Einstein famously spent several years as a patent clerk, reviewing ideas far removed from the spectacular physics that he was developing at the same time.  He was busy but not so busy that his mind couldn't break free of conventional ways of thinking. 

Author Jordan Rosenfeld wrote in Quartz about retraining her mind to be bored, suggesting:

• Get in the habit of "spacing out;" 
• Resist the urge for constant communication;
• Face your feelings, rather than trying to avoid them.  

Certainly many activities in health care are boring, or at least mundane.  Processing claims, coding bills, updating patient records in EHRs -- not anyone's idea of a good time.  But neither are they tasks that allow for much spacing out, for associative thought that can lead to creative ideas.

Instead, we try to force creativity.  We hire consultants to tell us their ideas, we pour over research to see what ideas other people have, we conduct "brainstorming" sessions, we go on retreats with exercises designed to spur teamwork and new ideas. 

It's not impossible that creative ideas come from all that; it's just not very likely.  It's more likely that we just get iterations and variations of existing ideas.     

Creativity can't be forced, but it can be encouraged.  A previous post talked about the value of "wrong thinking" and "dumb ideas."  Another post talked about the importance of failure as the price of success. 

You have to give people the time to think freely and the support when that freedom doesn't always pay off. 

People say that health care is too important to try creative ideas that might be risky.  People's lives are at stake, after all.  We have to be careful what we try, how we try it, on whom we risk it.  Perhaps that is true, but the end result of that kind of caution is a health care system that costs too much, delivers too little, and that makes no one happy. 

So, be willing to be bored.  Make time for it rather than letting every minute get filled.  Be open to flights of fancy that come from some good old associative thinking.  Stop trying to go from point A to point B and think instead about different kinds of destinations, using different modes of transportation.  Spend less time worrying about what has to be done and more time wondering what might be done.

I truly hope you weren't, in fact, bored reading this, but if a good idea or two came while you were, it will have been worth it.

Putting Our Health Before Their Dollars

You have to give CVS credit.  In early 2014 they announced that, as a health company, they would stop selling tobacco products in their stores, despite the estimated $2b in sales those represented.  Sure enough, by September of that year those products were gone.  A follow-up study suggested that many of those shoppers didn't just buy them elsewhere but actually reduced their consumption, with a significant number ceasing to buy them at all.  Credit to CVS.

This year CVS is doubling down, beefing up its selection of healthy food options and health-focused products, while moving candy and junk food to the back of the stores. "Pharmacy is the heart of our business and our focus on providing care to patients and customers defines everything we do in our stores," said their Pharmacy President. 

And yet, in those stores, right by those pharmacies, you can still find plenty of dietary supplements, including vitamins. 

This is not to fault CVS, at least not solely.  After all, other retailers with large pharmacy businesses -- e.g., Walmart or Walgreens -- never even stopped selling tobacco products.  Of course, they sell supplements as well.

It is no wonder: supplements are big business.  The industry itself says it is a $37b industry, although estimates range widely.  At least half of Americans take some kind of supplements, with use among people 60 and over even higher. 

Supplement use is so mainstream that we not only tell our physicians about using them, they are our leading source of trusted information about them.

The question is not whether supplements are mainstream.  The question is whether they should be.

Just last month a police officer died after taking kratom, an herbal supplement.  Kratom is banned in 6 states, and the DEA tried to ban it nationally, citing 15 deaths in three years.  That ban died due to intense lobbying by, believe it or not, the American Kratom Association.

The problem is that the supplement business is not what one would call heavily regulated.  It barely is regulated at all.  The FDA does not approve dietary supplements.  Companies making/selling them are responsible for ensuring their products are safe and that any claims about them are not false or misleading, but the FDA does not verify either safety or effectiveness. 

In theory, the FDA is allowed to inspect manufacturing processes and maintain adverse event reporting, and can take action if problems are discovered, but there is severe doubt about how well it can perform these tasks.  The FDA's Office of Dietary Supplements has a $5 million budget and about two dozen employees, to oversee an estimated 80,000 - 90,000 products on the market. 

It's not a fair fight.  Supplement manufacturers don't have to prove their products are either safe or effective, but to remove a product the FDA has to demonstrate it poses a "significant or unreasonable risk of illness."

This matters.  The U.S. Poison Control Center gets a call every 24 minutes, on average, related to dietary supplement exposures.  One study estimated there were 23,000 ER visits annually, and 2100 hospital admissions, due to supplements.  The number of deaths associated with them remains in dispute, although a rare FDA ban -- of ephedra, in 2004 -- drastically cut the number.  Shamefully, the industry had fought that ban, but ultimately lost in federal court. 

Part of the problem is that we don't really know what is in supplements.  In 2015 the New York State Attorney General's Office found that only 21% of ingredients listed on various store brands were actually in the products.  Another study looked specifically at one specific product -- "red yeast rice" (I am not making that up) -- from 28 manufacturers and found that the key ingredient varied wildly in dosage and wasn't even present in some versions. 

Keep in mind that there really is very little data that supplements -- even vitamins -- actually have a positive effect.  One study found no impact of vitamins or mineral supplements for cancer or heart disease.   Another study focused on antioxidant supplements taken to lessen risk of Alzheimer's or dementia, and similarly found no impacts.  Indeed, multiple studies have found at best no positive impact and sometimes negative impact.

S. Bryn Austin, a professor at Harvard's School of Public Health, pretty much summed up the industry, telling Business Insider:

Consumers should expect nothing from [supplements] because we don't have any clear evidence that they're beneficial, and they should be leery that they could be putting themselves at risk.  Whether it's on the bottle or not, there can be ingredients in there that can do harm.

And yet supplements are discussed one-in-four primary care visits, with at least 79% of physicians admitting that they have recommended them at some point.  Over half of physicians take supplements themselves.  Some physicians are even selling them directly, which has its own host of ethical and legal questions. 

It really shouldn't be a surprise that we fall for the supplement hype.  We like quick and easy solutions.  We are a nation of fad diets.  We'd rather get vitamins from a pill than from eating a balanced diet.  We'd rather take weight loss supplements than eat less and exercise more. 

And we fall for placebos of all sorts, mainstream and alternative, while allowing use of prescription drugs and medical devices that are not nearly as safe or effective as we think.  Supplements aren't an outlier; they fit quite nicely into the rest of our health care system. 

Part of me feels that if people want to spend their money on products with no validated efficacy, that's their choice, as long as those products are marketed accurately (which is a big caveat).  If they want to go to GNC, a health food store, even to the junk foods section of a drugstore to buy them, well, it's their money.

Just don't pretend they belong in the pharmacy.

A larger part of me, though, wishes that, rather than embracing supplements due to their popularity, "mainstream medicine" should be even more vigilant about requiring evidence for use of any treatments -- prescriptions, devices, procedures, tests, or supplements.

When CVS -- or other pharmacies, doctors, hospitals, or other health care professionals-- start only selling or recommending treatments that have proven value, then I'll believe they're putting our health above their dollars.