"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. 

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?

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 companies, doctors 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. 

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.