With Rights Come Responsibilities

Rosenthal has done it again. Her An American Sickness was a brilliant, insightful indictment of our dysfunctional healthcare system, along with some potential remedies. Now her recent Nine Rights Every Patient Should Demand details nine financial rights we should all expect from our healthcare system. They are all things that we should, indeed, expect — demand! — but, unfortunately, don’t seem to typically have.

I agree with Dr. Rosenthal’s suggestions, but they made me think about what responsibilities come with such rights. 

Let’s face it: virtually all of us could be in better health. Almost all of us could take steps today to improve our health, and even more steps tomorrow. That more of us don’t take that responsibility is baffling, because no one will benefit from our better health than we will. 

I’m not as ambitious (nor as smart!) as Dr. Rosenthal, so I’m only going to list seven proposed responsibilities:

1.  The responsibility to ask “how much”: We talk about wanting more price transparency in healthcare, as well as how difficult that is to meaningfully have given its convoluted pricing approaches, but nothing will happen until we start asking about how much things will cost. All. The. Time. In the short term, health care professionals will plead ignorance or try to explain why that is a hard question to answer, but eventually those responses will not do. We are never going to get the answers unless we start asking. 
2. The responsibility to care about costs: We all-too-often tend to think of healthcare services as free, and/or priceless. That is, we expect our services to get paid for with as little outlay from us as possible, and without really caring what they might cost anyone else. A million dollars for a new drug? That’s what insurance is for, right? Well, no; any form of insurance, whether public or private, has a limited amount of money. We should treat our spending as though every penny comes from us, and recognizing that money spent on our healthcare is money that can’t be spent on anything else — and sometimes should be.
3. The responsibility to ask “why:” It has been increasingly accepted that there are a lot of unnecessary healthcare services, perhaps a third, maybe more. In An American Sickness, Dr. Rosenthal outlined some of the types of unnecessary treatments and surgeries, and it wasn’t an exhaustive list. We get excited about new prescription drugs, without recognizing that most drugs do not help most people. Enough is enough. We’ll keep on getting over-treated until we start demanding to know what the odds are that proposed treatments will actually help us, and having hard discussions about cost-benefits.
4. The responsibility for our own health: Face it, most of us have delegated our health to the health care professionals. We think we can get away with poor health habits because, well, other people are worse, and besides, if something bad happens, our doctor can just give us a pill or perform a surgery. That doesn’t work. It is not their health; their responsibility to treat us is not the same thing as responsibility for our health. We have to own it; we have to live it; we have to make caring about our health an integral, ongoing part of our life. That is easier for some of us than others — attribute that to good genes, good luck, good circumstances, or whatever — but we all have the same responsibility.
5. The responsibility for others’ health: We don’t live in a vacuum. Our actions, or inactions, can greatly impact the health of others. It’s not just about trying to avoiding passing along a cold or the flu. It’s also about making sure people have clean water, enough food, a safe environment, and access to affordable health care, to name a few. We have to realize that other people’s health matters too. We can contribute to their health through our taxes and/or health insurance premiums, through how we vote, by fighting pollution and poverty, even just by encouraging them in their health efforts. It is possible to only care about our own health; it is just wrong to do so. 
6. The responsibility to say “enough:” We’ve all seen the TV shows where heroic doctors perform CPR on a dying patient and miraculously save them. Unfortunately, usually that is just on TV; in real life, things don’t usually work out so well. Similarly, we all have come to expect doing everything possible to keep us or our loved ones alive as long as possible. But health isn’t just about being alive, and life isn’t either. Quality of life matters. Is giving a cancer patient 2 more months of life really worth the added side effects (or costs)? Should your dying 95 year old grandmother really get admitted to the hospital for more treatment? Are premature babies worth every effort, at any cost? These are hard, hard questions, but we have to start asking them, and take responsibility for when it is time to say “enough” to more health care. 
7. The responsibility to expect better: In most walks of life, we expect things to get better. Lower prices, better products, more services, added convenience. In healthcare, though, we seem to be more passive. We accept long waits, incomplete answers, inconvenience and even indignity, incomprehensible documents, steadily increasing prices, and bad outcomes. It’s just healthcare, we shrug; what are you going to do about it? Well, for a start, don’t expect it, and don’t accept it. Complain. Suggest. Demand. Make it better. 

At the end of the day, responsibility for our health must be ours. And, whether we like it or not, the same is true for our healthcare system. Our healthcare system has much wrong with it. Some would say that calling it a “system” is a stretch; it wasn’t designed or purposely built. It has evolved, in ways that no one intended and few would have expected. It is not the system that anyone would choose.

It’s not as good as it could be now, and it is not anywhere near as good as it is could be in the future. Getting to the latter will require a lot of smart, dedicated people taking responsibility to make it, and their health, better.

Starting with you and me.  

Healthcare's Overseas Gold Rush

I know it is one of our largest industries.  I know politicians want us to cut our trade deficits.  But, really, do we feel so good about our healthcare system that we want to be exporting it?

The Wall Street Journal reports that U.S. hospital chains -- non-profits as well as for-profits -- are looking to bolster their bottom lines by expanding overseas.  They cite the example of ProMedica, a non-profit chain of about a dozen hospitals in northwest Ohio/southern Michigan, exploring possible deals in China.  "We have to look outside our traditional world if we’re going to survive," their President and CEO said.

Now, I've visited ProMedica facilities.  I've known people who have received care from them.  As far as I know, they deliver fine care.  But, well, let's put it this way: I live in southwest Ohio, about a hundred miles from their service area, and no one here is longing for ProMedica to come to our market.  So I doubt that many people in China are excited about ProMedica coming, not the way they might have once looked forward to their first McDonalds or Starbucks.

Or that they might view, say, The Mayo Clinic.

Other hospitals are racing ProMedica to get into China.  WSJ noted that Brigham Health, Mass General, and The Cleveland Clinic are all working on projects in China, either with partners or providing consulting expertise.

International business is nothing new for some U.S. hospitals.  The Cleveland Clinic has been drawing wealthy patients from overseas for its heart and other programs for decades.  They now have programs catering to them, as do Cedars Sinai, Johns Hopkins, Sloan Kettering, and UPMC, to name a few.

The Cleveland Clinic and UPMC, both of which are well-known but primarily regional, non-profit chains, have had international locations for years.   Crain's Cleveland Business reports that The Cleveland Clinic is now planning a London location.  It would appear that crossing the Ohio-Pennsylvania border is harder for both systems than crossing the Atlantic.

Cleveland Clinic London is expected to open in late 2020. CLEVELAND CLINIC

WSJ further cited:

• Boston-based Steward Health Care System's efforts in Malta; 

• UPMC's interests in Italy, Ireland, Kazakhstan and China; 

• "Other U.S. hospital corporations have struck deals in the U.K., Colombia and France in recent years."

Health plans like UnitedHealth and Aetna are also investing in overseas opportunities.

The Gold Rush is on.

In a way, it is fitting that we're exporting our healthcare system.  First we exported agricultural products overseas.  Then we exported our unhealthy fast food restaurants and packaged foods.  It is no wonder that the rest of the world is now catching up on chronic conditions like obesity and diabetes.

First we help make them less healthy, then we offer to treat them -- for a price.

Perhaps it is not too surprising that hospitals are looking overseas.  WSJ also reported that median hospital operational cash flow margins fell to the lowest point since 2008, when we were in a deep recession.   ACA was supposed to be their salvation, but its positive effects are diminishing.

The international allure for hospitals is money; specifically, wealthy, self-pay patients.  That's who they've been drawing to the U.S., and that is a common theme in where they are locating -- e.g., London, Dubai, Rome.  When they go in to China, one suspects that they'll be more interested in Shanghai than Longhua.

If hospitals can get overseas self-pay patients who can afford to pay "charges," that's got to be more appealing than fighting with state Medicaid programs about reimbursement, or waiting for the latest hit on revenues from CMS.  You can't really blame them.

There are not a lot of comparisons international healthcare systems in which the U.S. system comes across very well (e.g., last year's The Commonwealth Fund report).   We pay wildly more, for uneven quality and mediocre outcomes, and with too many barriers to access.   And yet other nations are still interested in importing some of what we do.

It is true that we can get some of the best care in the world here, but it is not as though you'll necessarily benefit even if you happen to live near a distinguished hospital system (e.g., Baltimore or Cleveland).  It helps to have lots of money, and/or to be really sick.

It may be that hospitals won't find the overseas markets as lucrative as they are hoping for.  There are only so many wealthy people, after all.

Pharmaceutical companies and medical device companies have been selling overseas for decades, and do well, but do not get away with some of the pricing shenanigans they get away with in the U.S.  Regulators may view hospitals' chargemasters with skepticism...as they should.

I have no trouble with people and/or organizations making money, even in health care.  If a for-profit hospital or other health organization thinks it can make more money overseas, more power to them.  Let's just not pretend they are about serving patients, either here or there, except perhaps as a means to their end.

I don't even have a problem with non-profits making enough money to further their mission, but I have a problem with how non-profit health organizations sometimes don't use those profits to serve the community good.  I really have a problem when non-profit health organizations use the reputation that their tax status has helped them build to not only invest in more businesses but also to do so overseas.  That's not the purpose of those tax breaks.

We have plenty of innovation that our healthcare system can export.  Techniques, devices, digital strategies, VR/AR/AI -- we're pretty good at these.  Delivery of care, not so much.  Pricing and financing of care -- we probably shouldn't even want to talk about them, much less try to export them.

I wish other countries wanted to import how our community health centers deliver care to disadvantaged populations, or how managed Medicaid plans assure financing of care for those populations.  Those are things to be proud of, although we don't seem to be.  I wish we had better successes in keeping populations of people healthy that we were exporting.

Instead, we're exporting how to treat the 1%, and how to treat people who get very sick.    Because, after all, that's what we're good at.

For any U.S. healthcare organization looking overseas for opportunities: hey, there is plenty to do here.

No Signatures Required!

If you live in the U.S., you've probably had the experience of paying for a meal using a credit card.  The server takes your card, disappears to somewhere in the back, does something with it that you can't see, and returns with your card, along with two paper receipts, one of which you need to sign.

Everything that happens to me, I think, what is this, the 1960's?

As of last week, the major credit card companies -- American Express, Discover, Mastercard, and Visa -- are no longer requiring that signature.  As a Mastercard person told CNET, "It is the right time to eliminate an antiquated practice."  

No kidding.  Healthcare should be eliminating its antiquated practices too.

The demise of the credit card signature has been long in coming.  Many merchants already don't require it, or only require it for purchases over specified amounts.  And, of course, the rise of online shopping has greatly lessened not only purchases with signatures but purchases where the card is present at the merchant at all.

Ending the requirement was announced last year, went away last week, but its actual demise will happen more slowly, as individual merchants can still require it.  Some will need changes to their systems to get rid of the requirement.  But, as with the introduction of chips in U.S. credit cards (which is a whole other saga), no signature will gradually become the norm.

The credit card companies realized that, (a) the signature wasn't doing much to verify identity anyway, as many don't take it seriously and no one really seems to check the signature, and (b) loss of physical cards has become only a small fraction of the fraud that credit card companies fight.  Cybercriminals are more likely to steal masses of numbers through security breaches, allowing fraud on a scale that no old-fashioned thief could have imagined (and, oh, by the way, that's one reason those vaunted chips haven't done much to lessen fraud).

Of course, the signature is only part of the antiquated process.  They're probably not looking up your card number on a monthly list of stolen cards any longer, nor using a manual imprinter to charge your card, but both using the physical card and taking it from you are steps that there are 21st century alternatives to.  For example, they could bring the chip reader to you, or they could accept smartphone-based payments. 

Still, I'd be willing to bet that the credit card companies and merchants bring their processes fully into the 21st century before healthcare does.

Let's go through some of these:

• Healthcare still relies heavily on faxes, from which most other industries have, for the most part, long ago moved on.  Supposedly it is because of security, "HIPAA," etc., but this reliance is a lot like requiring signatures for credit cards.  In the immortal words of Inigo Montoya, "I do not think it means what you think it means."
• It is not just faxes.  In an era of ubiquitous smartphones, healthcare is still making heavy use of pagers, especially within hospitals.  As with faxes, proponents cite solid reasons for this continued use, but -- really?
• I can use an AMT pretty much anywhere in the world, and can not only access my bank account to obtain balance or transfer funds, but even to get cash on the spot.  The system "knows" me and my bank and can act accordingly.  In healthcare, I can't even go to a new doctor or healthcare facility without having to start from ground zero in terms of information about me (unless they are part of a health system I've already used).  
• Patient portals have proliferated, with more options to do tasks online, but how many times do you visit a health care professional without having to fill out or sign yet another form?  Why are we ever filling out paper forms?
• We can make online reservations for, say, restaurants, airlines, or hotels.  When it comes to making healthcare appointments, though, we're almost always forced to go through a tedious phone tree and end up negotiating with a human scheduler.   In 2018?
• Manufacturers have overwhelmingly turned to just-in-time processes, so that they get exactly what they need at exactly the right moments in exactly the right amounts, even though they often use supply chains that span the globe.  Meanwhile, in healthcare, an appointment time is usually at best an approximation; we expect to be seen late.  If you are in a facility expecting a test or procedure, it's even worse; things happen when they happen, and no one seems to know when that will be.  These aren't even 1960's levels of precision.
• Chances are, most of the time you see your doctor, it is in person, which probably means you'd had to make an appointment, drive to his/her office, wait more there (while filling out some forms), get ushered into an exam room for more waiting, then hope you'll have enough of his/her time to explain your problem.  Telemedicine is widely available, but usually it won't be with your doctor and the doctor you end up getting won't have your medical history.  Shouldn't virtual visits usually be the first step?  
• For better or worse, with a few pieces of information -- a social security number or a credit card number -- financial institutions can pull up pretty much all of our financial history.  With healthcare there, no institution has access to even most of our medical history, which remains highly scattered, siloed, and sometimes even still paper-based.  How 1980's!  
• We continue to urge people to get annual preventive exams, even though the value of them for most adults is highly dubious.  We still make people get unpleasant procedures like digital rectal exams, or tests of questionable value like PSAs or even mammograms.  We're doing all this more out of tradition than based on solid evidence.  

In many ways, we do have "space age" healthcare, but that space age is too often more like 1960's NASA than 21st century SpaceX. 

Note all the binders at NASA.  Source: Michael Smith-Welch, Boing Boing

We can do better.  Much of healthcare has one foot firmly planted in the 21st century, and its vision looking forward.  But too much of it still has the other foot dragging in the 20th century. 

It is past time to not only identify but also to act upon antiquated practices in healthcare.

Road to Zanzibar

No, I'm not going to talk about the Bob Hope-Bing Crosby movie (ask your grandparents).  Rather, I want to cover some new kinds of interfaces, the new platforms upon which our computing needs are going to be based -- including but not limited to Microsoft's Project Zanzibar.

Voice is the new interface, right?  Wired said so a couple years ago, and Farhood Manjoo recently agreed, both picking Alexa as the likely "winner" (although Siri and others aren't conceding anything).  In Forbes, Ilker Koksal predicted that voice-first devices are the "next big thing, " since:  "Finally, there will be a single interface for interacting with a diverse variety of devices at home or on-the-go, making it easier than ever for users to accomplish any task hands-free."

The Harvard Business Review recently speculated on what healthcare would look like in a world of smart speakers, and Healthcare IT News wrote a "Special Report" explaining that "AI voice assistants have officially arrived in healthcare."   The case for voice, it might seem, is officially closed.

Not so fast.  There certainly will be voice interfaces, but that's not all there's going to be, and even voice interfaces won't necessarily be what we're now getting used to.

For one thing, "voice" interfaces may not even require you to actually speak.  MIT researchers have developed a wearable device and associated computing system that "can transcribe words that the user verbalizes internally but does not actually speak aloud."  It can also "talk" back to you silently, transmitting vibrations directly to your inner ear.  You could, in effect, have a complete conversation with your AI without either of you uttering a sound. 

Image: Lorrie Lejeune/MIT

The system had an average transcription accuracy of 92% within 2 hours of use, which is remarkable.  Alexa, did you hear that?

All right, the device makes Google Glasses look cool, but it is still a prototype.  One can imagine that, at some point, it will be much smaller -- perhaps even simply implanted -- and this kind of technology could become ubiquitous.  We all have experienced loud smartphone users whom we wish had this technology.  

All right, very impressive, but still a voice interface, just very quiet.  Example number two, then, are "virtual wearables," such as Project North Star from Leap Motion.  Keiichi Matsuda, their VP of design, told Fast Company, "Our hands are our original interface with the world, and foundational to any immersive experience."  

They've designed two tools to give our hands more control in our cyber-world, whether AR, VR, or screens.  Power Tools gives our hands "superpowers," an array of apps that have discrete functions -- "a virtual palette attached to your wrist."  They couple that with "Virtual Wearables," which  Fast Company describes as:

Think of it as a smartwatch that exists in virtual space, and therefore can morph based on context. Instead of memorizing an innumerable amount of gestures to call up different menus or buttons, Virtual Wearables look and act like familiar interfaces. Users can click, open, twist, turn, or swipe them, just like they would in real life.

Mr. Matsuda sees these as integral to our future:

We are on the verge of a new era of human-computer interaction, that will ultimately supersede not only mobile and desktop, but also many of the physical interfaces that we rely on.  The more the technology progresses, the more absurd it will be to have to rely on controllers, keyboards, and touch screens

Pretty cool.

Then there is Project Zanzibar, which Microsoft will formally announce later this month but which has already started leaking out.  They describe their goal as wanting to blur the lines between the physical and digital world.

As currently constituted, there is a flexible, portable mat that "has the ability to locate, sense and communicate with objects as well as sense a user’s touch," using Near Field Communication (NFC).  It uses Bluetooth to connect with whatever screen you happen to have handy.  

For example, toy pieces could be on the mat and then be represented on the screen, interacting with their virtual counterparts.  Toys could "come alive."  The use cases now include toys, games, and learning, but one suspects we're barely scratching the surface of what we might be able to use it for.
Microsoft's description notes:

One reads all this and senses that the moment for tangible user interfaces indeed is upon us. And if the passion of this research can be as inspiring in the outside world, then we may indeed be at a turning point in the realization of natural interactions with computers that lead to the next era of how we think of – or don’t think of! – computers when we are using them to create, learn, play and build.

Again, pretty cool.

Healthcare is full of bad interfaces.  It can't quite figure out exactly who the "user" is in its UI, or exactly what they do, how they do it, or how the interface should make things better.

If anything, interfaces get in the way of better care -- too many error messages, confusing visual display, and too much keying.  Patients and physicians alike complain that physicians spend too much time inputting into the EHR and not enough listening, looking, or touching.

Voice inputs -- spoken or sub-vocal -- could clearly help with the input problem, but it may take a little longer to figure out how to use Power Hands, Virtual Wearables, or the Zanzibar mat in healthcare.  But figure it out we will.

E.g., I keep wondering how NFC could be used in, say, a physical exam or even a surgery, tying the physical of our body with the digital of more information about our body.

So, you can keep using your keyboard, or perhaps your game controller, if you want.  You can even start using Alexa or Siri or Google Now to free your hands for some tasks.  But don't get too used to any of these, because there are some new interfaces on the road ahead.

It may even be, indeed, the Road to Zanzibar, but it almost certainly won't stop there.

When an Umbrella Is Not Just an Umbrella

A lot of innovation comes from simply looking fresh at a problem, or at something that has grown so familiar to us that we no longer even see it as a problem.  Saying something is "just the way it is" doesn't mean that is the way it has to be.

Here are a couple great non-healthcare examples of this that healthcare could learn from.

Let's start with umbrellas.

We all have an umbrella.  Many of us have more than one.  We know what they look like and what they do.  They've been around for thousands of years, without much change in the basic design.  As Cheeky Umbrella says:

Of course these ancient versions of the modern day rain umbrellas were designed and built with very different materials...but the canopy shape is very similar to the products seen today.

And, unfortunately, most of us know how they fail.  Given a strong enough wind -- and it doesn't have to be all that strong -- they not only fail in their purpose but can get destroyed, turning inside out.  We accept that, because that's just their limitation.  That's just the physics of umbrellas.

That's the wrong way to look at it, thought a Dutch design and engineering student named Gerwin Hoogendoorn.  Not the physics of umbrellas; we should be looking at the physics of windsurfing.  And so was born the "storm-proof" umbrella, the Senz. 

Mr. Hoogendoorn says he can hold his umbrella with two fingers in 40 mph, and the company claims their umbrellas can withstand winds of over 70 mph.  Check out their video:

 Can your umbrella do that?

Senz actually dates back to 2006, but I hadn't heard of it until the Washington Post wrote about it a few days ago.   Mr. Hoodendoorn explained:

Our umbrella is different.  If the wind gets underneath, then it catches the backside of the umbrella, causing it to turn into the same direction of the wind.  This is what you want because the rain is almost always coming from the direction of the wind.

Or, more succinctly, “Like a windsurfer, the idea is to use the wind to your advantage.”

An umbrella is an umbrella is an umbrella...until it is something very different.

Example number two: building a house.

Again, this is something most of us are familiar with.   We may not have built one ourselves, but we've probably seen it done.  We know the basic steps, and the kinds of people it takes to build one -- carpenters, masons, electricians, plumbers and so on. 

As with the umbrella, the basics haven't changed all that much in the past couple thousand years.  Sure, the materials are sometimes -- but not always -- different, electricity and indoor plumbing are common (at least in developed countries), but many of those skilled laborers from 2,000 years ago could easily work on a construction site today. 

Enter 3D printing.  As in, 3D printing a house.  Check out this video:

A house  built within 24 hours, largely using 3D printing, and costing under $10,000.  New Story, a non-profit dedicated to affordable housing, thinks it can do the same for under $4,000.  Their CEO told Fast Company: "We thought, what would it look like to have more of an exponential breakthrough for such a big challenge?"  That led them to 3D printing, and a prototype they unveiled at SXSW last month.  

New Story estimates the construction will eventually only require 2 to 4 workers, using a 3D printer that currently costs around $100,000 and that should be able to produce 1,000 homes.  

The idea is taking hold all over the world, with leading companies based in Russia, China, Italy, and the U.S..  Dubai wants to be the world's 3D printing hub, with a goal of 3D printing 25% of every building by 2030. 

As Christopher Mimms wrote:

the more you examine the basics—the way the technology could potentially save energy, materials and time—the more it starts to feel like an idea that just might work.

Our grandchildren may look at how we now build buildings much like we look at how cars were made before Henry Ford introduced the assembly line...or as our children will look at assembly lines that use humans instead of robots.  That is, as the past.  In fact, they're already 3D printing electric cars. 

Healthcare can learn from all this.

Healthcare is already on the 3D printing train.  People have been experimenting with it for some time, and the FDA has even issued a guidance.  Human organs, prescription drugs, tissues, medical devices; each of them is going to have its 3D printing moment and movement. 

We've got robots, and we're going to have more.  We've got implantable and ingestible chips, and we're going to have more.  We're finally realizing we need to deal with the health of our microbiome, and we're developing treatments that do that. 

That's all great, but it's like the umbrella example: what problems are we not solving because we think they are just the way it is?   

Most of our health problems stem not from failures of treatments, but from our health habits.  Most of our cost problems -- in the U.S., anyway -- stem less from the acknowledged unnecessary care but from the prices of our care. 

We hyper-specialize our medical professionals, while at the same time talking about the interconnectedness within our bodies.  We restrict the practice of medicine despite skepticism about how well that licensing is serving us. 

We allow more physicians to be gobbled up by health systems despite lack of evidence that this improves quality or reduces costs, and allow increased consolidation within markets despite solid evidence this increases costs. 

We've become so used to the problems of our healthcare system that, although we may complain about them, we often simply take them for granted, rather than finding new ways to solve them.  We focus much of our innovation on the margins, making improvements to the existing healthcare system, without fundamentally reshaping it.

If, after thousands of years of building houses, we can revolutionize the time, labor, and cost to build them, then we can do the same with how we deliver health care.  If, after thousands of years of the same basic design, we can finally figure out how to "storm-proof" umbrellas, then we can do the same for how we protect our health. 

Healthcare needs some Gerwin Hoogendoorns.