Shoot Them Up, Lock Them Up

I've gotten so used to seeing charts of how poorly the U.S. healthcare system compares to other countries -- such as on spending or health outcomes -- that I sometimes forget that those are not the only ways that we are exceptional, and not in a good way.  I want to focus on two issues that, unfortunately, have become politicized almost beyond the point of rational discussion, but which very much are health issues.

Guns and prisons. 

Credit: Jeremy Neufeld, Niskanen Center

The U.S. is gun crazy.  Maybe it isn't so surprising that we own almost half of the world's civilian guns -- we're a rich country and have a disproportionate amount of most things -- but it may come as a surprise that only a small minority of us actually own guns, and the ones who do tend to own multiple guns. 

What shouldn't be a surprise, of course, is what happens with all those guns.  People get killed.  Our homicide rate by guns is almost literally off the chart compared to other countries (in fact, see the chart).
 
It's not that our violent crime rate is higher than those other countries -- it is not -- as it is that, well, there are just a lot of guns out there.  The line charts are pretty clear, whether they are done by state or by country: more guns are correlated with more gun deaths. 

And, of course, too many of those gun deaths come from mass shootings.  The U.S. is not the only country that has mass shootings, of course, but we seem to do a lot more and a lot deadlier than other countries. 

According to the Gun Violence Archive, we've had 261 mass shootings this year alone (as of September 20).  That's almost one a day.  Our shock and dismay at what was once a rare event can't keep up with each new shooting, and we become almost numb to them.  Parkland drives out Sandy Hook, and who is still talking about Las Vegas?

It is too much.

As bad as our gun-related homicide rate is, it is worth pointing out that most gun deaths in the U.S. are suicides,  as Vox pointed out.  There are 50% more gun-related suicides than homicides.  Firearms account for half of all suicides. 

Our supposed rights to life, liberty, and the pursuit of happiness seem to be in conflict with the 2nd amendment "right to bear arms," and the arms have better lobbyists.   

Then there are prisons, America's new growth industry.  Americans like to think of ourselves as benevolent people, living in a democracy that offers hope and opportunity to everyone.  Well, as it turns out, not so much (and I'm not even going to get into our immigration policies). 

The U.S. imprisons over 2 million people.  You might think, well, we're a big country, maybe that is not so much as per capita but our incarceration rates are similar to our gun ownership rates: almost off the charts.  OK, maybe we're not that much higher per capita than, say Russia (and we are higher), but compared to OECD countries, we're pretty far out there.

We have over 40% more people in prison than China does, and they have over four times our population. 

You might think that perhaps we have all those people in prison because of all those guns and those gun deaths, but you'd be wrong.  As cited above, our overall violent crime rates are not particularly high.   What we like to put people in prison for are drugs.  Almost half the people in U.S.prisons are there due to drug offenses. 

We do have a drug problem in the U.S., not just with the current opioid crisis but generally compared to other countries, but the problem is how we deal with it.  Other countries send people with drug problems to drug treatment; we like to send them to jail.  Such is the consequence of our decades long War on Drugs.

As the Sentencing Project details, we've seen explosive growth in sending people to prison over the past 40 years, sending them there for longer terms, and doing so disproportionately for men of color.  Once they do get out of prison, if they get out, they likely are on probation (we have over twice as many people on probation as in prison), and are at risk of being sent back for the slightest infraction.

Of course, once someone has a felony conviction, their options are limited -- many employers won't hire them, they have great difficulty getting in public housing or on SNAP,  and they usually can't vote or serve on juries.   Many were poor before they went to prison and their outlook is worse once they get out.

One estimate of this disenfranchised population puts it at 23 million people.  They are a hidden population.  As Nicholas Eberstadt described::

We don’t know how many children they have, their marital status, who they live with, their housing situations. We don’t know their mortality rates or life expectancy, their disease and disability profile, their mental-health status. We do not know their labor force participation rates, unemployment rates, jobs by sector or wages. Apart from broad generalities, we know roughly nothing about their education patterns, skills or training.

Poor people and people of color have a tough enough time with our healthcare system, but throw in a felony conviction and the barriers to better health grow almost insurmountable.  They might be better off with the prison healthcare, and that is an extremely low bar. 

It's almost political suicide these days for a politician to talk about gun control or about reversing the "War on Drugs," but at some point some of us energized citizens have to say enough is enough.  Allowing so many gun deaths and allowing so many non-violent people to be sent to prison is not the America we believe in.  What we are allowing now is not how we should be protecting the health of any Americans. 

America is an exceptional country, filled with exceptional people.  It is tragic that too many of them are killed by guns or are sent to prison.  These are health crises of the first order.  We should be embarrassed.

Let's stop waving the flag and start addressing the real problems. 

In China, It's the 21st Century

It is 2018 everywhere, but not every country is treating being in the 21st century equally.  China is rushing into it, even in healthcare, while the United States is tip-toeing its way towards the future.  Especially in healthcare. 

Ready or not, the future is here...and the U.S. may not be ready. 

Let's look at a few examples:

5G: You may just be getting used to 4G, but 5G is right around the corner, with U.S. carriers expected to start offering networks in a few cities by the end of this year.  Meanwhile, China has committed to having national 5G coverage by 2020, and the government is working closely with its private sector to spur development. 

According to The Wall Street Journal, being the leader in 5G matters.  Rob McDowell, a former FCC commissioner, said: "The Ubers, the Airbnbs, the Netflixes of the world came about because of 4G.  No one foresaw the app economy coming. What’s exciting about 5G is that nobody can really fathom what’s going to happen."  Not being the leader, he thinks, would put "the U.S. at a competitive disadvantage globally."

U.S. wireless trade association CTIA believes China is leading the 5G race.  

Deloitte agrees; in a recent report, they cite reasons why China is leading, and warn that countries that adopt 5G first "are expected to experience disproportionate and compounding gains in macroeconomic benefits caused by “network effect.”'

Artificial Intelligence: Yes, the U.S. has been the leader in A.I., with some of the leading universities and tech companies working on it.  That may not be enough. 

A year ago China announced that it intended to be the world leader in A.I. by 2025.  The Next Web recently concluded that China's progress since then "remains unchecked."  China is far outspending the U.S. on A.I. research and infrastructure, coordinating efforts between government, research institutes, universities, and private companies.

Dr. Steven White, a professor at China's Tsinghua University, "likens the country’s succeed at all costs AI program to Russia’s Sputnik moment."  We have yet to have that wake-up call.

Quantum computing: Don't worry if you don't understand quantum computing; no one does.  What matters is that quantum computing is literally a quantum leap above what current computing, so the first to deploy it will have unimaginable advantages. 

Take a guess what country is leading.

Paul Stimers, the founder of the U.S. Quantum Industry Coalition, told CNN: "They [China] have a quantum satellite no one else has done, a communications network no one else has done, and workforce development program to bring new Chinese quantum engineers online.  You start to say, that's worrisome."

Axios summarized a new report from the Center for New American Security, which believes China has "some serious advantages" in the field.  The report doesn't claim China is the leader yet, but it is already "world-class" and quickly catching up to U.S. advantages.  As with A.I., the authors believe China has had a "Sputnik moment" for quantum computing.  and is "far outstripping American planning."

Genetic research: The U.S. has been the leader in genetic research, but -- you guessed it -- that lead has been rapidly diminishing.  Earlier this year, Eric Green, the head of the National Human Genome Research Institute told Asia Times:

I do know that if you look in the last 15 years, the investment in genomics, in particular, have been more substantial in countries like China, South Korea, Singapore, and even places like Brazil.  Support for biomedical research in the United States has not really kept up with inflation, and other countries have taken our playbook and run with it more aggressively." 

For example, the U.S. is still doing research on techniques like CRISPR, but The Wall Street Journal found that China is "racing ahead" in gene editing trials, in large part due to a more relaxed attitude towards regulation and possible ethical considerations. 

When it comes to healthcare, China recognizes shortcomings of its existing system, and is rapidly trying to deploy 21st century solutions to it.  China adopted a universal healthcare system in 2011 (about the same time the U.S. adopted ACA, which was considered a success to "only" leave 15% of the population without coverage), and has been investing heavily since then.

Last year Fortune reported on China's healthcare "boom," spurred in part due to direct government investments and favorable regulatory processes.  Similarly, earlier this year The New York Times noted U.S. tech companies' interest in healthcare, but pointed out that their Chinese counterparts  had already jumped in. 

Laura Nelson Carney, a healthcare analyst at Bernstein Research, told The Times: "It’s fair to say that across the board, the Chinese tech companies have all embraced being involved in and being active in the health care space, unlike the U.S., where some of them have and some have not." 

They are doing this because China sees technology -- especially A.I. -- as the way forward in healthcare.  Check out these headlines:

• MIT Technology Review: AI could alleviate China's doctor shortage
• LA Times: China plans to dominate AI, with vanguard of robotic doctors like 'Biomind'
• Reuters: AI ambulances and robot doctors: China seeks digital salve to ease hospital strain
• South China Morning Post: China counts on AI to find a cure for ailing healthcare system
• DOTMed: China's Interversion brings AI tech to 200th hospital

You get the picture.  As Sigal Atzmon, president and CEO of Medix Global, told ejinsight: "What’s going on [in China healthcare sector] is so big, that even if only 70 percent of this comes true, it’s a revolution." 

Instead of looking to the 21st century, in the U.S., our healthcare system still uses faxes.  Its data is still largely stuck in silos. 

Instead of vigorously advancing AI doctors like China is, we're hoping to address our supposed physician shortage by training more physicians, by offering "free" medical school tuition, and by addressing physician burnout.  Our crazy-quilt sets of regulations have made doing innovative approaches like telehealth difficult, with licensing and certification processes that are burdens for physicians and which don't seem to help patients much either. 

Imagine when we want to license A.I. doctors. 

I don't want to live in China, nor would I want to get my health care there.  Yet.  But if we don't soon have our own "Sputnik moment" (or moments),  we're going to see the 21st century of healthcare happen in China, not here. 

It's a Bird! It's a -- What?

Let's be clear about this: I'm never going to ride a scooter, motorized or not.  In fact, I've never ridden a scooter.  I've ridden bikes, roller skates, even roller blades, but scooters have always seemed to me to be an unnecessary version of transportation. 

Evidently I'm in a minority about this.  Scooters companies are all the rage.  After just a few months, ride-sharing leaders Bird and Lime are valued at over $2b and $1b, respectively.  There are also Skip, Scoot, and Spin.  It may be that investors are just desperate not to miss the next Uber, but, still, something seems to be happening here.

Credit: ROBYN BECK/AFP/GETTY IMAGES

Starting as what might have been passed off as just another California fad, appearing in San Francisco and Santa Monica in the spring, the scooter ride sharing services now are available in at least 65 cities across the nation, according to Vox, and are breaking into Europe and the Middle East.  They've already been banned, regulated, and debated.  And they are popular.

Even car ride sharing services Uber and Lyft are jumping onto the bandwagon, or, rather, scooter.  Uber's CEO predicts that within 10 years they'll be doing more rides with "individual electric vehicles" than cars. 

The concept is simple.   You use an app to find available scooters, such as in designed parking areas, use the app to unlock it, and take it where you want to go, typically a short trip in town.  The ride is charged to your stored credit card.  Depending on the local regulations, you ride it on the streets, bike lanes, or sidewalks.  What traffic laws apply can be murky.

Most rides average 1 - 2 miles, longer than most people want to walk, yet shorter than they might feel justifies getting in a car.

One might assume that these are just toys for hip tech millennials, but that may not be the case.  Vox found more support for them among lower income people, for whom they may help address "transportation deserts."

Bloomberg speculates that electric scooters may be the future of urban transportation, potentially "reshaping cities," although they note bike ride-sharing services haven't had much of a dent.  In addition, weather may make them a seasonal mode of transportation in many markets. 

Another Bloomberg article cited some advantages of scooters:

What they are great at, though, is being a last- or only-mile option for quick, inexpensive movement. Like electric bicycles, the scooters accelerate briskly. Unlike bicycles, they’re friendly to pretty much any attire. (Also unlike pedal-assisted electric bicycles, scooters require riders to have a driver’s license, as scooters have a throttle.) Scooters are also easy to dispatch: A delivery van can hold a lot more charged scooters than bicycles, and that makes them easier to move to where and when they’re most in demand.

Behind the scenes, the scooters need to get periodically recharged and serviced, although when and how the latter happens is a pain point for the industry.  Scooter companies claim regular maintenance schedules, but more often may default to reports of issues from riders.

Phillip Rosescu, a forensic engineer, told The Washington Post: "Enterprise Rent-A-Car is not going to rely on renters and drivers to report that the brake fluid needs to be refilled or when the windshield wipers need to be changed.  Being reactive in the transportation industry is very dangerous."   Even more worrisome, The Post found numerous ads on Craiglist for scooter mechanics, some of which seemed to require little or no experience. 

It shouldn't come as a surprise that the increased scooter ridership is also being accompanied, at least anecdotally, by an increase in scooter injuries.  The Post says that injured riders "have been pouring into emergency rooms around the nation all summer."  Michael Sise, chief of medical staff at Scripps Mercy Hospital (San Diego), put it bluntly: "Injuries are coming in fast and furious.  It’s just a matter of time before someone is killed. I’m absolutely certain of it." 

Credit: News Channel 5 (Nashville)

The San Francisco Chronicle had a similar article on the rise of scooter injuries in that city, saying  they are the "untold story" of the industry.  They noted injuries not just to riders but also to pedestrians.

It doesn't help that riders are not usually required to wear helmets, or that the user agreements require arbitration in case of any liability issues. 

The hope is that more scooters will mean fewer cars, both personally owned ones or ones used by taxi companies or ride sharing services.  That remains to be seen; they could equally be drawing from public transportation or even walking, which would confound the optimists who believe scooters will somehow be a healthy alternative. 

 It would be nice if scooters help us redesign cities to lessen their orientations around cars -- all that traffic, all those roads, all those parking lots and parking spaces, and all that pollution.  It would be nicer still if we were convinced to travel under our own power, such as walking or on bikes. 

Still, when I look at the scooter craze, I keep thinking about something else: where is the healthcare "ride-sharing" craze? 

I mean that figuratively, not literally like actual ride-sharing services for healthcare such as UberHealth.  I mean things that would be like us reducing our dependence on cars.  I mean things that could fundamentally change where and how we get care and/or attend to our health. 

I touched upon this recently in First, Let's Blow up All the Hospitals, arguing that hospitals shouldn't be big buildings but rather should be community-based services.  Certainly telehealth services tout being on-demand, and retail clinics have changed perceptions about both needing appointments and about going to a doctor's office.  But I don't see their valuations exploding like Bird's. 

Consider this analogy: perhaps the "car" in our healthcare system are doctors.  We historically have relied on them.  They're expensive to "build," expensive to own and operate, and come with a lot of associated regulation and infrastructure.  Although there are some situations where we definitely need them (e.g., longer/faster "trips"), many of the times we use them we probably could use a less expensive option.

Where is healthcare's scooter? 

Trust, But Verify

I recently was part of two separate Twitter threads that both ended up with one side -- mostly physicians -- arguing that people should just trust their doctors, while the other argued that trust is good, but let's not forget the data.  Not surprisingly, neither side convinced the other.

The threads made me feel that, even though we're well into the 21st century, some physicians long to go back to a time when physicians were trusted absolutely.

The first thread centered around a tweet that warned people about the risks of overuse of CT scans, claiming they cause 50,000 cancer cases a year.  The tweet advised people:  "Get one if you need it. Refuse it if you don't."

Now, that seems like good advice to me. I thought the 50,000 number was probably overstated, but the point was valid. There are risks to most tests, especially ones involving radiation, and not getting ones that you really don't need to makes sense. It seems like good advice generally when it comes to medical treatment. Just ask Choosing Wisely or the Lown Institute.

Many people did not agree, and most appeared to be physicians. They charged the Twitter user with "giving medical advice." That's right: to them, recommending to be judicious about getting care was giving medical advice.

They were justifiably critical of the 50,000 figure, and felt it was an attempt to scare people away from getting scans. But few seemed to acknowledge that there was overuse, much less that there are health risks to patients from it.

Even when presented with links to studies about overuse of CT scans, they maintained that, well, if they ordered one, it was the right thing to do. After all, they had years of medical study and practice; patients didn't.

A few claimed they were happy to answer any questions patients had about any tests they'd ordered, but it seemed clear that they'd be more interested in explaining why they were right than in actually having an open discussion. They didn't sound like doctors I'd be very comfortable having such a conversation with.

Trust us, we're doctors.

The second thread was on Direct Primary Care (DPC). The original tweet linked to an article in JAMA Network, "Direct Primary Care: One Step Forward, Two Steps Back," by Adashi, et. al. As the title suggests, it allows that the model may be good for some people, but it is "not the promised panacea of payment reform."

A few people, myself included, expressed support for the model, but noted it had to prove itself. I referenced capitation in the 1990's, where the game all-too-often was how to refer sicker patients/more expensive services out of the scope of the capitation. I had, and have, the same concern about DPC.

Don't get me wrong: done right, primary care can help ensure better, more cost-effective care to patients. That is the vision not only for DPC but also for efforts like Patient Centered Medical Homes (PCMH) or Comprehensive Primary Care Plus (CPC+).

It's the "done right" part that is the issue.

Those on my side of the discussion wanted data. Demonstrate that DPC saves money and/or improves care. Show that it works for all types of patients. Explain how it uses data to pinpoint patient needs and develop plans to address them.

It sounded very mom-and-apple pie to me, but it was like throwing a hand grenade into the discussion.

Those on the other side of the discussion -- and, again, many of them appeared to be physicians -- were aghast. Why should they have to prove anything? They don't need data to know the model works. They know what was best for their patients.

Credit AAFP

Some complained about the burden current data requirements have imposed upon practices, especially so-called quality metrics. That complaint has much validity; physicians are asked for a lot of data on a lot of things, few of which are either clearly actually related to quality or meaningful to patients.

But as I said in one reply, OK, the answer to bad data requirements is not to not use data, but to come up with better ones. No one should care more about how to measure quality and effectiveness than the people directly delivering care.

Physicians need data on their patients, and that data can't just cover what happens to them within their practice but also what happens to them in the rest of the healthcare system, and in their lives. DPC or not.

The overwhelming impression from the DPC advocates was that they were tired of the burdens that conventional physician practices placed on them.  DPC allowed them to practice as they thought best, with no insurance company or practice owners (e.g., health systems) second-guessing them.  They were sure that this would end up being better for patients.   

Trust us, we're doctors.

I like the concept of DPC. I hope it works. I think it might. But if physicians go into it mainly to escape oversight and other administrative burdens, then it is going to fail. Better care for patients has to be the goal, not a welcome by-product.

It's the 21st century.  Traditional information asymmetries are narrowing, especially in healthcare.  Physicians should expect -- and encourage -- patients to ask questions, demand answers, and suggest alternatives.  If they're not, they're not yet really engaged about their health, and that is bad not only for them but also for their physician(s).

It's the 21st century.  Data has never been so available, and we've never had such powerful tools to interpret and apply it.  In centuries past, it was enough to rely on physicians' training, skills, and instincts.  Those remain important, but if they're not also using data to deliver care, then they're practicing with blindfolds on. 

This is not about CT scans.  It is not about DPC.  It is about our relationship with, and expectations of, our physicians.  To me, it is incomprehensible that anyone would not want to understand risks/benefits of any recommended treatments and to explore their options.  It is equally baffling to me that some physicians -- not all, hopefully not even most -- would not want this as well.

Trust is a key part of the physician-patient relationship, but blind trust is no longer acceptable.

Trust, but verify.