OK Boomer: About Healthcare...

I am, for better and for worse, a Baby Boomer.  We're the rock-and-roll generation, the generation that challenged authority, the generation that some prefer to call the Me Generation.  And we're the helicopter parent generation, the Facebook generation, and the generation that has failed to address crucial issues like climate change or wealth inequality,

We're also the generation that increasing finds fault with the generations that follow us.  Take your participation trophies and get off our metaphorical lawns.  Got it, snowflake? 

What I didn't know until today is that younger generations have a meme to mock us: "OK Boomer."  InsideHook says the phrase "...has become a mass insult Generation Z routinely hurls at the un-woke."  As Urban Dictionary defines it: 

When a baby boomer says some dumb shit and you can't even begin to explain why he's wrong because that would be deconstructing decades of misinformation and ignorance so you just brush it off and say okay.

I'm thinking that there is a lot about our current healthcare system that must make younger generations roll their eyes and just say, "Ok Boomer."

I read about it in The New York Times, but I quickly found that NBC News and InsideHook also addressed it today, and outlets like Stayhipp and The Daily Dot had already addressed it.  Had I been on Tik Tok, I might have known about it sooner, but, like most Boomers, I'm not. 

One 19 year-old told The Times: "The older generations grew up with a certain mind-set, and we have a different perspective...Teenagers just respond, ‘Ok, boomer.’ It’s like, we’ll prove you wrong, we’re still going to be successful because the world is changing.”  Another complained: "Everybody in Gen Z is affected by the choices of the boomers, that they made and are still making.  Those choices are hurting us and our future."

Similarly, NBC News said:

The phrase is a culmination of annoyance and frustration at a generation young people perceive to be worsening issues like climate change, political polarization and economic hardship. The 10 teens and young adults who spoke to NBC News about the phrase said “OK boomer” marked a boiling point for Gen Z and younger millennials, who feel pushed around or condescended to by older generations.

It is already being merchandised, and there is, of course, a song:

Healthcare is perhaps not on the top of Gen Z and millennials' minds, but it is up there.  They complain about not being able to afford health insurance (especially after they can't stay on their parents' health insurance), and when they do have to interact with getting healthcare system, they must just roll their eyes.  Faxes?  

Our healthcare system was, in many ways, shaped by the Greatest Generation: anchored around big institutions like hospitals and health insurance companies, with expectation of acquiescence to authority and tolerance with waiting and certain indignities.  

Despite our rebellious youth, Boomers have done precious little to really reshape the healthcare system we inherited.  If anything, it has gotten even bigger, more monolithic, more specialized, and certainly more expensive.  Meanwhile, we're less healthy and living less long.  

Boomers are proud of ourselves for using Dr. Google to do research and (sometimes) challenge our doctors, but our idea of victory is to have options like patient portals, televisits, and Apple Watches, none of which we actually use very much nor have done much to deliver real change to the healthcare system.  

OK Boomer.  

A healthcare system built by the Greatest Generation and only tinkered with by the Boomers is not going to cut it for Millennials/Gen Z.  Our healthcare system is much like climate change: it is already a disaster and is only going to get much, much worse unless we take drastic actions quickly.  Yet we do not.  As Greta Thunberg has shamed us, how dare we?  

Credit: CS News

These are generations born using technology.  They expect to be able to find what they want immediately, to obtain it almost as quickly, and to share what they are doing in real time, as well as benefit from others sharing similar experiences and interests.  These are generations going to climate change and gun violence protests -- much as Boomers might have gone to Vietnam War protests in our youth.  

The healthcare system they are going to demand will end up giving them experiences more like what they have come to expect elsewhere:

• It will be more on-demand;
• It will be more on-demand, 24/7; 
• It will be more participatory and more based on sharing/community;
• It will use technology that makes us feel more comfortable, rather than intimidating us;
• It will be more interactive and more fun;
• It will be built into the fabric of our lives.

Those long waits to get an appointment in an office somewhere, those long periods in healthcare settings when you don't know what is going to happen or when, those outrageous (and non-transparent) costs, those unpleasant mammograms/colonoscopes/MRIs, those siloed data -- OK Boomer. 

Chelsea Stahl / NBC News

Younger generations could explain to us why none of that makes sense, but why bother?  As much as Boomers like to complain about our health and our healthcare, they're right: they'd have to deconstruct decades of our inertia and preconceived concepts in order to do, and we still might not get it. 

Boomers seem to think that passing MedicareForAll (whatever that means) and maybe trying to legislate away high drug prices or surprise bills is what we need.  That's not going to cut it.  We're just stepping on the gas of a car already headed towards the cliff. 

OK Boomer. 


As The Times reported: “You can keep talking,” Ms. Kasman said, as if to a boomer, “but we’re going to change the future.”

I don't know what kind of a healthcare system Gen Z/millennials will come up with when they finally turn their attention to it -- they have a lot of other, more-pressing-to-them issues on their plate -- but I know they can't do any worse than we've done. 

Personally, I can't wait to see. 

Care Detours May Be Advisable

Most of us use map apps to help us navigate, such as Google Maps or Waze (which is, ironically, owned by Google).  They help us find our destination, give us step-by-step navigation along the way, help us avoid construction or congested traffic, and even offer tips about nearby restaurants or other points of interest.

Now Google Maps is also helping to identify police activity, including accidents, disabled vehicles, or speed traps.  These features had previously been available on Waze.  

Google, if you are reading this, I have some thoughts about how Maps could help people better find health services.  

Example of Google Maps new features

Certainly people already use Google Maps (or search) to find health care professionals or institutions.  E.g., where's the nearest emergency room or urgent care?  Where is the closest drugstore?  How do I get to Dr. X's office?  Many/most health plan provider directories build a map function into their provider directory as well, so that searches on them can be immediately mapped.  Mapping has become an integral part of our healthcare experience.

But knowing where someone/something is only answers part of what people need to know, even if they don't always realize it.  Here are some features that would make a map app even more useful:

• Delays: It's easy enough to find the closest ER/urgent care, but the closest one may also be the busiest.  Which one is likely to be the fastest to actually see you, taking into account wait time?  Driving an extra 10 - 15 minutes could save hours of waiting.  This kind of information might also steer you to urgent care instead of making an appointment with your doctor.
• Rx prices: GoodRx does a great job of helping people find the lowest cost for prescriptions, steering them to the right drugstores with the right coupons.  Google needs to buy or replicate GoodRx and build these features directly into our searches for drugs or drugstores.  

  

  GoodRx results

• Surprise bills: Despite all the concern about them, and even though they are becoming both more common and more expensive, the likelihood of getting a surprise bill varies widely.  It depends on the state, the specialty, the institution, and the specific healthcare professional.  It would be a great thing to crowdsource where you are most likely to get a surprise bill, for what conditions, then use that information for a map app to warn patients in advance where they are more likely to be hit by them.  
• Conflicts of interest: We don't like to think about it, but some physicians may be receiving money from drug companies or medical equipment manufacturers that could steer them to using their products -- not always in patients' best interests.  Open Payments has this kind of information, but few of us use it.  A Map app could alert us that, hey, this person is getting money from X, so be sure to ask the right questions/get another opinion before taking any recommendations for treatment.  
• Debt collection: Kaiser Health News and ProPublica have done a terrific job of investigating how some hospitals send patients to collections and/or sue them for unpaid bills.  There's something unseemly about usually non-profit hospitals going after (often uninsured/under-insured) patients for bills that weren't disclosed in advance and frequently based on inflated charges.  Few of us keep these kinds of reports top-of-mind when selecting a hospital, but Google could, and that information on a map result could dissuade us from giving them a chance to do the same to us. 
• Outliers: Most of us don't begrudge our doctors from making a good living, but there are some doctors whose income might raise some eyebrows.  Back in 2014 Vox found one doctor who made $21 million in 2012 from Medicare alone.  The top 100 earners made $610 million, with the top 1% getting 15% of all Medicare payments ($11b!).  That's an awful lot of money.  Of course, being such an outlier doesn't necessarily mean they are delivering unnecessary care, or committing fraud, but knowing they were an outlier when you did mapped them might persuade you to get care elsewhere.  
• Volume:  There are varying opinions about whether doing more of specific procedures improves the outcomes, but when you are considering a procedure it is natural to wonder how often your physician has done them.  Is it once a day, once a month, once a year?  Does the person in the next office do more?  Sadly, getting this information currently is virtually impossible, but it is something that could be crowdsourced and built into map results (along with outcomes?)  

Which of these, or other, ideas on Maps might help you with your healthcare decisions?

Some of these are things rely on data that are in the public domain, others are things that require crowdsourcing, both of which Google Maps have experience with.  Some are things that could, and should, be built into health plan provider directories, but I'm pretty sure more of us use (and trust) our map apps than we do our provider directories.  Plus, of course, the more people providing information, the most useful the information becomes.

The police aren't happy about the new Google Maps features, and I suspect healthcare professionals and institutions wouldn't like these kinds of features either.  Tough.  As long as there are provisions for reporting/correcting inaccurate information, all of the above would benefit patients, and that's what healthcare is supposed to be about.  

Google already dominates maps, and is fiercely interested in health, so a combination of the two could benefit us all.  OK, Google?  

Healthcare's Third Law

Anyone who has taken even a basic physics class can probably recite -- perhaps with a little prompting -- Newton's Third Law of Motion: "for every action there is an equal and opposite reaction."  Physicians aren't physicists, but something like this is surely applicable to healthcare as well.

If healthcare's first law is "first, do no harm," then the second law would be "do some good."  The third law must then be: "trying to do good can result in doing harm."

The harm may not necessarily be "equal and opposite" to the good, but we can't pretend it isn't there. 

I was reminded about this by a Kaiser Health News investigation on fall prevention, as published in The Washington Post and elsewhere.  The investigation concludes that well-intentioned efforts to prevent falls -- particular in hospitals and nursing homes, and especially for elderly patients -- were resulting in "an epidemic of immobility." 

We've read about epidemics of obesity, diabetes, opioid addiction, even vaping, but an immobility epidemic is not something we hear much about.  We should. 

Fall prevention become a big thing with CMMS implemented penalties for hospital falls; the goal was that falls never happen.  That is understandable; falls can result in serious injuries, including broken hips, concussions, and/or laceration, especially for already fragile patients.  In fact, falls are said to be the leading cause of fatal and non-fatal injuries among the elderly. 

The result of the new penalties, which was not intended but which should not have been surprising -- was a "climate of fear of falling" for hospital staff. 

As a result, more efforts were made to keep patients from moving in order to help assure their safety.  Unfortunately, not moving can be as dangerous as falling.  The article cites Kenneth Covinsky, a UCSF geriatrician, whose research found that one-third of elderly patients leave the hospital more disabled than when they came on.  As Dr. Covinsky said: "Older patients face staggering rates of disability after hospitalizations."

Hospitals and nursing homes have all sorts of alarms when patients try to move on their own, and are required to track falls, but don't track how often patients move.  One study found that previously mobile patients spent 83% of their hospital stay in bed, which helps lead to those disability rates.  Research has shown, and many clinicians acknowledge, that moving during an inpatient is good for patients, but trying to do some good by avoiding falls is leading to the opposite reaction of the "epidemic of immobility."

Here's a second example of healthcare's Third Law, with an equally catchy phrase: how efforts to identify urinary tract infections are creating a "culture of culturing," as posited by Drs. Jerome Leis and Christine Soong in JAMA Internal Medicine last month and expounded on this week in The New York Times.  

Most seniors, it appears, have asymptomatic bacteria in their urine, so when a zealous clinician orders a urine test, odds are high that it will show positive results -- and result in a course of antibiotics.  As Dr. Christine Soong said.  "Once a clinician sees bacteria in the urine, the reflex is, you can’t ignore it. You want to treat it."

Healthcare Second Law in action.  Unfortunately, the Third Law also applies: the United States Preventive Task Force has repeated pointed out, most recently last month, that testing for asymptomatic patients has no benefits but some potential harms.  The Infectious Diseases Society of America and Choosing Wisely also warn about the risks of routine urine tests.  Most urine tests result in unnecessary courses of antibiotics, which contributes to our problem of antibiotic resistance.  

One final example of the Third Law (and I'm sure others could provide endless other examples) comes from oncologist Azra Raza, in a recent WSJ article and new book The First Cell.  Dr. Raza overall rates of cancer deaths have fallen dramatically in the last three decades, but argues that most of this is due to reductions in smoking and increases in screening -- not to better treatments.  

"Status quo treatments...can be brutal and indiscriminate killers," Dr. Raza says.  "Treatments often leave patients in agony, while providing mere months of added survival."  Moreover, she laments: "42.4 percent of the 9.5 million cancer cases had lost all of their life savings within two-plus years," with cancer drug costs "spiraling out of control." 

We're trying to help patients, but Dr. Reza says: "Despite some advances, the treatments for most kinds of cancer continue to be too painful, too damaging, too expensive and too ineffective."

The Third Law in action.  

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A recent BMJ study found that 12% of care, across all medical settings, resulted in patient harm, and that half of that harm was preventable.  It called patient harm a "serious problem," and called for more efforts to track and mitigate it, especially preventable harm.  

An associated BMJ editorial argued: 

Discussions about patient safety describe healthcare as an industry. If that’s the case then what is healthcare’s business? What does it manufacture? Health and wellbeing? Possibly. But we know for certain that healthcare manufactures harm.

Let that last phrase sink in: "Healthcare manufactures harm."  One might as well make that the Third Law.

The editorial goes on to say that: "These data make something of a mockery of our principal professional oath to first do no harm," saying that it is an "impossible oath." It concludes: "First do no harm, it seems, is an ancient oath true in spirit but impossible to practise in the messy business of modern healthcare."

Healthcare is, indeed, a messy business.  We don't always know what is wrong, or why, or what to do about it.  People don't often do what they should, including clinicians, patients, and anyone hoping not to become a patient.  The problems of unnecessary care and medical errors are widely recognized, if not well understood.  But we don't always recognize the potential consequences of healthcare's Third Law, or assume that any harm will only happen to others.

Sometimes, as the Times put it in their review of Dr. Raza's book, we have to know when it is time to say "enough."  Sometimes, as I previously wrote,  we have to stop believing in "magical fairy dust."  But all the time, we should recognize that healthcare's Third Law is out there, waiting for us.

We can't change the laws of physics, and we can't entirely avoid harm coming from care, but we can do a better job of trying to anticipate and minimize that harm. 

VA for All!

We hear a lot these days about Medicare for All.  It has gone from being a fringe idea to being the litmus test for Democratic Presidential contenders, advocated most fiercely by long-time proponents Senator Bernie Sanders and Senator Elizabeth Warren.  A majority of Americans now support the concept, although what they think it means and how much they are willing to pay for it are less clear. 

The arguments for Medicare for All are simple: the current system generates too many profits (especially for health insurers and pharma), has too much administrative complexity, and exposes too many people to high cost-sharing and premiums.  Medicare for All would take care of all those, proponents assert.

So, I wonder -- why would people be calling for a new system that would still have thousands of private hospitals/facilities and millions of healthcare professionals, practicing FFS medicine using countless systems and data structures?  In short, why aren't people calling for VA for All?

Like Medicare, the VA -- more specially, its healthcare component, the Veterans Health Administration -- is charged with providing healthcare to a designed population, in this case, veterans.  Unlike Medicare, though, it does so as an integrated health system (by far the largest in the U.S.), with 170 VA Medical Centers, over a thousand outpatient facilities, and somewhere over 10,000 physicians.

Despite what you might read about problems with wait times (which may, in fact, be overstated) or poor care, studies have found that, generally, "The Veterans Affairs health care system generally performs better than or similar to other health care systems on providing safe and effective care to patients."  For some conditions -- PTSD or prosthetics come to mind -- it offers some of the finest care in the world. 

It offers a range of services that Medicare can only dream of, and it does so at, it is believed, lower costs than private coverage or even Medicare.  Plus, it also was an innovator in electronic health records and is today in telehealth. 

What's not to like?

Well, of course, the VA has capacity issues already, which has led to the Choice program, and we'd need to figure out what happens to all those current health care organizations and professionals.  Some of them would end up as part of the VA -- of course, with lower salaries and fewer administrative functions -- but many others simply wouldn't be needed.  It couldn't happen overnight, of course, but neither could Medicare for All. 

But, hey, as with driving health insurers out of business, some healthcare job losses are a small price to pay for better coverage for more people at lower costs, right? 

Skeptics might think this is just another way of saying the U.S. should adopt something like the U.K.'s National Health Service (NHS), but that can't be true, because those skeptics think NHS is socialized medicine but only have good things to say about the VA.  So what's the problem extending the VA to more of us?

The truth is that Medicare for All isn't really about lowering administrative costs or expanding coverage, but about picking two of the least popular parts of the healthcare system to criticize.  Health insurers and pharmaceutical companies are seen as big, faceless corporations, usually located somewhere else.  They're not your local hospital or personal physician, and they don't directly deliver care, so people feel free to criticize them at will. 

Credit: Patrick George/Kiplinger

But there's nothing that Medicare for All could do that an expanded VA for All couldn't do better.  It's just a simplistic, easily packaged catchphrase as a "solution" for a fiendishly complex mess of a healthcare system.

I don't think "VA for All" is the right solution either, but I also think that proponents of Medicare for All are not being quite honest about what they are proposing, or what it most likely do (as I've outlined previously).  Political campaigns are probably not the best time to have serious health reform debates, but it seems that that is when we usually try to have them. 

There's a lot wrong with our current healthcare system, and that includes with both Medicare and the VA.  I like a good health reform discussion as well as the next person, but I don't have much patience for "solutions" that gloss over realities and don't really address the true underlying problems. 

The core problems, I believe, are that we often don't really know what "works" in healthcare, or how to truly gauge quality of care. Wake me when we get to reform discussions that address those.   

Biology Really May Be Our Future

Many of us are fascinated by our various computing devices -- our smartphones, our smart watches, and an ever-growing array of smart devices.  What we sometimes forget is that we are biological creatures (at least, until The Singularity), and that even though biology as a discipline has been around much longer than computing, biology may yet supersede it.

If the 20th century was the era of computers, the 21st century may be the era of biology.  And the two may even merge. Hello, synthetic biology and biological computing!

Last week SynBioBeta hosted The Global Synthetic Biology Summit, "where tech meets bio and bio meets tech."  People were urged to attend "to see how synthetic biology is disrupting consumer products, food, agriculture, medicine, chemicals, materials, and more." 

Chrissy Farr of CNBC reported:

“The conference has an irreverent, counter culture vibe to it,” said Jorge Conde, an investor at Andreessen Horowitz, who spoke at the event. Conde said that the founders are a “new breed” and they reminded him of the first generation of Silicon Valley entrepreneurs in the era of Steve Jobs.

Indeed, the field is attracting tech insiders.  Former Google CEO Eric Schmidt spoke at the conference, and was practically giddy about the prospects:

I’m always interested in the question: What is changing the fastest right now? Because whatever that is determining the history of next year. There’s lot of evidence that biology is in that golden period right now.”

He also added: "Biology will undoubtedly fuel computing. Taking biology, which I’d always viewed as squishy and analog, and turning it into something that can be digitally manipulated, is an enormous accelerator."

It's not just talk.  Take a look at this list of synthetic biology companies and their funders:

SynBioBeta boasts: "The industry has raised more than $12.3B in the last 10 years and last year, 98 synthetic biology companies collectively raised $3.8 billion, compared to just under $400 million total invested less than a decade ago."  It counts 628 new synthetic biology companies formed in 2018 alone.

As a sure sign that the field has hit, or expects to soon hit, the mainstream, StatNews reports that synthetic biology now has a new lobbying group (and a new magazine). 

I've written before about biohackers and gene editing, how we're using DNA to create "lifelike" mechanisms,  how DNA may prove to be the ultimate storage medium, even how DNA may prove to be a computing platform.  They, and many other avenues, are all exciting, but I'm probably most interested in the latter two.  Can biology power our computing?

In 1995 (!), Bill Gates famously wrote: "DNA is like a computer program but far, far more advanced than any software ever created."  As Microsoft researcher Karin Strauss put it more recently: "Think of compressing all the information on the accessible Internet into a shoebox.  With DNA data storage, that’s possible."

Jayshree Pandya writes in Forbes: 

While silicon microprocessors have so far been at the heart of the computing world, they are reaching their physical limit. With on-going challenges of physical speed, energy efficiency, and miniaturization limitations of silicon microprocessors, there is a need to find alternatives. DNA is emerging as the alternative and has the potential to take computing to new levels. Moreover, with the cheap supply of DNA and the evolving DNA manufacturing processes, the process to develop DNA chip is becoming much cleaner and realistic. DNA-based computers will not only make computers smaller, but they will hold more data as well. The DNA microprocessors are transformative.

We're trying to learn from our biology.  Shelly Fan reported for Singularity Hub on an effort by Penn State researchers to develop a "probabilistic neural network" (PNN) that acts more like neurons and synapses.  The team pointed out that the brain deploys "billions of information processing units, neurons, which are connected via trillions of synapses in order to accomplish massively parallel, synchronous, coherent, and concurrent computation."  They sought to replicate that with their PNNs.  

They think they succeeded, at least as proof of concept.  As a result, they concluded:   

Combined, these new developments can facilitate exascale computing and ultimately benefit scientific discovery, national security, energy security, economic security, infrastructure development, and advanced healthcare programs.

Microsoft has a research team focused on biological computation, "developing theory, methods and software for understanding and programming information processing in biological systems."  The head of the group, Dr. Andrew Phillips, explained how biological computing is different:

So, it’s more like a chemical soup where you have thousands of proteins interacting in parallel in a noisy fashion, and many of these interactions can go wrong with some probability. But yet out of all that noise emerges a fairly robust algorithm that is used to compute things like, when should a cell divide?...So, these algorithms are actually very complicated for us to understand because we’re not used to that. We’re still trying to reverse engineer them.

Dr. Phillips believes "that programming biology is going to transform many of the industries that are in existence today. I think it’s a sort of an underpinning technology that will help transform medicine, food, energy, and build the foundations for a future bio economy that’s based on sustainable technology."  

Hold on to your hats.

There has been much speculation about nanobots swimming around in our body correcting problems, implantable computer chips, and brain-computer interfaces, such as Elon Musk is working on at Neuralink.  Some of these are already coming to fruition.  We're controlling paralyzed limbs, operating computers, even networking brains.  

All that's very exciting, for sure.  Still, I think it's a very 20th century notion to implant foreign objects into our bodies.  We've had some good results with doing that, and we're going to have even more options, but it still seems like only an interim approach.  

Reprogramming our cells, storing data in DNA, turning ourselves into even more powerful computers -- that's 21st century technology, and that will be 22nd century health care.  

Those Damn Fees

On the face of it, GoodRx and fintech company Dave wouldn't seem to have anything to do with each other. 

To be honest, I had never heard of Dave until yesterday, when I read that Dave was now valued at $1b, just two years after launching its financial management product.  They now claim 4 million customers, with another 800,000 on its waiting list. 

Dave's raison d'être is helping users avoid overdraft fees.  It uses AI to monitor your spending habits, warn you when you might be nearing an overdraft situation, and even advances you up to $100 to avoid the overdraft, with no interest.  It can either be linked to an existing bank account, or through a Dave checking account.  It even plants a tree every time you "tip" their service. 

Overdraft fees average around $35 per occurrence, but add up to over $34b annually, so the problem Dave is addressing is not a trivial one.  Still, I wonder: if Dave is valued at $1b, what would a service in healthcare like that -- say, for surprise bills -- be worth? 

Which brings me to GoodRx.

As many people know, GoodRx's mission has been to help people find more affordable prescription drug prices.  If you have a prescription, you can use their website or their app to find prices at nearby pharmacies, and often to use a coupon as well to further reduce your cost.  The company claims that since their inception in 2011, their customers have saved over $14b, $5b in 2019 alone. 

The range of drug prices GoodRx exposes is astonishing, as is their ability to track and display them, much less to target coupons.  The prescription drug industry has been technologically ahead of the rest of the healthcare industry as long as I can recall; for example, it was doing electronic claim submission in the 1970's.  It shouldn't be too surprising that a prescription-focused service like GoodRx is effectively doing what transparency companies like Castlight or Healthcare Bluebook have been trying to do for the rest of healthcare. 

GoodRx is now stepping outside its legacy space with its launch of GoodRx Care, a telehealth service powered by its purchase of HeyDoctor.  Online consultations start at $20 and can be used for women's and men's health, preventive care, and chronic care, and the online consultation can lead to prescriptions not just for drugs but also lab tests.  Their pricing, of course, is transparent. 

GoodRx co-CEO/co-founder Doug Hirsch explained: "In an increasingly fragmented and confusing healthcare system, our goal is to provide a one-stop shop for services that address most basic healthcare needs."  He further told CNBC: "We’re a marketplace in prescriptions, and with GoodRx Care, we’re a marketplace for both prices for medical care and we’re even offering medical care."

There are plenty of telehealth companies, and a fair number of transparency companies, but no one that I know of is doing in medical what GoodRx has done with prescription prices -- truly exposing costs, steering patients to least expensive options, and helping further reduce those costs, especially for those without insurance. 

The Administration has been advocating more healthcare transparency, but its latest effort to have hospitals disclose negotiated rates is not being met with open arms.  Similarly, despite widespread support to stop so-called surprise bills, the prognosis for federal legislation to address them is turning grimmer. 

We need Dave.  Or, rather, we need a Dave.

We need a service that people can use as they are getting or about to get healthcare services.  "Hey, Kim," it might say.  "You're going to see Dr. X about condition A.  You should expect it to cost $Z, and expect him/her to order A, B, and C, which would cost $Y.  You can get the best prices at ____.  And, oh, by the way, you'll still be in your deductible."

It might even suggest seeing Dr. X1 instead, who not only has better outcomes but also results in lower costs.  

If you still ended up with a surprise bill after all that, it might help you negotiate the bill to a more reasonable amount, and perhaps help you finance it.   

This service seems like a lot to ask for, but I don't really understand how GoodRx manages to stay on top of all the prescription pricing either, or how Dave manages to offer no interest financing for overdrafts either.  They each have different business models than others in healthcare and banking, respectively, but both models happen to be ones that help people be less surprised by unexpected costs.  

Those seem like business models healthcare should be embracing. 

Maybe Dave or one of its fintech rivals will focus on managing healthcare expenses as a niche.  Perhaps GoodRx's new foray into medical care services will broaden its appetite to expose prices and help consumers manage them.  Or, as many expect, Amazon -- which just launched its own virtual care clinic -- might finally bring its marketplace platform to bear on pricing healthcare.  

We don't yet know who it will be, butut it will be someone.
  
Earlier this year Jason Wilk, Dave's co-founder and CEO, said:  

Banks have failed their customers by building products that put their own interests ahead of the humans who use them. People don’t need predatory fees, they need tools that actually solve their challenges around credit building, finding work and getting access to their own money to cover immediate expenses. Dave is the banking product that works with its customers, not against them

Now substitute "banks" and "banking" with "healthcare," and you'd have a pretty good mission statement for a new healthcare company.  The question is, who will it be, when? 

Dave may kill, or at least hurt, traditional banks because people are upset about overdraft fees.  Netflix killed Blockbuster in part because people got annoyed with late fees.  Healthcare has plenty of fees that seem even more perverse -- and much larger -- than either of those (think facility fees or balance/surprise bills), making it even more ripe for similar disruption. 

The $1b valuation for Dave would be small change for the company that can do something about helping consumers with those unexpected costs.