Need Care, Should Travel

As tempting as it is to write about the parallels to healthcare of the Texas power/water debacle, or about IBM’s rumored desire to sell off its Watson Health division, I find myself thinking once more about our inability to distinguish quality in our health care. 

I live in Cincinnati (OH).  The metro area has five hospital systems, including an academic medical center (University of Cincinnati), plus a renowned children’s hospital (Cincinnati Children’s) and a VA hospital. Most Cincinnati residents go their entire lives getting all their medical care here. 

That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  Most people have some nationally ranked hospitals within a few hours drive, and everyone is within a few hours flight from some, but all-too-few actively pursue them, despite “centers of excellence” programs that many health plans have used to encourage such travel.  Even people living in cities with such hospitals don’t always choose to get their care from them. 

There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally; it’s harder on the patient, harder on the family, and those travel expenses/time are usually not reimbursed. 

What, me travel?

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine.  If you have a cold or the flu, chances are you can get pretty good care for it locally.  Even if you have a more serious condition like diabetes or asthma, local physicians and hospitals can usually help you manage it well.  But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling.   

The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care?  I can get a heart transplant locally; I can get almost any kind of cancer care I might need here, and, if not, certainly in Columbus.  When is that care likely to be not good enough?

I don’t know, you don’t know, and even “experts” are likely to disagree. 

I wish all the hospital advertising I see spent at least a little time telling me when I shouldn’t go there, instead of telling me why I should always go there.  The facts are that outcomes aren’t the same, that doctors in different hospitals don’t have the same experience/expertise, and that all-things-to-all-people is not the best recipe for best-in-class.  

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

E.g., outcomes for colds are likely to be similar no matter where/from whom you get treatment, but chances that you’ll survive a heart transplant (and have high quality of life afterward) are heavily dependent on where/from whom you get the transplant.   

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

I’m not intending to do business development for The Cleveland Clinic, or, for that matter, for USN&WR.  I’m just using them to make the point.  Pick your preferred hospitals, pick your preferred rating mechanism, but the fact remains that all care is not the same.  Some hospitals are better for some things than others.  We just don’t act as though that was true.

Of course, there would be non-trivial financial implications to such a change.  Hospitals that are not nationally ranked aren’t likely to be willing to give up those more severe patients; instead, they’ve been investing over the past few decades to bring more & more services within their walls.  Whether that results in better outcomes for patients, though, is at best unclear. 

Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  For the most part, we pay regardless of the quality.  Value-based programs are, to date, more for show than for effect. 

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. 

All politics, as they say, is local, but all health care shouldn’t be. 

Healthcare Needs Its Mary Barra

With all that has been going on, I’ve been remiss in reflecting on General Motor’s big announcement a couple weeks ago: it is going to have an all electric, zero emissions fleet of “light duty” vehicles (cars, SUVs, pickups) by 2035, and be carbon neutral by 2040.  One of the largest manufacturers of internal combustion vehicles for over a hundred years is recognizing that its past is not its future.

Of course, I immediately wondered what the equivalent move in healthcare would be, and from whom. 

GM's Mary Barra Credit: GM

 In the announcement, GM Chairman and CEO Mary Barra declared:

General Motors is joining governments and companies around the globe working to establish a safer, greener and better world.  We encourage others to follow suit and make a significant impact on our industry and on the economy as a whole.

You can just imagine Henry Ford fuming in his grave.

GM has had electric vehicles for some time, but they remain a small percentage of its business, as they do among the auto industry generally (Tesla’s market cap notwithstanding).  GM had supported the Trump Administration’s policies efforts to rescind emission standards, which benefited internal combustion engines, but quickly changed course in light of Biden Administration priorities on climate change.

GM now plans to spend some $27b on electric and autonomous vehicles over the next few years.  “We’re committed to fighting for EV market share until we are No. 1 in North America, Ms. Barra said at an investor’s conference.   “EVs are core to creating GM shareholder value.”

None of the major auto manufacturers immediately matched GM’s move, although all have introduced electric vehicles and Ford, in particular, vowed to invest $29b in electric/autonomous vehicles through 2025. A Ford spokesperson said the company was “committed to leading the electric vehicle revolution in the areas where we are strong.” 

Although there are, not surprisingly, skeptics, most observers praised GM’s announcement.  Paul Bledsoe, a climate expert at the Progressive Policy Institute, told The Washington Post: “When America’s most iconic manufacturer commits to carbon neutrality, that’s a huge signal to the rest of the economy.” Erik Gordon, a business professor at the University of Michigan, told The New York Times:

This is a guardedly bold move.  It’s not that risky. Fifteen or 20 years from now, who knows where we might be? Mary Barra won’t even be C.E.O. But right now it’s hugely symbolic. This is very forward-looking.

To be sure, the 2035 emissions deadline is a goal, not a commitment.  Mike Ramsey, a vice president at Gartner told Sierra: “I think GM is serious in the sense that it is an aspirational goal. If the market doesn’t move that way fast enough, they aren’t going to stop making engines and gas tanks just because they said they would.”

“The central point is that we made a firm commitment to carbon neutrality by 2040,” Jessica James, assistant manager of sustainability communications at GM, explained. “That is happening. But some things need to come together to meet the 2035 deadline—it’s out of our direct control.” 

I don’t know if GM will live up to its announcement, or even if GM will still be around in 2035, but I love bold promises from otherwise stodgy companies.  If Microsoft can become a leader in open source software, who’s to say that GM can’t reinvent itself?  More power to them.

So what are some equivalent things healthcare organizations might do, changing core parts of how they’ve operated to better serve society?  Here are a few suggestions:

• Epic could promise that data in its EHRs will be fully interoperable with other EHRs, with a consolidated patient record across health systems.  “Patient data belongs to patients.  Our job is to use that data to help patients and all of their health care professionals make better health decisions.”
• Sutter Health could announce it is getting rid of its chargemaster.  “Medicare payments shall be our base payment level, and no payor will have rates more than 120% of that."
• UVA Health could vow to stop suing its patients.  “We’re here to help patients, not go after them during vulnerable times in their lives.  Any billing/collection disputes will be worked out through third party arbitration.”
• UPMC could agree to pay local property taxes.  “We are committed to helping improve the health of our community, and we recognize that paying our fair share of local taxes is an important part of that goal.”
• TeamHealth and Envision Healthcare, both owned by private equity firms, could put an end to their surprise billing practices.  “We commit that all of our professionals will be in-network for all major health insurers, or will accept the payment level from the largest health insurer in the given market as our charge.” 
• Pfizer and Eli Lilly could put an end to pricing practices that make their drugs much more expensive in the U.S. than in other countries, especially for such necessary products as Epipen and insulin (respectively).  “We can no longer drive our profits from U.S. customers.  Our U.S. prices will be consistent with prices charged in G20 countries.”
• The AMA and the medical specialty societies could agree to give up control of the Relative Value Scale Update Committee (RUC), which determines changes to RBRVS weights.  “We recognize that, in this era of transparency, our involvement in helping set payment levels that our members may benefit from is no longer appropriate.” 
• The Association of America Medical Colleges and The American Association of Colleges of Osteopathic Medicine could agree to merge.  “Over 110 years after the Flexner report, we believe it is long past time that the historical differences between M.D.s and D.O.s be eliminated, in favor of a single system of education, training, licensing and oversight of physicians that will best serve patients in the 21^st century.”

One difference between these promises and GM’s: we shouldn’t have to wait until 2035.  These are things that can and should be done within a few years.

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 Almost seventy years ago, GM President Charles Wilson made his famous (mis)quote: “what’s good for GM is good for America” (although his actual quote was “I thought what was good for our country was good for General Motors, and vice versa.”)  Healthcare is a much bigger portion of our economy than auto manufacturing is or ever was, and anything that is good for healthcare but bad for the people using it cannot really be good for either healthcare or the country.

Healthcare has a chance to re-stake its future.  It should make, and keep, some bold promises.  If doing so is good for GM, it should be good for healthcare as well.  Where are its Mary Barras? 

If It Ain't Real-Time, It Ain't Really Real

Here’s a damning opening paragraph from an article in The New York Times about the frustrations that COVID-19 vaccinations are causing:

For a vast majority of Americans, a coronavirus vaccine is like sleep for a new parent: It’s all you can think about, even if you have no idea when you will get it.

Because, as Kaiser Health News reported: “Many states don’t know exactly where the doses are, and the feds don’t either.” 

Think about that: in 2021, we can’t – or don’t – track something as vital as where vaccine doses are, in the midst of the pandemic they were designed in record time to mitigate. Nor, as it turns out, are we doing a good job of tracking how many have already had them, who is now eligible for them, or assuring that essential workers or disadvantaged populations are getting them. 

Credit: MedCity News

Amazon tells me when my purchases have shipped, where they are in the shipping process, and when they’ve been delivered.  They even send me a picture of purchases sitting on my porch to make sure I notice. Walmart’s supply chain management is equally vaunted. 

Health care executives evidently aren’t required to learn supply chain management. 

What started me thinking about this was an article in The New York Times by three economists: Raj Chetty (Harvard), John N. Friedman (Brown), and Michael Stepner (University of Toronto) on economic data.  Early in the pandemic they realized that existing economic indicators were lagging indicators, based on surveys and transactions that happened weeks or months ago.  So, they built “a new publicly available economic tracker to better monitor the economy in real time.”

As they explain:

But we live in the age of information, where virtually all economic transactions leave a digital trail — from credit card receipts to paychecks to loans. These data are routinely used by companies and financial analysts to make better business decisions. And when the same data are put in the hands of the public, they can be used to guide our most important policy decisions, too.

The data provide “an unprecedented lens into how the economy is functioning — county by county, day by day, for low-income and high-income Americans.”  For example, they were able to show that people spent last April’s $1,200 stimulus checks very differently than December’s $600 ones.  Higher income people saved most of the latter, whereas lower income people spent most of both. 

Since Congress is now debating another round of stimulus checks, this information seems important.  The authors assert “if we make policy in February 2021 based on economic conditions in April 2020, we risk reaching the wrong conclusions.”   Good rule of thumb: the older the data, the less confidence we should have in decisions based on them.

Meanwhile, in healthcare we don’t know where our vaccines are, much less how many people are already (or have been) infected.  Other important questions like how many people lack health insurance are only estimated, months late.

Of course, the pandemic started with us failing at testing and contact tracing, so we started in a data deficit that has only gown worse, and more lethal.  It’s happening again right now, as we’re failing to accurately track and react to the new coronavirus variants that are spreading rapidly in the U.S. 

Tracking COVID-19 cases, hospitalizations, and deaths has become something of a cottage industry, with each county health department, hospital and state trying to figure out how to track and report these important data.  We may never know how accurate most of it is.  One only need look at what has been happening in Florida to get a sense of how shaky the data might be. 

Some good work has been doing during the pandemic about using more real-time data, such as use of cell phone data to track how much people are travelling and even degree of social distancing.  Similarly, there are apps that allow cell phones to warn of potential COVID-19 exposure, although the low rate of uptake has hampered their usefulness.  

But it’s not enough, and it shouldn’t just be for COVID-19.

You've got to be kidding me

It is beyond me why, for example, there’s not a universal app for people to register for COVID-19 vaccines, alert them when there are local doses, allow them to schedule appointments (including second doses as needed), track vaccination (including which vaccines were used), and report to state and federal health agencies.  It should be technologically feasible, except maybe not in healthcare due to the various siloed, creaky IT infrastructures.

I’ll go a step further.  People worry about potential vaccine side effects, but there is no systemic way to track them – just as there isn’t for other prescription drugs.  It falls to the patient to determine if they think their side effects are serious enough to alert anyone, and even then that report may not get passed on.  Again, there aren’t technological barriers to tracking these, just inertial ones.

Similarly, it has always concerned me that, if you’ve had a surgery or have been discharged from the hospital, tracking how you are doing is a rather loose affair. Patients usually have some sort of follow-up visit or phone call, but those might be days or weeks later.  Otherwise, the premise is, if the physician doesn’t hear from the patient, all is well. 

Apple Watch activity tracking rings

In fact, that is usually the premise most physicians rely on.  Their patient may suddenly be bed-ridden, or have a sharp decline in mobility, and only if the patient is concerned enough – or able – to contact them would they know.  Anyone who wears an Apple Watch, for example, can track daily, even hourly, mobility, but physicians aren’t alerted to any sudden changes in patterns.

They could, and should. 

We need “real-time, granular data,” as the professors said about their economic data, to know what is happening in our healthcare system, and to those of us who might use it.  We need to be proactive, not reactive. 

Yes, there are privacy concerns.  Not everyone will want even their physicians to know how they ae doing in real time.  It needs to be specifically targeted and permission based.  Nor will physicians be able to manage the amount of data that such tracking would generate.  This is the kind of monitoring where A.I. can help: understanding norms, identifying deviations from them, and reporting when they may pose potential health risks. 

We can’t keep running our healthcare system, or managing our health, using ad hoc, dated data.  It’s time for healthcare to be real-time and proactive.

Better Get Your Quantum Computer

By all rights, I should be writing about the battle between Reddit forum WallStreetBets and Wall Street hedge funds.  Depending on one’s point of view, it’s hilarious, frightening, or a searing indictment on stock trading – maybe all three. 

But I’m going to let Elon Musk and Elizabeth Warren handle that one.  Instead, I want to talk about quantum computing – and why healthcare needs to looking ahead to it.

Let’s start with this: for the low, low price of $5,000, you could have your very own quantum computer.  Spin Q Technology, a Chinese company, has recently introduced its Spin Q, a less expensive, less powerful version of its Spin Q Gemini, which went for $50,000.  Other quantum computers, such as those by Google, IBM, or D-Wave, have a few more zeroes in their price.  Spin Q Technology has a clear goal in offering this version:

We believe that low-cost portable quantum computer products will facilitate hands-on experience for teaching quantum computing at all levels, well-prepare younger generations of students and researchers for the future of quantum technologies.

You may remember that Steve Jobs and Apple had a similar strategy in the 1980’s, establishing a presence in the education market and among a generation of users that has served it well. 

If you’re looking for something more powerful, maybe even use for business purposes, you are also in luck: today Microsoft announced that Azure Quantum “is now open for business.”    Microsoft bills Azure Quantum as “the world’s first full-stack, public cloud ecosystem for quantum solutions.”  

The announcement waxes eloquently:

As you start on your quantum journey, you can explore at your own pace, with the peace of mind that your data is secure in the most-trusted public cloud. You pay as you go, and scale when you are ready. You have the flexibility to choose from self-service development or tailored development services with our Enterprise Acceleration Program

As with Spin Q Technology, they expect many users will treat it as a learning mechanism.  “This means that developers, researchers, systems integrators, and customers can use it to learn and build,” Julie Love, senior director at Microsoft Quantum told ZDNet.  “…I'm most excited to see what new ideas developers come up with once they've had the tools and solutions in their hands.”

Once you’ve got computers, of course, the next thing you want to do is network them, and – voila! – soon there’s a quantum internet.  A quantum internet would exchange “qubits” – the basic unit of information for quantum information, akin to how the bit is to classical computing.  It involvement “entanglement” of qubits on different machines, so that a change in one instantaneously impacting the other. 

Last summer, the U.S. Department of Energy released its blueprint for development of the quantum internet, asserting it was one of the most important technological frontiers of the 21^st century – and that a prototype was achievable within a decade.  One wonders if that goal is ambitious enough.  

Last fall researchers at Brookhaven National Lab and Stony Brook University used standard internet cables to entangle qubits from two quantum computers with a third several miles away.  “It’s not really feasible to lay new cables everywhere, so being able to use what’s in the ground was important,” said Kerstin Kleese Van Dam, the director of Brookhaven’s Computational Science Initiative. 

Then, in December, researchers from Fermilab announced they’d demonstrated “sustained, long-distance (44 kilometers of fiber) teleportation of qubits of photons (quanta of light) with fidelity greater than 90%.”  Panagiotis Spentzouris, head of the Fermilab quantum science program, bragged: “This is a key achievement on the way to building a technology that will redefine how we conduct global communication.”

It’s not entirely clear what a quantum internet would do, but it is expected to be much, much faster and allow for levels of encryption that are impossible now.  But, as Dr. Egan Figueroa told Dan Hurley of Discover Magazine:

Many of the things these devices will do, we are still trying to figure it out.  At the moment, we are just trying to create technology that works. The really far reaches of what is possible are still to be discovered.

Gary Fowler, writing in Forbes, proclaims: “The truth is, a revolution is coming. And it has already begun making significant promises for security, speed, efficiency and capabilities.”  He specifically cites healthcare and drug development as one of the industries most likely to be impacted.

Illustration: Brian Wang, South China Morning Post

It’s worth noting that, what is still to be discovered is actively being worked on in China.  It is already sending “uncrackable” encrypted messages far distances, even into space; it claims to have the fastest quantum computer; it has a quantum communications network; it is testing a mobile quantum network using drones; it has achieved three dimensional quantum teleportation. 

John Prisco warns in Forbes that, when it comes to quantum computing, “the United States isn’t winning — we’re battling for second place behind China.”

If you think this may all be very interesting but something far downstream from what healthcare, with its faxes and data interoperability issues, needs to worry about, well, the future comes at you fast.  IBM already has its list of quantum computing use cases for healthcare. 

Back in 2018 three St. Louis University researchers predicted:

We may be at the advent of a revolution in computer applications in clinical care and medical research. Quantum computing can exponentially advance computational power and promises to usher in a new epoch in computing technology.

Basically, if you’re already bought in to the application of AI to healthcare, or recognize the need for more secure healthcare data, then you better also be thinking about quantum computing and the quantum internet. 

Quantum physicist Shohini Ghose suggests business leaders should be developing strategies around:

• Planning for quantum security;
• Identifying use cases;
• Thinking through responsible design.

The latter issue is what has led a group of quantum computing experts – The Quantum Daily -- to call for open discussion of the ethics around it.  Professor John Martinis, formerly of Google, warns: “Whenever we have a new computing power, there is potential for benefit of humanity, [but] you can imagine ways that it would also hurt people.” Cambridge Quantum Computing CEO Iiyas Klan added: “This is the equivalent of a whole new industrial revolution…We ought to have those conversations today.” 

If healthcare isn’t careful, it’s not only going to use quantum computers/internet too late, but realize too late the ethical issues it should have prepared for. 

So, maybe you should buy a Spin Q and start playing with it.