Healthcare's Million Dollar Blocks

 Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.”  For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills,  Chicago’s Gold Coast, or Manhattan’s Hudson Yards -- areas where the wealthy congregate.  No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.

Million Dollar Blocks. 
Credit: Center for Spatial Research

I, of course, have to think about the healthcare parallels.

The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR).  The power of the concept is to use data visualization to illustrate the problem. 

Here, for example, is CSR’s map of Brooklyn for prison spending:

Prison spending in Brooklyn. 
Credit: Center for Spatial Research

CSR describes the findings as follows:

The maps suggest that the criminal justice system has become the predominant government institution in these communities and that public investment in this system has resulted in significant costs to other elements of our civic infrastructure — education, housing, health, and family. Prisons and jails form the distant exostructure of many American cities today.

Think about that: “criminal justice is the predominant government institution in these communities.”  Something is wrong with that picture – not theirs, but, rather, the picture of our society that it presents.

Mr. Cadora told NPR in 2012:

No one had ever actually sat down and gotten the home street address of everyone going into prison and jail, as well as all the background information about their age and their employment status, etc. And when you have all that data, it tells you a lot about what's going on on the block.

In all honesty, what we mapped was not a big surprise to people. But when you actually gather the real data ... on maps, [it becomes] immediately understandable to people who didn't see it — like legislators, city council people, researchers.

No, not a big surprise, not to most people.  We know we spend lots of money on criminal justice; we just don’t always realize how we spend it.  We’ve long had the dubious distinction of locking up more people – in total and per capita – than any other country.  

But if, as they say, a picture is worth a thousand words, then perhaps data visualization is worth a million dollars.  Even hardened criminal justice advocates have to blanche at how spending is so often concentrated in certain blocks, and should wonder if perhaps there are better ways to use that money for them.

CSR has a variety of projects in addition to their criminal justice work, including some focused on healthcare.  Earlier this year, for example, they created an interactive vaccine allocation map to help guide decisions about allocating then-scarce COVID-19 vaccines, and late last year their New Politics of Care project used an interactive map to highlight existing areas of health care needs.  They proposed a New Deal for Public Health, with a million new community health workers deployed around the country based on the identified needs.   

New Politics of Care.  Credit: Center for Spatial Research

Somehow the Community Health Corps didn’t make it into the Biden infrastructure proposal.  Perhaps no one in the Administration has seen the map.

Data visualization is nothing new for healthcare.  The CDC has an Interactive Atlas of Heart Disease and Stroke, the Dartmouth Atlas has been highlighting healthcare variations for close to thirty years, and, more recently, the Johns Hopkins Coronarvirus Resource Center has been tracking what’s been happening in the pandemic.  

CMS has a dashboard that purports to show “standardized per capita costs” down to a county level, based on Medicare fee-for-service claims, but that’s only for Medicare spending for only a portion of the Medicare population.  That’s still a long way off from total spending for the whole population, at a city block or even zip code level. 

Still, if anyone is tracking where healthcare’s “million dollar blocks” are, I’d like to hear about it. 

We know -- or think we know – that there are underserved communities where too many people end up in the emergency room.  We know that there are communities in which maternal and infant mortality/morbidity are much worse.  We know that there are food deserts that lead to poor nutrition and subsequent poor health outcomes.  We know that environmental factors like lead poisoning, air pollution, or, of course, gun violence, lead to differences in health and in healthcare spending.

But do we know where these are concentrated, or do we know how much we’re spending on the results of them?  No. 

I want to know in which communities the hospitals are the predominant healthcare institution.  I want to know in which communities diabetes is rampant.  I want to know what communities are falling behind on preventive screenings and vaccinations.  I want to know which communities have suspiciously low healthcare spending, and whether that is a function of better health or lack of healthcare resources.

I want to see the interactive data visualizations for these types of issues, and I want smart people acting on them.

If the pandemic has highlighted anything, it’s that our public health system is woefully inadequate.  It’s a patchwork of overworked county and state public health departments, with a too-tenuous connection to the CDC.  It doesn’t have the right resources and doesn’t have the right data, collected and acted upon at the right time.

Credit: Getting Images

Healthcare generates scads of data, but not the right data, timely, aggregated across all payors for all kinds of services, and we certainly don’t have anyone in a position to really use it to manage. 

The “million dollar block” concept highlights the fact that we’re good at spending money, but we’re not very good about how we end up spending it.  It emphasizes the rationale of “defund police” movement, and should be applied to healthcare as well (as I’ve discussed before).   

I guess we need to see the pictures first.

Let's Build Some LTC Infrastructure!

 Quick now: what’s the biggest single component of President Biden’s infrastructure plan (a.k.a The American Jobs Plan)?   Fixing roads and bridges?  Upgrading the power grid?  Preparing the nation for electric vehicles?  Giving all Americans access to broadband?  Wrong.  If you guessed home and community services, you’ve been paying attention. 

President Biden is proposing $400b (out of some $2 trillion total spending) for this component, compared to, for example, $115b for roads and bridges or $174b to support electric vehicles.  He wants to improve the pay of home care workers, fund more of those jobs, and ensure more people have access to home and community services.

All laudable goals, but not nearly enough, and not spent on the right things.  I worry that we may miss a generational opportunity to fundamentally rethink the infrastructure for long-term care.

Opponents of the Biden plan argue that this part of the program is not “infrastructure” in any normal use of the word, and cynics believe it is more about satisfying the SEIU.  On the other hand, long-term care advocates worry that it doesn’t do anything to improve nursing homes, nor the existing long-term care financing mechanisms.  

No one is happy with our long-term care system, except maybe the people profiting from it.  We spend well over $300b annually on long-term care services, plus billons more in unpaid care, but that doesn’t seem to be money well spent.  Long-term care makes the rest of our messed-up healthcare system look futuristic.   Since 70% of us are likely to require some kind of long-term care assistance during our lifetime, this is an issue we should all care about.  

Depending on the source, there are currently somewhere between 2.4 and 3.5 million home care workers, with the need to expected to grow 50% by the end of the decade.  They make, on average, just over $12 on hour – less than they could make at Amazon.  The proposal would seek to pay them as much as $20 an hour. 

Credit: The Brooking Institution

Even if we manage to boost wages, it’s not like these jobs are prestige jobs; they often entail unpleasant and difficult tasks.  Caring for people is a calling, and not everyone can do it, at least not well, and even those who can often burnout over time.

Our long-term care infrastructure is failing as badly, or worse, than any of our roads, but simply throwing more money at more people to do the same things is like simply paving over those roads.  It neither addresses the underlying problems nor prepares for the future.

The future is that there are going to be more seniors, living longer, and living those extra years with more chronic conditions.  The future is that we don’t have enough nursing home beds to handle the increased volume, nor enough workers to care for people. 

We need new long-term care infrastructure.  Here are some suggestions:

Rethink Nursing Homes: I’ve written before that we should “blow up” hospitals: rethink them from first principles, revamp them to ensure that only people who absolutely need to be in one are there, and even then only for the minimum time needed.  All of that applies even more to nursing homes.

Let’s admit it: glossy brochures and 5 star rating aside, the quality of care in nursing homes is far from what it should be.  That’s particularly true for nursing homes that predominately serve Medicaid patients.  Staffing issues, lack of oversight, and low payments are part of the problem, but the entire concept needs to be rethought.

When do we need institutional care, for which patients, for long?  How should they be designed and staffed to safeguard patients’ rights and dignity?  What technologies can be used to improve the quality of life for both residents and workers?

What might a nursing home from 2050, or even 2100, look like?

On-Demand Technology: We live in an on-demand society, and need to apply those kinds of technologies to help people remain at home as long as possible.

The Myosuit.  Credit: Eazilee

We can monitor people’s well-being.  We can send support upon request, or when monitors indicate that support is needed.  We can use assistive devices (e.g., exosuits!) to help support/restore capabilities and offer more independence.  We can use AI to pinpoint when what interventions are likely to be needed.

21^st century technologies can keep us at home longer than we’re taking advantage of now, and will only get better at it.

Robots: I have long been advocating that there may be no better use for robots than to support people with long-term care needs.  Watching with unwavering patience and presence, assisting with especially personal needs like bathing or toileting, repeatedly lifting a body weight: all are ideal for robots.    

Yes, people can do all these things, and do.  No, robots are not yet entirely ready to assume most caregiving tasks.  But emphatically yes, they will be – and should.

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Lest anyone think I believe long-term care should only be a technological marvel, let me emphasize that people are and should always be integral to any kind of long-term care. People with long-term care needs need other people.  They do better when there are meaningful social interactions.  But we should design our long-term care system to maximize human empathy and caring, not to rely on humans primarily for caregiving tasks. 

I don’t begrudge long-term care workers better wages and better working conditions.  They deserve it.  I’m just not sure the infrastructure bill is the best way to accomplish this, especially since it appears money will just flow through our deeply flawed Medicaid system.  As Robert Espinoza of PHI told The New York Times, “It’s hard to imagine Medicaid is the right funding vehicle.”  

Financing for long-term care is particularly problematic, since so much of the spending is out-of-pocket, and wipes out assets for more people than any other type of healthcare service.  We need more equitable methods of financing long-term care.  Revamps of Medicare and Medicaid are required.

Let’s not just throw more money at home and community care workers; let’s reinvent the long-term care system in which they work. 

To Add Is Expected, To Subtract Is Design

 A couple years ago I wrote about how healthcare should take customer experience guru Dan Gingiss’s advice: do simple better.  Now new research illustrates why this is so hard: when it comes to trying to make improvements, people would rather add than subtract. 

That, in a nutshell, may help explain why our healthcare system is such a mess.

The research, from University of Virginia researchers, made the cover of last week’s Nature, under the catchy title Less Is More.  Subjects were given several opportunities to suggest changes to something, such as a Lego set-up, a geometric design, an essay or even a travel itinerary.  The authors found: “Here we show that people systematically default to searching for additive transformations, and consequently overlook subtractive transformations.”

In the Lego picture above, for example, when asked how to strengthen the upper platform, most people wanted to add new columns, instead of simply removing the existing column.  The researchers note: “The subtractive solution is more efficient, but you only notice it if you don’t jump to an additive conclusion.”

Giving cognitive nudges – like explicitly mentioning the option of deleting something – improved the likelihood that people would come up with subtractive options, but increasing cognitive load (through additional tasks) decreased it.  Co-author Benjamin Converse said: 

Additive ideas come to mind quickly and easily, but subtractive ideas require more cognitive effort.  Because people are often moving fast and working with the first ideas that come to mind, they end up accepting additive solutions without considering subtraction at all.

Leidy Klotz, one of the authors, told Technology Networks:

…just think about your own work and you will see it. The first thing that comes to our minds is, what can we add to make it better. Our paper shows we do this to our detriment, even when the only right answer is to subtract. Even with financial incentive, we still don't think to take away.

“Overlooking subtraction may mean that people are missing out on opportunities to make their lives more fulfilling, their institutions more effective and their planet more livable,” the team wrote.  

In a companion Nature paper, NYU professors Mayvis and Yoon have an interesting explanation: “we propose that the bias towards additive solutions might be further compounded by the fact that subtractive solutions are also less likely to be appreciated. People might expect to receive less credit for subtractive solutions than for additive ones.” 

They also speculate that subtractive solutions “might feel less creative,” that “people could assume that existing features are there for a reason,” and that the sunk cost bias is strong. 

I think they may be on to something.

Generally speaking, people don’t get paid for removing features.  They don’t get applause for eliminating jobs.  And they rarely get promoted for telling their bosses they’ve been wasting their money.  Much safer to propose something new, which is almost always additive.

Credit: Getty Images

Our healthcare system is like a living archaeological site, with layers upon layers of history.  We have email but we still have faxes.  We have digital ultrasound but we still have X-rays.  We have electronic records but we still have plenty of paper.  Doctors still wear lab coats because, well, some surgeons in the 19^th century thought it was a good idea. 

The ABMS has – count ‘em! – 40 specialties and 87 subspecialities for physicians, who might be M.D.s or D.O.s.  That doesn’t include other non-physician medical specialties whose practitioners also refer to themselves as “doctor,” such as PharmD, DPM, DDS, DMD, DPT, AuD, or certain Ph.D.s.    

We have emergency rooms, free-standing emergency rooms, and urgent care centers.  We have surgical centers and freestanding ambulatory surgical centers.  We have in-person doctor visits and telehealth doctor visits.   

We have for-profit and non-profit hospitals, health plans, nursing homes, and home health agencies, although you couldn’t predict the amount of profit earned just by the type they claim to be.  At least pharmaceutical companies and medical device manufacturers are honest about their goals.    

Digital health is exploding, with scores of new companies and record-setting amounts of funding for them.  Most offer point solutions for specific problems/populations.

We created employer-sponsored health insurance to get around wage controls in the 1940’s, and just kept it when they went away.  We created Medicare and Medicaid in the 1960’s and tweaked them ever since, while adding related programs like CHIP.   We have the Veteran’s Health Administration and the Military Health System, not to mention the Public Health Service, federally qualified health centers, and the National Health Service Corps. 

We have health insurance, both public and private, but we also have health coverage through workers compensation and auto insurance, plus dental and vision coverage.  People on Medicare usually have Parts A, B, and D, plus a supplement, or may have a Medicare Advantage plan.  I’ve lost count of how many health-related IDs and portals I have. 

We have deductibles, copays, and coinsurance.  We have in-network and out-of-network coverage.  We have generic and brand prescriptions, covered in multiple tiers.  We have premiums and out-of-pocket limits, and subsidies for when each gets too excessive. 

Each of these things was a good idea if considered alone, but the aggregation is mind-numbing – and expensive.

It’s great that so many people have so many ideas about how to make improvements to our healthcare system.  Aside from those urging that we get rid of private health insurance, though, few of these ideas do much to subtract things from it. 

If you have ever used the healthcare system, at some point you’ve probably wondered: why do they need that, or why did I have to do that?  If you work in healthcare, at some point you’ve probably wondered: why do we make people go through that, or why do I still have to do that? 

Because of additive thinking.  In healthcare, less not only isn’t seen as more, it’s seen as a risk. 

It’s easy to add bells and whistles.  It’s cool to think up a new app or a new feature on a website.  It’s great to give people more options.  It’s rewarding to create new jobs.  But, gosh, it all adds up, doesn’t it?

If less is more, where are the incentives for people to develop subtractive solutions?  Who are the people getting paid to, you know, make sure there is less?  Who are the leaders who are proactively seeking out what their organization doesn’t need to be doing? 

We might ooh and ahh over a cool design, but what’s more awesome is design that takes away what you don’t really need.

Some Discord Could Be Good For Healthcare

By the time you read this, Microsoft may have already struck a deal with the messaging service Discord.  VentureBeat reported two weeks ago that Discord was in an “exclusive acquisition discussion” with an interested party, for a deal that could reach at least $10b.  Bloomberg and  The Wall Street Journal each quickly revealed that the interested party was Microsoft (and also confirmed the likely price). 

Me, I’m wishing that a healthcare company – hey, TelaDoc and UnitedHealth Group, I’m looking at you! – was in the mix. 

Let’s back up.  If you are not a gamer, you may not know about Discord.  It was launched in 2015, primarily as a community for gamers.  Originally it focused on texting/chat, but has widened its capabilities to include audio and video.  The Verge described it: “Discord is a great mix of Slack messaging and Zoom video, combined together with a unique ability to just drop into audio calls freely.”

Zoom meets Slack meets Clubhouse.

As you might infer from the potential asking price, Discord has done quite well.  It has over 140 million monthly users, and, despite having no advertising and offering a free service, generated $130 million in revenues last year (through its “enhanced Discord experience” subscription service Nitro).  OK, it still isn’t profitable, but a December funding round gave it a $7b valuation.

GeekWire gushes:

As of right now, Discord is nearly inescapable in the gaming space. It takes about a minute to open a new public or private Discord channel for any given topic, complete with voice chat, image hosting, and browser access.

The pandemic helped growth, as it did for gaming generally, as well as for services like Zoom, but Discord leaned into the moment and broadened its reach.  NPR says: “What started as a community for gamers has in the past year become a hub for virtually everything: conferences, karaoke, book clubs, group therapy, homework help, sneaker trading and analyzing Wall Street stocks.” Popular Science believes: “If you’re interested in a topic, there’s almost certainly a subsect of people talking about it on Discord right now.”

Discord CEO Jason Citron told NPR: “You can text chat, voice chat, video chat seamlessly, switch between them on your phone or on your desktop. And it's great for playing games together, studying homework, hosting an online book club or even a karaoke night.”

He went on to explain:

We surveyed 20,000 of our users and asked them questions like, 'What is the biggest misconception that people have about Discord?' The resounding answer was that the biggest misconception is that Discord is only used for gaming.

So in 2020, we relaunched the company to tell the world how people on are doing so much more than playing video games. And with everything that happened with COVID, it dramatically accelerated that transition.

It’s fairly clear why Microsoft wants Discord; it is big in the gaming business through Xbox platform, but weak in the social media space (especially since its efforts to acquire TikTok seem to have petered out).  Microsoft CEO Satya Nadella told Bloomberg recently: “Creation, creation, creation — the next 10 years is going to be as much about creation as it is about consumption and about the community around it, so it’s not creating alone.”

Or, as VentureBeat put it, Microsoft’s objective with Discord is “community, community, community.”  Discord has them and Microsoft wants them. 

While most analyses of Microsoft’s interest focus around the gaming world, Bloomberg sees a broader play:

And as more young people grow up with operating systems, email, chat apps and productivity software from companies like Apple and Google, owning a community popular with that age group could acquaint them with Microsoft in a way their elders have been in the past because of Windows and Office.

This is where I substitute “Microsoft” for TelaDoc, UnitedHealth Group, or other healthcare companies. 

The healthcare world is awash in good feelings about telehealth, convinced that the pandemic has demonstrated that telehealth’s time may finally have come.  More people have tried it, more healthcare companies have embraced it, and more people agree that it is going to play a major part of healthcare’s future.  Virtual care models are exploding, both existing ones like TelaDoc or AmWell and a host of newcomers. 

Patient communities have been around as long as there have been online communities, such as PatientsLikeMe or a host of Facebook-based ones (although the latter not without controversy).  But communities built on a multi-faceted messaging platform, and that is popular with young people – no, we haven’t seen that in healthcare yet. 

People could use Discord to securely message with their physician or other healthcare professionals, or to be part of ongoing or episodic health-related communities. It may not have been designed for healthcare, but 2020 has shown us that Discord could easily be adopted for it.

Christophe Jammet, a managing director at Gather, told Bloomberg: “Microsoft buying Discord would be a really strategic move—it shows that Microsoft understands the power of community in the context of the pandemic.”

Do any healthcare companies understand the same thing? 

Even more important for healthcare, remember that Discord is ad-free, and that Mr. Citron stresses:

From the beginning, privacy has been built into Discord…We believe that people's data is their data and that people should feel comfortable and safe to have conversations and that their data is not going to be used against them in any way that is is improper.

That’s the attitude we should expect healthcare services to have.  

Microsoft would have many challenges if it were to acquire Discord, especially ensuring that users believe that it would remain agnostic towards gaming platforms and not (overtly) favor Xbox.  Yahoo Finance says: “By continuing to offer Discord as a neutral service, Microsoft could engender more good will from gamers while also getting its name in front of PlayStation and Nintendo players.”

The healthcare version of that could be: “By continuing to offer Discord as a neutral service, UnitedHealth Group could engender more good will from patients while also getting its name in front of CVS/Aetna and Anthem members.”

I have long advocated that healthcare desperately needs to prepare for its future by learning from the gaming world and by figuring out how to appeal to younger people (who may not yet be actively engaged with the healthcare system).  An acquisition of Discord by a healthcare company could accomplish both those goals with one acquisition.

The questions are, though: what healthcare company sees that future -- and is prepared to outbid Microsoft for Discord?