Let's Start Over

When I first read the reports about some Silicon Valley billionaires wanting to start a new city, I figured, oh, it’s just a bunch of rich white guys wanting to take their toys and go to a new, better home. After all, they’ve seen what’s been happening to downtown San Francisco (or Portland, or Chicago – pick your preferred city). 

The Jetsons' city as reimagined by Bing

Cities these days may be an what one expert calls an “urban doom loop” – struggling to recover after having been hollowed out by the pandemic. These so-called elites probably figured it’s easier to build something new rather than to try to fix what already exists.  And, you know, they may be right.  

Now that I think about it, the same may be true of our healthcare system.

The group, fronted by a mysterious entity called Flannery Associates, has been busy buying up land outside San Francisco for the past five years, spending a reported $1b for some 57,000 acres in Solano County. The proximity of its purchases to Travis Air Force Base had already raised concerns. Believed to be behind the group are a number of well known tech names, including LinkedIn co-founder Reid Hoffman; former Sequoia Capital partner Michael Moritz; venture capitalists Marc Andreessen and Chris Dixon; Stripe co-founders Patrick Collison and John Collison; Laurene Powell Jobs, Steve Jobs widow.

Rich white guys. Credit: Kats Weil/Unsplash

It doesn’t help that earlier this year Flannery sued dozens of local landowners for colluding to drive up prices, or that they’ve been so secretive. John Garamendi, one of the area’s Congressmen, said: “Flannery Associates has developed a very bad reputation in Solano County through their total secrecy and mistreatment of generational family farmers.”

The group finally went public with its intentions last week. “We are proud to partner on a project that aims to deliver good-paying jobs, affordable housing, clean energy, sustainable infrastructure, open space and a healthy environment to residents of Solano County,” said spokesman Brian Brokaw. “We are excited to start working with residents and elected officials, as well as with Travis Air Force Base, on making that happen.”

Most of the land is currently zoned for agricultural use, so getting permission for residential or other business uses will take some effort, which is why Flannery Associates is planning to meet with local, state, and federal officials.

The New York Times reported that Mr. Moritz spearheaded the effort in 2017, sending out a note: “He painted a kind of urban blank slate where everything from design to construction methods and new forms of governance could be rethought.” A poll sent out last week to Solano County residents asked if they’d be in favor of a ballot initiative that would “include a new city with tens of thousands of new homes, a large solar energy farm, orchards with over a million new trees, and over 10,000 acres of new parks and open space.”

What’s not to like?

If this is going to be another enclave of rich people, then I hope it never gets off the ground, after burning off lots of their money (not that they’d miss it). If they’re sincere about having a diverse city, all incomes and racial/ethnic backgrounds, then I’ll be watching closely. They have a chance to build new infrastructure (hint: include robust wastewater monitoring!), ensure safe and affordable housing for all, use renewable energy, design it for walkability, and fill it with plenty of green space. They could hire the good people at Building H to help “build health into everyday life.” And if they really want to impress me, they could even replicate/expand on Stockton’s universal basic income initiative.

But what are they going to do about health care?  What’s the point of building a 21^st century city from scratch only to overlay it with our 20^th century healthcare system -- the notoriously frugal Medi-Cal program, scads of employer health plans, and ACA individual plans, not to mention Medicare/Medicare Advantage for any seniors who happen to end up there. There’ll be lots of hospitals and specialists who might see the new city as a great chance to make lots of money from all those private pay patients. It will be our familiar mess.

No, if they want to do this right, they should rethink health care too. Here’s a few ideas they should consider:

Universal coverage: if you live in the community, you’re covered. No exceptions, no opt-outs, no ineligibles.  Think of it as their own group health plan.  They might need some Medicaid and Medicare waivers to do this right, but they should make this the first community where everyone is covered.

Wealth-based funding: everyone should participate in how the healthcare system is funded, but not through the inequitable premium system we’re used to but through taxes on income, wealth, and/or property.  No one should ever be priced out of coverage (or care).

Health, not medical: we always say “healthcare system” but what we mean is our medical care system. It’s built around doctors, hospitals, and other medical professionals and institutions. They’re all part of it, but they’ve become the tail that wags the dog. Nutrition, exercise, sleep, social support, and so many other factors contribute far more to our health. These shouldn’t be ancillary to the new system but integral to it, with medical care what happens only when those don’t suffice.

Primary care emphasis: the system should focus on recruiting (and retaining) enough primary care physicians (including OB/GYNs and mental health professionals) that waits are nominal, visits aren’t rushed, and primary care is the main locus of care. Forget traditional fee schedules/salaries; make income for primary care commensurate with its value.

Tech enabled: the Silicon Valley folks should love this: the system should be designed around the latest tech – e.g., virtual care. real-time monitoring (e.g., wearables), AI support, and so on, along with proactive Big Data analysis and recommendations. And do better than Epic!

Hospitals: to be honest, I’m not sure there should be any hospitals, at least not initially. Don’t build any big buildings that become capital sinks. Maybe let the Johns Hopkins (or other) experts design a Hospital At Home program that suits the community, keeping people in their homes. Only build physical hospital(s) when the population warrants it, and even then build them as small as possible. And certainly don’t let them employ physicians.

That’s not an all-encompassing list, but it’s a start.

That looks like 21st century care. Credit: Bing

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I’m not holding my breath that Flannery Associates will build their new utopia, but, let’s admit it, they have a better chance than they do to create a 21^st century healthcare system.

The Next Pandemic May Be an AI One

Since the early days of the pandemic, conspiracy theorists have charged that COVID was a manufactured bioweapon, either deliberately leaked or the result of an inadvertent lab leak. There’s been no evidence to support these speculations, but, alas, that is not to say that such bioweapons aren’t truly an existential threat.  And artificial intelligence (AI) may make the threat even worse.

AI in the lab. Create: Bing

Last week the Department of Defense issued its first ever Biodefense Posture Review.  It “recognizes that expanding biological threats, enabled by advances in life sciences and biotechnology, are among the many growing threats to national security that the U.S. military must address.  It goes on to note: “it is a vital interest of the United States to manage the risk of biological incidents, whether naturally occurring, accidental, or deliberate.” 

"We face an unprecedented number of complex biological threats," said Deborah Rosenblum, Assistant Secretary of Defense for Nuclear, Chemical, and Biological Defense Programs. "This review outlines significant reforms and lays the foundation for a resilient total force that deters the use of bioweapons, rapidly responds to natural outbreaks, and minimizes the global risk of laboratory accidents."

And you were worried we had to depend on the CDC and the NIH, especially now that Dr. Fauci is gone.  Never fear: the DoD is on the case. 

A key recommendation is establishment of – big surprise – a new coordinating body, the Biodefense Council. "The Biodefense Posture Review and the Biodefense Council will further enable the Department to deter biological weapons threats and, if needed, to operate in contaminated environments," said John Plumb, Assistant Secretary of Defense for Space Policy. He adds, "As biological threats become more common and more consequential, the BPR's reforms will advance our efforts not only to support the Joint Force, but also to strengthen collaboration with allies and partners."

Which is scarier: that DoD is planning to operate in “contaminated environments,” or that it expects these threats will become “more common and more consequential.” Welcome to the 21^st century.  

Let's get on all that, then. Credit: DoD

The report specifically calls out Iran, North Korea, the People’s Republic of China (PRC), and Russia as having the knowledge and capabilities for such weapons, and assesses that North Korea and Russia still possess offensive biological weapons (it suspects Iram does too, and notes that China considers biology “a new domain of war”). China and Russia “have also proven adept at manipulating the information space to inhibit attribution, to reduce trust and confidence in countermeasure effectiveness, and potentially to slow decision-making following deliberate use.”

It directs further attention to China: “The United States has compliance concerns with respect to PRC military medical institutions’ toxin research and development given their potential as a biothreat. The PRC has also released plans to make China the global leader in technologies like genetic engineering, precision medicine, and brain sciences.”

Asha M. George, executive director at the Bipartisan Commission on Biodefense, told The Washington Post. “I would not be surprised if by next year they’re saying China has some offensive biological weapons programs. Usually, they just say something like, you are concerned about dual use. And this year they didn’t do that,” He added that Russia remains an equally concerning threat.

Here’s where it gets really scary:

New technologies, such as big data, artificial intelligence, and genomic modification, have the potential to significantly influence the chemical, biological, radiological, and nuclear (CBRN) environment. Such technologies simultaneously offer the prospect for more effective, resilient, and cost-efficient military and civilian solutions while also representing potential new threats from state and non-state actors. The same biological and chemical science advancements created to develop life-saving medical countermeasures could also be used by potential adversaries to develop new or enhanced agents. Technologies intended to reduce testing and production inefficiencies, such as biofoundaries and additive manufacturing, create opportunities to reduce the development footprint and increase the number of proliferation pathways available to malign actors. In this way, emerging and disruptive technologies present both risks and opportunities to the United States, its allies, and partners.

Writing in Vox, Jonas Sandbrink, a biosecurity researcher at the University of Oxford, similarly warns: “large language models (LLMs) like ChatGPT, as well as novel AI-powered biological design tools, may significantly increase the risks from biological weapons and bioterrorism.” AI-powered biological design tools (BDTs), he says, “could allow the design of biological agents with unprecedented properties.”  E.g., ones without any evolutionary constraints or precedents.

Obviously, we need more and better oversight over not just bioweapons but also AI generally, but the fear is that bad actors – whether nations or malign individuals/groups – probably won’t feel constrained by any rules or guidelines such oversight degrees.  Even U.S. Senators, not known for their technical prowess, expressed alarm in a recent hearing.  

One witness at the hearing, Dario Amodei, chief executive of the AI company Anthropic, warned: “certain steps in bioweapons production involve knowledge that can't be found on Google or in textbooks and requires a high level of expertise. We found that today's AI tools can fill in some of these steps.”  He thinks an AI-bioweapon is a “medium-term risk,” and by that he meant: “Whatever we do, it has to happen fast…I would really target 2025, 2026, maybe even some chance of 2024.”

The only thing that has remotely offered me any hope is that, whatever DoD or others are doing, DARPA is already working on it.  It established its Biological Technologies Office (BTO) in 2014, recognizing “the vanishing of once longstanding gaps between the life sciences, engineering, and computing disciplines.” One of the key capabilities DARPA is focusing on “is creating innovative biotechnological approaches to rapidly detect and characterize these threats, preventing surprise and maintaining force readiness.”

Credit: BTO, DARPA

Sure, DARPA is focused on the military, but if its work on the Internet and GPS, among others, ended up with wide-reaching civilian applications, one would hope that its efforts here would as well.  There’s no point to the military surviving a bioweapon attack if all the civilians end up dead.

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With synthetic biology, gene editing, and other biological tools, creating bioweapons is or will soon become much easier, and perhaps much more powerful, than building nuclear weapons. With AI, that will happen much quicker and perhaps become even more dangerous. 

The genie is not going back in the box. We’re not going to unlearn all we now know about manipulating biology. We’re not going to stop using AI. Like all tools, though, they’re neither good nor evil; only how we use them is. Let’s hope we use these right.

What Robotaxis Mean for Healthcare

You may have seen that last week the California Public Utilities Commission (CPUC) gave approval for two companies to operate self-driving taxicabs (“robotaxis”) in San Francisco, available 24/7 and able to charge fares.  Think Uber or Lyft but without drivers.

Meet the future. Credit: Waymo LLC

It has seemed inevitable for several years now, yet we’re not really ready.  It reminds me, of course, of how the future is coming fast for healthcare too, especially around artificial intelligence, and we’re not really ready for that either.

The two companies, Cruise (owned by GM) and Waymo (owned by Alphabet) have been testing the service for some time, under certain restrictions, and this approval loosens (but does not completely remove) the restrictions. The approval was not without controversy; indeed, the San Francisco police and fire departments,  among others, opposed it. "They are failing to regulate a dangerous, nascent industry," said Justin Kloczko, a tech and privacy advocate for consumer protection non-profit Consumer Watchdog.  

The companies brag about their record of no fatalities, but the San Francisco Municipal Transportation Agency has collected almost 600 “incidents” involving autonomous vehicles, even with what they believe is very incomplete reporting.  “While we do not yet have the data to judge AVs against the standard human drivers are setting,” CPUC Commissioner John Reynolds admitted, “I do believe in the potential of this technology to increase safety on the roadway.”

Credit: Cruise LLC

I’m willing to stipulate that autonomous vehicle technology is not quite there yet, especially when mostly surrounded by human-driven vehicles, but I also have great confidence that we’ll get there quickly, and that it will radically change not just our driving but also our desire for owning vehicles.

One of the most thoughtful discussions I’ve on the topic is from David Zipper in The Atlantic. He posits:

A century ago, the U.S. began rearranging its cities to accommodate the most futuristic vehicles of the era, privately owned automobiles—making decisions that have undermined urban life ever since. Robotaxis could prove equally transformative, which makes proceeding with caution all the more necessary.

A century ago, cities didn’t really have speed limits, vehicle-only streets, parking spaces/lots/garages, and certainly not freeways cutting through city neighborhoods.  He notes: “More than half of the land in many downtowns is used to move and store motor vehicles, occupying space that could otherwise accommodate housing, retail, playgrounds, and parks.” 

Mr. Zimmer warns that wider use of autonomous vehicles could lead to more miles driven, and much less public transit used.  He cites a 2018 quote from Frank Chen, of Andreessen Horowitz:   “We don’t understand the economics of self-driving cars because we haven’t experienced them yet. Let’s see how it plays out.”  But waiting to see how the future plays out often means not really planning for it.

If we were certain that in, say, 10-15 years, most vehicles would be autonomous, or at least could communicate/coordinate with each other, we’d be making different investments in things like smart roads, speed enforcement cameras, traffic police, or – you guessed it -- parking.  Some of those investments take years to bring about, so we’d better lay out bets down soon if we want to be ready. We can’t even seem to get our heads around a future with largely electric vehicles (EVs) – e.g., where are all the charging stations? – so preparing for autonomous vehicles seems like a future we’re not thinking enough about.

Which leads me to healthcare. 

For example, one of my pet peeves about the discussions of using AI in healthcare are the ones about how they’ll help with “paperwork.”  AI will take care of physician notes!  AI will handle all the prior authorization requests!  AI will help fill out all those patient forms!  All of those, and many more, certainly reflect 2023 pain points in healthcare, but they’re missing the future.  AI should not do the paperwork, hiding it from us; it should help us eliminate the need for it.  Don’t use AI to make the system work faster, use AI to make the system more efficient and effective.

Don't do this. Credit: Bing

In an AI world, for example, there should never be a question about a patient’s eligibility or available benefits; we’d know those in real time. Similarly, I don’t think there will be a role for claims processing as we know it; instead, we’d have real time adjudication and payment.  Don’t even get me started on what we now ludicrously call “price transparency;” AI will take all the guesswork out.

Buildings are healthcare’s version of cities’ parking lots.  We require a lot of them, be they hospitals, medical office buildings, or others, because patients usually have to be in such places to get care. They’re also like parking because much of what patients do in them is wait.

The future healthcare system is going to be much more distributed. Care will shift from being given in a place where health care professionals are to where you and your devices are, with those devices omnipresent, connected, and smart.  They will sometimes but not always interact with human clinicians.  So which buildings go, when? 

Healthcare will also be much more proactive and predictive. Impressed with what your Apple Watch can monitor?   That’s nothing compared to the monitoring we’ll have available in the near future, including those long-predicted nanobots swimming around in us. We’ll know how we’re doing, we’ll know how we’re trending, and in many cases we’ll know well in advance when it is time to take action.

AI will also help us make better predictions about which people are going to need expensive care, when, which will have dramatic impacts on how health insurance works and when it is actually needed.  Plan for that future.

My last warning, which I’ve touched on before, is how AI impacts payment.  Right now some argue we should treat AI as medical devices, regulating and paying along the same lines. Others want more CPT codes for AI, building on our existing mess of that system.  Neither of those are anticipating the future; they’re trying to lock in the present.

You're pricing AI wrong. Credit: Bing

We should be thinking about pricing AI as the technology that it is, which should get cheaper yet more powerful as time goes by. If the AMA, through its CPT Editorial Panel, gets to decide how AI is priced, God help us and our healthcare system. 

We’re not ready for self-driving cars, or for AI in healthcare, which is understandable given that both have a long way to go.  But the future comes at us fast, so if we’re not preparing now we’ll be too late.

I Want a Lazy Girl Job Too

I came across a phrase the other day that is so evocative, so delicious, that I had to write about it: “lazy girl job,” or, as you might know it. @#lazygirljob.

Image by Amarily Moreno from Pixabay

Now, before anyone gets too offended, it’s not about labeling girls as lazy; it’s not really even about lazy or even only girls.  It’s about wanting jobs with the proverbial work-life balance: jobs that pay decently, don’t require crazy hours, and give employees flexibility to manage the other parts of their lives.  Author Eliza Van Cort told Bryan Robinson, writing in Forbes: “The phrasing ‘lazy girl job’ is less than ideal—prioritizing your mental health and work-life integration is NOT lazy.”

The concept is attributed to Gabrielle Judge, who coined it on TikTok back in May (which is why I didn’t hear about it until recently).  According to her, it means not living paycheck to paycheck or having to work in unsafe conditions. She believes job flexibility doesn’t mean coming in at 10 am instead of 9 am because you have a dentist appointment; it means you have more control over your hours and when you get your work done. If Sheryl Sandberg was all about “leaning in,” Ms. Judge is about leaning out. 

Ms. Judge explained to NBC News:

Decentering your 9-to-5 from your identity is so important because if you don’t, then you’re kind of putting your eggs all in one basket that you can’t necessarily control. So it’s like, how can we stay neutral to what’s going on in our jobs, still show up and do them, but maybe it’s not 100% of who we are 24/7?

“I’m only accepting the soft life, period,” she says.

Danielle Roberts, another TikToker and who describes herself as an “anti-career” coach, told NBC News: “And rather than calling the people who are divesting from that system lazy, and telling them that they just need to work harder, we need to talk about why it’s a trend in the first place and go one level deeper.”

She went on to explain:

We’ve seen that the 40-hour work week is now outdated. We can produce the same amount of work, if not more work, in a fraction of the time. So wanting to keep those butts in seats, and not just for 40 hours, but for 40-plus hours, is just really a means of control. If you hired them, you should trust your employees to do their job and do it well.

It’s not only the work week that is outdated, but also the concept of loyalty. Ms. Judge told NBC Los Angeles: “The whole lazy girl job thing is a thing because it's a two-way street. Like of course this is attractive to employees, but there's a reason why this was caused and that's because employers in general just can't hold their weight when it comes to company loyalty like they used to be able to traditionally.”

Hailey Bouche, writing in The EveryGirl, makes an even stronger point:

Things like work-life balance and reasonable pay shouldn’t be considered luxuries. We all deserve jobs that give us access to the benefits, flexibility, and salary that we need to live a fulfilled life—and having or wanting a job that allows us all of those things does not make us lazy.

Amen.

Image by Rosy from Pixabay

It's a Gen Z thing, of course, as is/was “quiet quitting.”  The cultural zeitgeist that was already bubbling up around all this got supercharged by the pandemic, when many people were forced to work from home and work suddenly seemed less important. 

But this trend is broader than Gen Z girls or even Gen Z generally. A recent Gallop poll found that 6 in 10 workers admit they aren’t putting in maximum effort, and that their biggest complaint was workplace culture. As The Wall Street Journal headlined it last week: Workers to Employers: We’re Just Not That Into You.

The WSJ article cites a number of workplace trends, such as more employers are offering the option to work remotely, more employees are taking it, employees, employees are taking more vacation and have more options for paid time off. And, perhaps as a result, the Conference Board found that worker satisfaction rose sharply in 2022 and is now at its highest point since 1987.

Another WSJ article reported that companies that allowed at least one day or remote work per week increased staffing twice as fast as those requiring full-time office requirements.  “One of the more straightforward potential explanations is that people put a really high value on being remote and generally having flexibility, so recruitment is likely quite a bit easier,” Emma Harrington, a University of Virginia economist, told WSJ.

President Biden evidently is missing out on the #lazygirlsjobs trend too, since he’s pushing to get federal workers back in the office by this fall. Other organizations and other CEOs feel the same, wanting things to go back to “normal,” or at least more directly under their control, in the office.  But that genie may be out of the bottle.

@lazygirlsrule

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There are plenty of lazy girl jobs in healthcare, or, at least, ones that could be.  “Administrators” – whether they’re billing clerks, claims processors, marketing experts, or managers – far outnumber people actually delivering care in every part of the healthcare system, and there’s no reason many of those jobs couldn’t be made to qualify.

When it comes to the people delivering our care, though, we want them to be where we want them when we need them, for as long as we need them. Physicians, in particular, are known for working long hours, being responsible for life-and-death decisions, and suffering the stress with comes from all that. Well, no wonder physician burnout is a real problem, as it is for nurses and other front-line healthcare professionals. 

Healthcare professionals haven’t fled their jobs in any great numbers yet, although the warnings are there. Healthcare doesn’t have its Gabrielle Judge yet, there’s no #lazydoctorjob meme (that I am aware of), but the societal trends that caused #lazygirljobs are going to impact healthcare too, and we better figure out what we want that to mean.