Spotify, Joe Rogan, and Healthcare

Here’s a sentence I never thought I’d have to write: the most interesting discussion in healthcare in the past week has been about Neil Young versus Spotify. 

For those of you who have not been following the controversy, Neil Young gave Spotify an ultimatum: it could have his music or Joe Rogan, but not both.  “I am doing this because Spotify is spreading fake information about vaccines – potentially causing death to those who believe the disinformation being spread by them.”  Spotify chose Rogan.

Mr. Young was not the first to express alarm at some of the Covid “information” promoted on Mr. Rogan’s podcast, The Joe Rogan Experience (JRE); in December, for example, several hundred scientists from around the world issued an open letter to Spotify specifically about JRE, warning:

By allowing the propagation of false and societally harmful assertions, Spotify is enabling its hosted media to damage public trust in scientific research and sow doubt in the credibility of data-driven guidance offered by medical professionals.

Nor is Mr. Young the only artist now boycotting Spotify due to the content on JRE; Joni Mitchell and Nils Lofgren have followed suit.  Notably, though, more current artists like Taylor Swift or Adele have not yet, nor have celebrity podcasters like Meghan Markel and Prince Harry or the Obamas, although the former royal couple have expressed their concerns.

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To put things in context, Mr. Young is risking some 60% of his streaming income, estimated at around $750,000 annually, whereas Mr. Rogan has a $100 million deal with Spotify for his 11 million faithful listeners.  It evidently wasn’t a hard decision.  Spotify lost as much as $4b in market cap last week but seems to have fully recovered.

Mr. Rogan has issued regrets, of sorts, not really apologizing but sorry if some people were offended.  He’s not anti-vaxx, he claims, but just wants to get alternative information discussed and debated.  He admits he doesn’t do much research prior to a guest coming on the podcast, claims he doesn’t try to be controversial, but hopes to try to offer more balanced discussions.

Spotify also has issued its own mea culpa, not planning to censor more content but, when it comes to COVID-19 topics, at least directing people to its Covid-19 Hub for “easy access to data-driven facts, up-to-date information as shared by scientists, physicians, academics and public health authorities around the world, as well as links to trusted sources.” 

Show’s over, folks.  Nothing to see here.  Move along.

I don’t have a Spotify account.  The only podcast I pay attention to is THCB Gang (which, by the way, you can listen to on Spotify).  I doubt that many people listen to JRE to be educated; more likely, they tune in to be entertained, and, perhaps, to harden existing views that may be out of the “mainstream.”  To be honest, I’m not even that big a Neil Young fan, and the last time I really watched Joe Rogan was on NewsRadio.  But I do think what Mr. Young has done is important.

The COVID-19 anti-vaxx movement threatens everyone.  We’d still be living with polio and measles if such distrust had existed a few decades ago.  As anyone could have predicted, controversy over requiring vaccines for other diseases is widening, with state legislators already working on bills that could weaken existing requirements, such as for measles.  “Measles is like a jam jar full of wasps that is raging to get out,” Professor Liam Smeeth of the London School of Hygiene and Tropical Medicine warned CNBC. “The minute vaccine coverage drops, measles will reappear. So that is a worry, that that [Covid anti-vax sentiment] and that dent in confidence is seeping across into other vaccines. That is a real worry.”

The scientists who signed the open letter to Spotify opened themselves up to criticism, but Mr. Young put his income at risk.  It’s not like his music isn’t available elsewhere, but a loss of $750,000 annually would get most people’s attention.  He was already critical of Spotify for what he perceived as issues with sound quality, so perhaps there are other motives here, but I’ll choose to believe that he’s willing to take the loss of income "in solidarity with the frontline healthcare workers who risk their lives every day to help others."

Bravo.

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In my opinion, though, this is even broader than COVID misinformation, and we shouldn’t be relying on musicians for moral leadership in healthcare.  People working in healthcare need to be willing to walk away from some of their income when they see things that are wrong.

In the midst of incredible bravery and sacrifice by frontline healthcare workers throughout the pandemic, there are some physicians who have spread misinformation and promoted remedies that are at best useless and at worst harmful.  Where are the healthcare workers who resign rather than be associated with them?  Where are the medical boards who believe that such practitioners are still deserving of their medical license?

And, let’s be clear, there are physicians who do such things outside of COVID.  They do surgeries that aren’t necessary, they promote cures that aren’t, they treat conditions they don’t really have qualifications for.  Unless something particular egregious happens, we allow it, because once physicians get a license, it’s awfully hard to take it back.  Doctors don’t like to criticize, much less penalize, other doctors.

Similarly, there are hospitals who sue patients for unpaid bills, even when those bills are based on charges that no one really ever expects to have to be paid in full.  There are hospitals who contracted with, say, emergency room practices or anesthesiology groups who, they knew, would be issuing “surprise” bills to patients (at least, before the No Surprise Act). The medical staffs can claim, oh, we didn’t know about these practices, but, yeah, they probably did, or at least choose to look away. 

There are people – physicians and others – working in health insurances companies that deny treatments for critically ill patients, or make them jump through needless loops that they don’t have time or energy for.  Who in those companies are fighting for those patients, risking how much?

There are way too many situations when people in healthcare should be pulling Neil Youngs and walking away -- noisily. 

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It takes courage to speak up about injustices and dangerous practices.  When someone puts their income at stake in doing so, all-the-more.  Healthcare has a lot of things that need to be spoken up about and stood up against.  If not now, when, and if not us, who? 

The Tests Were a Test

Raise your hand if you’ve gone out shopping for home COVID tests, only to find empty shelves and signs apologizing for the lack of availability.  Raise your hand if you’ve been able to obtain one, but were surprised at its cost.  Raise your hand if you took one and weren’t quite sure you did it right, or wondered who, if anyone, would be getting the results.

Vox says that the COVID home test reimbursement process “is a microcosm of US health care,” and I think they’ve understated the situation.  Testing has been a microcosm for the US health care system generally.  It was a test, and our healthcare system failed.

Throughout the pandemic, we’ve never had enough tests or done enough testing.  You could start back in the early days when snafus in the CDC/FDA meant there weren’t approved tests quickly enough, or how, even when tests become more available, we didn’t do enough to keep ahead of COVID’s spread.  By the time we knew COVID had penetrated a nursing home or a community, it was too late.  We didn’t take advantage of macro-tracking approaches like wastewater monitoring.

We developed “rapid” tests but questioned their accuracy.  The “gold standard” PCR tests took/takes too long to return results.  As we encountered the highly transmissible variant Omicron, we didn’t scale up the production of tests – or the labs to process them -- enough to keep up with the demand, much less with the number of acquired cases.  We had, and continue to have, leaders at both the state and federal level criticizing testing, suggesting that the problem is not too many cases but too many tests. 

In our free-for-all pricing system, it’s anyone’s guess what a test might cost.  Most PCR tests have been required to be covered “first dollar” by insurance plans, so consumers haven’t been immediately faced with how much those tests cost, but costs picked by insurance end up in premiums eventually.  Home tests have not been, and costs might vary ten-fold or more depending on the manufacturer and/or seller. 

The Biden Administration has belatedly attempted to address these problems, but in a ham-handed way that is also typical for our healthcare system.  Earlier this month, it set up a system to for each household to order 4 free home tests.  The goal is to have 500 million, perhaps a billion, such tests available, although whether it has actually procured anywhere near that number is unclear.

The Biden Administration also required private insurers – but not Medicare -- to pay for 8 home tests per member per month, which seems to have come as a surprise to the insurers.  In many, perhaps most, cases, individuals would have to submit claims to their insurer to get reimbursed for these tests.  Insurers only have to pay up to $12 per test; consumers must pay anything above that.  Surprise!

When I read about that process, as a former health insurance executive, I immediately thought: that is not going to work.

There was a time when people submitting their own claims to their health insurer was not atypical.  Insurers used to refer to the “shoebox effect,” where people would save their receipts in a literal or metaphorical shoebox and send them in en masse, often at the end of the year, and armies of claim examiners would process them.  Between the development of preferred networks and electronic submission of claims, though, those days are long gone.  Indeed, one of the reasons that network plans like HMOs and PPOs became popular was because they didn’t require members to file claims.

These days, few companies have staffs of claim examiners sitting around trying to decipher paper claims, much less the processes to receive and sort them.  The fact that the rules were announced on a Monday but went into effect on the following Saturday made things worse.  Ceci Connolly, president and C.E.O. of the Alliance of Community Health Plans, told The New York Times: “It is going to be exceedingly difficult for most health plans to implement this in four days.”  No kidding.

What documentation needs to be submitted (receipts, product codes, pictures of the test, etc.), and how, are still unclear, and will vary between health insurers.  A survey of 13 major health insurers by the Kaiser Family Foundation found that 6 had some form of “direct reimbursement” (e.g., pay nothing upfront and network pharmacies deal with payment), 4 required claims to be mailed or faxed, and 2 had an online submission option.  KFF couldn’t determine what the remaining insurer required.

As you can imagine the Twitterverse found the fax option ludicrous…as it is.

As bad as all that is, we now have a scenario where there are potentially hundreds of millions of tests being taken, but no system for tracking how many are used, by who, or how many positive results there are.  We thought we were doing a bad job counting how many people have received how many doses of the vaccine, but at least there was some reporting system in place.  With these tests, we’re pretty much going to be in the dark.  We’ll never know how many positive cases we’ve had.

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Initially, we had no testing strategy.  Then our testing strategy was just “get tested,” with no  supporting tactics to make that feasible.  Then, almost 2 years in, we get grand announcements about directly providing free tests, but not enough for everyone, plus mandates on insurers for more free tests that don’t do anything to make the tests more available, affordable, or easy to get reimbursed for.

Yeah, all that sounds like a microcosm of our healthcare system.  As Vox put it, “It’s a needlessly complicated process that provides little benefit but creates plenty of problems.”

Countries with universal coverage have an easier time.  They can negotiate the price and dictate where and how their citizens can obtain tests.  We prefer, or, at least, choose to tolerate, a fragmented system where even getting tests during a pandemic ends up putting the burden on us.   

Shame on us.  It’s not just the healthcare system that failed the test.

DAOs May Rescue Healthcare

You may have seen the news that Kaiser Permanente has signed on to be an organizing member of Graphite Health, joining SSM Health, Presbyterian Healthcare Services, and Intermountain Healthcare.  Graphite Health, in case you missed its October launch announcement, is “a member-led company intent on transforming digital health care to improve patient outcomes and lower costs,” focusing on health care interoperability. 

That’s all very encouraging, but I’m wondering why it isn’t a DAO.  In fact, I’m wondering why there aren’t more DAOs in healthcare generally.

For those of you not yet on the Web3/crypto bandwagon, a DAO is a “decentralized autonomous organization.”  Cointelegraph defines DAOs as “internet-native organizations collectively owned and managed by their members…Decisions are made via proposals the group votes on during a specified period.”  There is no hierarchy – decisions get made “bottom-up” -- and they are intended to operate via blockchain-powered smart contracts. 

Cointelegraph goes on to explain:

One significant advantage of DAOs is the lack of trust needed between two parties. While a traditional organization requires a lot of trust in the people behind it — especially on behalf of investors — with DAOs, only the code needs to be trusted.

Trusting that code is easier to do as it’s publicly available and can be extensively tested before launch. Every action a DAO takes after being launched has to be approved by the community and is completely transparent and verifiable.

I touched upon DAOs in a previous article on Web3. 

Credit: Graphite Health

Graphite Health seeks to create “a standardized, interoperable data platform that enables a secure and open marketplace to streamline the distribution of digital health solutions for both health systems and entrepreneurs.”  CEO Dr. Ries Robinson said” “Right now, when a hospital wants to adopt new innovative solutions, it is hampered by overly cumbersome processes that can require years to implement.”

Dan Liljenquist, a Graphite Health board member and SVP/Chief Strategy Officer at Intermountain, added:

Graphite Health is more than a new start-up, it represents a new approach to solving one of our long-standing national problems: health care is too expensive and inconvenient. By embracing the collective membership approach, and committing to our Digital Hippocratic Oath, we will ensure patients are treated as people rather than products.

The Kaiser announcement specifically praised Graphite Health “focus on trust and transparency.”

Let’s see: it wants to streamline innovative digital solutions, represent a new approach to solving problems, focus on trust and transparency, and embrace the collective membership approach.  If that doesn’t sound like a job for a DAO, I’ve misunderstood their purpose.

Graphite Health has certainly hit on a big problem in healthcare – the lack of interoperability for health records – but instead of ensuring that ownership of, and control over, patient records belongs to, you know, the patients, they’ve set up a new organization overseen by four very large healthcare organizations.  I don’t question the motives of the various executives involved, and credit them for trying something different, but the approach doesn’t take away the kind of hierarchy we’ve seen in healthcare for decades. 

Graphite Health credits Civica Rx as an inspiration, as it used a health care utility model to try to improve the supply and cost of prescription drugs.  That model had four tenets:

1. Nobody would own the company.
2. Everyone would be charged the same price and there would be no special deals.
3. The company decided to go big and go long.
4. The purchasers of the products would become the funders of the company.

Again, that’s all very noble, but when compared to a DAO, with its decentralized decision making and inclusion of all stakeholders, it doesn’t seem as innovative as it could be. It’s still the corporate owners running the show.

When Cointelegraph says that, in DAOs, “decisions get made from the bottom-up; a collective of members owns the organization,” when it comes to healthcare data and data standards, I’d hope that those members aren’t big healthcare organizations.  Isn’t that how we got to where we are?

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This should be a time for trying something truly different.  Joan Westenberg, writing in The Next Web, discusses how Web3/DAOs could be a “blessing” for the music industry.  Over the last 20+ years, peer-to-peer file transfers and streaming have wreaked havoc on revenues in that industry, especially those received by musicians, but “the founders and CEOs of the world’s music companies make more money than any of the top musicians.” 

The music industry already has a DAO. Credit: MODA DAO

She believes: “For the music industry to thrive in the future, it needs to find a way to distribute revenue that properly incentivizes all participants in the ecosystem, from artists and fans to technologists and investors.”

Ms. Westenberg believes that way could be DAOs:

DAOs would allow artists, consumers, and other stakeholders to interact directly with one another without the need for third-party intermediaries.

DAOs could help to rectify music industry imbalances by giving artists a direct say in how their work is distributed and consumed, giving audiences a direct connection to the musicians they support, and giving infrastructure layers such as management and record companies a chance to collaborate with their core demographics and get closer to the music itself than ever before.

DAOs could be used to distribute profits more fairly within the music industry.

Whether it’s the music industry or healthcare, when you’ve got the wrong people – CEOs and other executives -- making the most money, consumers feeling they are paying too much and having too little input/control, the people doing the actual work feeling undervalued, no one quite trusting each other and everything taking way too long, it’s time to be looking for radically different solutions. 

Like DAOs.

Dave Chase, for example, believes his Health Rosetta project will be a “DAO of DAOs, including community owned health plans, calling for “#DeHealth (i.e., decentralized health)”

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There aren’t, to my knowledge, any DAOs in healthcare yet.  It’s not entirely clear to me how many successful DAOs there are in the world generally.  We certainly haven’t worked out all the kinks in blockchain yet, nor proven the efficacy of smart contracts on a large scale basis.  I admit all that.

But one thing is clear to me: we are not going to solve healthcare’s problems by using the approaches we’ve been using, run by the entities who have been running healthcare.  So, yeah: if we want innovative approaches in healthcare, we should give DAOs a try.

What a Waste of a Healthcare System

An essay in Aeon had me at the title: The Waste Age.  The title was so evocative of the world we live in that I almost didn’t need to read further, but I’m glad I did, and I encourage you to do the same.  Because if we don’t learn to deal with waste – and, as the author urges, design for it – our future looks pretty grim.

Medical waste at scale

Healthcare included.

The essay is by Justin McGuirk, chief curator of the Design Museum in London, and accompanies an exhibit there: Waste Age: what can design do?  Mr. McGuirk states:

…waste is not merely a byproduct of culture: it is culture. We have produced a culture of waste. To focus our gaze on waste is not an act of morbid negativity; it is an act of cultural realism. If waste is the mesh that entangles nature and culture, it’s necessarily the defining material of our time. We live in the Waste Age.

He recaps some of the depressing facts about how much waste our society produces, and how this throwaway culture we’ve grown used to is a fairly modern development.  Like it or not, Mr. McGuirk points out: “To say that we live in the Waste Age is not to focus attention on an unpleasant but marginal problem; it’s to say that the production of waste is central to our way of life.”

We can blame capitalism, we can blame consumers, we can blame our typical shortsightedness, but to Mr. McGuirk, waste is, to a large extent, a design issue: “Design has been a driving forces behind our prodigious waste streams in the past century…In short, they’ve been doing what designers do best – creating desire.”

Design must change, he says, and designers must as well, reinventing “themselves as material researchers, waste-stream investigators and students of global economic flows.”  It is not enough to ask how something will look when new or how it will be used, but what will happen to it over time and how it/parts of it can be recycled/reused.

Powerful stuff.  Although Mr. McGuirk’s examples skew heavily towards common waste culprits like plastics and electronic products, I can’t help but think about healthcare, because when I think about healthcare, we’ve been living in The Waste Age for some time.

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Some of this is well recognized.  For example, there has been grudging acknowledgement for years that, in the U.S. healthcare system, as much of a third of our spending is “waste” (see, for example, Shrank, et. alia). We get procedures we don’t need, have tests that are duplicative, take too many prescriptions, use the ER instead of an office visit, and so on.  We waste too much of our time waiting.  We have too many healthcare facilities in heavily populated areas – and are building more – and not enough in less populated areas.  Our administrative costs are much too high.

Waste defines our healthcare system.

Some of this is known but not often thought about: the actual waste our healthcare system produces.  It has been estimated that each staffed hospital bed generates 33 pounds of medical waste each day, resulting in 5.9 million tons per year – and that doesn’t count waste from nursing homes, doctors’ offices, pharmacies, and other healthcare facilities.  For example, there are over 16 million injections annually (worldwide), and those needles and syringes end up somewhere.  Even worse, about 15% of medical waste is considered infectious, toxic, or even radioactive.   

You and I generate medical waste.  A surprisingly large amount of those prescriptions we take, or flush down the toilet, end up in the water.  We’d like to think that our water treatment plants remove these traces of pharmaceuticals, for the most part, that’s not true.  They end up back inside us.  The problem is worse than that. Antidepressants, for example, have been found to impact crabs’ behavior.  Some fish have built up high levels of pharmaceuticals.

Even worse, a number of us take prescriptions that don’t benefit the majority of us, and may actually result in some harm (e.g., statins for low risk individuals, not to mention all the antibiotics taken for viral infections). They’re just wasted.

We’re not even mining the waste we produce for valuable information it can provide.  Even in a pandemic, where is our wastewater monitoring to detect and pinpoint outbreaks? In a time of digital health, where are our smart toilets to help us track changes in our health? 

Mr. McGuirk discusses plastics and microplastics as a huge problem.  As I wrote in 2020, microplastics are everywhere: in the air, in the ocean, in the land, in the water we drink, in the food we eat, and, at this point, probably in our cells.  No one really knows what the impact on all this waste is/will be on our health, but I’m betting it won’t be good. 

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Mr. McGuirk writes: “it [waste] is now an internality – internal to every ecosystem and every digestive system from marine micro-organisms to humans.”  It needs, he urges, to become a central issue, “brought into the heart of every conversation about how things are extracted, designed and disposed of.”

As Mr. McGuirk suggests more generally, design can help. For any physical object in the healthcare system – from pills to devices to buildings -- designers need to view it “as a vehicle towards understanding the complex systems that produce it, and the even more opaque systems that dispose of it.”  All designers -- healthcare included -- need to be thinking about what happens to their products and their packaging; otherwise, they may generate, at best, those pesky microplastics and, at worse, even more toxic waste.

Waste isn’t just what happens to physical objects. When it is our health or the health of a loved one, we think “more is better” -- damn the waste, damn the potential adverse consequences. 

We’re going to learn how to temper our expectations. Our clinicians need to learn how to avoid the “more is better” mindset and how to help us understand cost/benefit tradeoffs. We’re going to have to be more discerning about when what we think we want in healthcare may actually be wasteful.

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Our current healthcare system is not sustainable – not from an ecological, economic, or even health standpoint. For it to survive, we must design for The Waste Age.

To close with Mr. McGuirk: “Recognising that waste is central, not peripheral, to everything we design, make and do is key to transforming the future.”

The Simpsons Explain Healthcare

 Happy New Year!  We’re starting 2022 full of hope and renewed optimism. Oh, wait; not so much. We’re not only still in a pandemic, the Omicron variant is the most infectious one yet.  Daily cases are setting new records. Our hospitals are full again. Our beleaguered healthcare workers – the ones who haven’t already thrown in the towel – are at their breaking points.  Two years in, and we still don’t have enough tests. We’re in the greatest public health crisis in a century, yet our legislators are taking power away from public health officials, and their angry constituents are forcing many of those officials to quit. We have effective vaccines, but millions still refuse to take them.

The Simpsons – specially, Homer -- has the right word for this: D’oh!

Homer Simpson Credit: Groening/Disney

Even those who are not Simpsons fans – and I don’t know who these people are – are probably aware of the show. At over 700 episodes and 33 seasons, it is the longest running American animated series, sit-com, and primetime television series.  The titular head of the family is the hapless, impulse-driven Homer, who is most associated with the expression “D’oh.”

Merriam-Webster defines “Doh” as an interjection “used to express sudden recognition of a foolish blunder or an ironic turn of events.”  One analysis found that if Homer were a real person, his various healthcare experiences over the years would have cost him over $143m, giving him plenty of opportunity for D’ohs.

D'oh!

Got a medical bill that seems outrageously high?  D’oh!  Your insurance won’t cover some procedure that you or a family member needs?  D’oh!  Can’t afford to see a doctor, fill a prescription, or buy insurance? D’oh! Have to wait days, weeks, even months to get an medical appointment?  D’oh! Have to carry your health records around on a CD or paper because your doctor’s/health system’s EHR doesn’t communicate with your other doctors’/health systems’ EHRs?  D’oh!

You have your own stories.  You’ve had your own frustrations.  You may even have your own favorite expression (or expletive) to use when running up against the healthcare system. But I prefer “D’oh,” because, as with Homer Simpson, at the end of the day we have ourselves to blame for the mess we’re in.

There’s another Simpsons clip that may help explain. You can watch the clip below, but, briefly, Homer gets his arm stuck in a vending machine trying to get a free soda. Emergency personnel are summoned, and they literally are about to cut his arm off when an EMS worker realizes that the problem is that Homer has refused to let go of the soda can. 

The question for us is, what is the metaphorical soda can in our healthcare system that we so tenaciously continue to hold onto, even at the risk to our health and lives?

Some might say it is our failure to implement universal healthcare, as almost every other developed country has done. It’s baffling that, even after ACA, we’ve got close to 30 million people without coverage, and there’s no political will to change that. It’s worse than baffling – it’s horrifying – that 12 states still haven’t expanded Medicaid, as ACA allowed/paid for, which would protect their most vulnerable citizens. But, even in states that have expanded Medicaid, affordable coverage is available to everyone, yet not everyone takes it.

Others might say it is our continued reliance on fee-for-service payment, which critics believe encourages overuse. We’ve tried capitation, we’re still trying value-based payment, and yet fee-for-service continues to dominate. But that doesn’t make our healthcare system different than most other countries’ systems.

Maybe it is that we act as though quality is a given: my doctor is the best, our hospital is just fine for any care, when, in fact, quality of care varies greatly and it very much matters what care you get and from whom you get it. “Quality” in healthcare is surprisingly amorphous; similar to Justice Potter Stewart’s belief about obscenity: we think we know it when we see it. We don’t. But, again, that’s true in every healthcare system.

Credit: Caitlin Hillyard/KHN illustration; Getty Images

A strong argument can be made that the foolish thing we persist in is allowing so many payors to each negotiate its own rates with health care providers. It’s well documented that Americans pay far more for healthcare products and services than anywhere else. We don’t have too many doctors, we don’t have too many hospitals, we don’t get too many procedures or tests, we don’t take too many prescriptions. We just pay way too much each of the times we do any of these.  As Dan Munro, author of Casino Healthcare, likes to say, we don’t need single payor, we need single pricing.  But, then again, we don’t have that kind of single pricing for anything else – not food, not energy, not water, or any other essential products and services.

And therein, I think, lies our real problem, the soda can to which we persist in holding on to no matter what. America preaches individualism, of the ability for anyone to “make it” here.  We claim to treasure self-reliance, and look skeptically at government help (except, of course, Social Security, Medicare, or disaster relief). 

We know we should lead healthier lives, but most of us don’t.  We know we should listen to the experts, including our doctors, but as the current pandemic is proving, too many of us don’t. We know healthcare and health insurance are way too expensive, but we continue to shrug at their costs. So we have an out-of-control healthcare system – and, for similar reasons, exploding deficits, crumbling infrastructure, and climate change that will soon drastically change our existence.

D’oh, indeed. 

The Simpsons is a cartoon.  It’s satire. Homer isn’t going to have to pay that $143m. Homer won’t suffer any consequences past the end of the episode. We’re not so lucky. We have to live with – or die from – the consequences of the foolish blunders we make or the ironic turns of events we find ourselves in, especially when it comes to healthcare

It’s 2022.  Let’s stop accepting the unacceptable.  Here’s what our New Year’s Resolution should be: no more healthcare D’ohs. 

Rooting for Schumpeter's Gale

Not familiar with Schumpeter’s gale?  You may be more familiar with the term “creative destruction.”  Schumpeter’s “gale of creative destruction” is the inevitable “process of industrial mutation that continuously revolutionizes the economic structure from within, incessantly destroying the old one, incessantly creating a new one.” 

Credit: Shutterstock

We need a Schumpeter’s gale in healthcare.

What made me think of this was the news that Tik Tok became the most popular internet site in the world, surpassing even Google.  It reminded me that things sometimes do change; perhaps there is some hope for healthcare after all.

If you missed the news about Tik Tok – perhaps you were too busy on it or too busy ignoring it – it came last week in Cloudflare’s Radar 2021 Year in Review. Tik Tok was a fairly distant 7^th a year ago, well behind leader Google and #2 Facebook, but shot up in 2021. Tik Tok has gone from being simply silly short videos to a force in social justice, the job market, celebrity status, and mental health.  It plays a role in Gen Z/Gen Y’s lives that Facebook desperately wishes it did.  Facebook’s demographic issues had been well known, but Tik Tok surpassing Google? 

That’s the kind of change I wish we saw tech bringing in healthcare.

The dominance of “Big Tech” – a.k.a., Alphabet/Google, Amazon, Apple, Facebook/Meta, and Microsoft – is oft discussed, and usually lamented, but we have to keep in mind that such dominance is typically transitory.  Twenty years ago Apple was an also-ran, Google was trying to be an also-used, and Facebook had yet to be invented.  Amazon had a market capitalization under $4b. Microsoft was still Bill Gates’ company, not the open source, cloud-based, subscription-oriented company Satya Nadella pivoted to within the last decade.

In twenty years, maybe within ten years, that list of Big Tech companies will look very different.  Maybe it will be Web3, maybe the metaverse, maybe quantum computing or AI, or even something few of us have even heard of yet, but new waves will come and will bring new tech giants.  That’s why Apple is investing in “face computers,” Facebook is transitioning into Meta, and Google has a “moonshot factory.”  Those efforts and others may help keep them relevant, but the barbarians, so to speak, are still coming.

Go back twenty years, on the other hand, and the big hospitals/hospital systems are pretty much the same.  Same for payors, pharma, medical device companies.  There have been mergers and consolidations, but the dominant companies then are mostly the dominant companies now – only moreso.  That’s not how it is supposed to work.  That’s not how it works in tech.

In last week’s “On Tech Newsletter” in The New York Times, Shira Ovide flatly says “technology won.”  She explains:

Tech is more like a coat of new paint on everything than a definable set of products or industries. Health care is tech. Entertainment is tech. Schools are tech. Money is tech. Transportation is tech. We live through tech.

Technology is also in a liminal phase where the promise of what might be coming next coexists with the complicated reality of what is happening now.

Credit: HealthTech Zone

You can certainly make an argument that “health care is tech,” and that much of that transition has happened in the last twenty years.  We have widespread electronic health records, minimally invasive surgeries, new types of cancer treatments, all sorts of 3D printed objects, CRISPR, greatly improved protheses, VR treatments and training, and, of course, more types of digital health efforts than even today’s venture capitalists can throw money at. 

It’s all very impressive, but you’d get a lot of argument that our nation’s health is better as a result, that our experiences in the healthcare system are better as a result, or that our healthcare is any cheaper as a result.  None seems true. Tech, in healthcare, is a bolt-on; it adds costs, it removes more of the human touch, and it does not fundamentally reshape the healthcare system.

Unlike the actual tech industry, tech in healthcare serves to further cement the position of the incumbents, not displace them. It doesn’t make the healthcare experience new, it just makes it seem “newish.”  TikTok is not going to dethrone Epic or The Mayo Clinic. People in healthcare aren’t too scared of the “what’s next” in tech.

Much has been made of the record setting 2021 for digital health investments -- $28b, which was double 2020 – but when I look at them I still don’t see an Uber or an Amazon, a company than is trying to break an existing industry.  I see a lot of innovators who think they can remedy some pain points, but within the existing system, and I see investors who mostly want their slice of the $4 trillion healthcare sector. 

Credit: Getty Images

I want to see tech innovators who look at our healthcare system and think, hmm, there’s too many people and places doing too many things for too much money – and, often, too late, after there is a problem. Who want to bring the cost structure down not 5-10% but to 5-10% of our current levels. Who want health to be an ongoing process managed in our daily lives.  Who want health tech – and the resulting healthcare -- to be ubiquitous, invisible, and largely autonomous. Who don’t think we need to rely on millions of highly trained healthcare professionals (and whose training, in fact, becomes one of the cost problems in the healthcare system).

Tik Tok would understand that.

With all due respect, I’m not sure that David Feinberg, for example, would. People who have spent their professional lives in the healthcare system can often see how to improve it, but not to fundamentally reshape it and almost never how to bring creative destruction to it.

I’m not expecting Tik Tok to revolutionize our healthcare system – but ByteDance or WeChat, maybe. An AI company?  Of course. A synthetic biology or nanorobotics company?  For sure.  By contrast, what CVS, Walmart, even Amazon are trying to do in healthcare are interesting, but, honestly, they’re like helping us hear the orchestra on the Titanic better: OK, but that’s not really the problem. 

If we recognize the healthcare system in 2050, if some Schumpeter’s gale hasn’t blown the current version away and replaced it with something truly new, we will have failed.   

Not Just Token Tokens

I recently watched some of the recent Congressional hearings on cryptocurrency, and, boy, if there’s anything funnier than watching experts try to educate most members of Congress on anything crypto-related, it’s probably me trying to explain it.  I don’t own any digital assets, still don’t see the point of NFTs, and am not going to buy any real estate in the metaverse.  

Credit: Colin Evran/Protocol Labs

All that being said, there’s something about Web3 that fascinates me).  Knowledgeable people are talking about Web3 “reinventing the internet,” “democratizing” it, giving people more ownership of/control over what they do on it.  It’s a counterbalance to the how the internet – both the traffic and the infrastructure -- has increasingly grown dominated by a few very large firms, such as Google, Facebook, or Amazon.

As the Web3 Foundation declares, Web3 is an internet where:

• Users own their own data, not corporations
• Global digital transactions are secure
• Online exchanges of information and value are
•  decentralized

All that sounds very intriguing to me, especially as someone who has dim views of how healthcare likes to silo information, has placed too little value on patient ownership of their own data, and is rushing to centralize.

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Credit: Euromoney Learning 2020

If I’ve got this right, the heart of Web3 is the concept of distributed ledgers – a.k.a., blockchain. Information is not stored in one place, controlled by one entity, but across these distributed ledgers.  Activity – transactions, changes to the source information, etc. – updates the blockchain, preserving the history and verifying the activity across the distributed ledgers. Someone wanting to change or use your information without your permission faces a large challenge because of its distributed nature.

On the distributed ledgers, you can do transactions (e.g., buy/sell), use “smart contracts,” participate in social networks, and many other interesting activities. If trying to do anything quickly across a distributed network sounds daunting, Bloomberg reported:

Operating through a distributed network can be clunky, but the user experience is getting better. “It’s still early, but it’s been transformed in the last six months,” says Jonathan Dotan, founding director of the Starling Lab.

To assist, there’s a related concept of a “distributed app,” which is, I suppose, to Web3 as apps have been to Web 2.0.  There’s even a “dapp store” called DappRadar that claims to allow you to “discover, track & trade everything DeFi, NFI and Gaming.”

We are already seeing DAOs – decentralized autonomous organizations – to help create /run Web3. “I think DAOs will be as ubiquitous as companies, clubs, nonprofits, and different kinds of ‘official’ organizations today,” says Maria Shen, a partner at venture capital firm Electric Capital told Bloomberg.

There is an explosion of funding in blockchain-based startups; CB Insights reports $15b in 2021, up 384% from 2020.  In The Wall Street Journal, Christopher Mims notes:

Almost every company with “Web3” or “blockchain” in its pitch deck describes its mission as a user-centered quest to empower—and just as often, enrich—its users, making them owners and investors as much as customers.

 That. Is. Intriguing.

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We can’t get away from Web3 without discussing tokens, which many associate with digital currency like bitcoin. That’s not entirely incorrect, but not quite right either.  Digital currencies are associated with specific platforms – e.g., bitcoin and Ethereum run on different platforms – but tokens are digital assets that transcend platform.

Cryptopedia says: “Tokens — which can also be referred to as crypto tokens — are units of value that blockchain-based organizations or projects develop on top of existing blockchain networks.”  It goes on to clarify:

• “Typically, crypto tokens are programmable, permissionless, trustless, and transparent.
• While crypto tokens, like cryptocurrency, can hold value and be exchanged, they can also be designed to represent physical assets or more traditional digital assets, or a certain utility or service.”

Tokens can be used, for example, like “voting shares” that help govern dapps or other structures.

This leads to something that Mr. Mims also discussed as one of the “inspired weirdness that is Web3”:

If money can become code, then money can be way more than a means of exchange; it can also do anything that other software can do.

This core insight, a sort of E = mc equivalence between money and software, is why true believers in Web3 think it could have a huge impact. Suddenly every activity humans engage in, from buying and selling a house to liking a post on social media, can be made part of a token-based financial system of a scale and complexity that makes today’s look like an antique.

I love the “E = mc² equivalence between money and software;” no wonder people are excited about Web3.

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Not everyone is a fan. For one thing, generating some blockchain takes tremendous computing power, which has a host of environmental impacts. For another, it can be a way for evading regulation, which could be a concern for fields like finance or healthcare.

Even more troubling, as Cornell professor James Grimmelmann told NPR:

"Web3 is vaporware… It doesn't make any sense.  The vision says the problem with the internet is too many centralized intermediaries. Instead of having lots of different applications and sites, we'll put it all on blockchains, which puts it all in one place.

Web3 has to be bigger than blockchain.

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I don’t know what a Web3 for healthcare would be, but I have some ideas. Of course, the idea that we own and control our health records, storing them on blockchain and giving permission for them to be viewed/added to, should be tempting to anyone who has had to fight or access to their own records. That’d be a necessary but not sufficient component of a healthcare Web3.

Credit: Aïda Amer/Axios

Imagine, if you will, a future where anytime you interact with the healthcare system, that interaction is not only stored in a blockchain record that you control, but also earn tokens for that interaction.  Imagine all the data from your fitness or other trackers also going into that blockchain record, and earning more tokens. Image all those tokens giving you voting rights in the governance of that healthcare system. 

We’re not at Web3, and we’re not going to be there Credit: anytime soon.  Moreover, experts predict, it’s less about Web3 supplanting Web 2.0 as becoming incorporated into it. Still, as Esther Crawford, a project manager who is helping Twitter orient towards Web3, told NPR: “For a long time, Web3 has been very theoretical. But now there is a surge of momentum to build."  Ignore it at your own risk

I can’t wait to see who is going to build what Web3 for healthcare.