Get Ready for (Healthcare) Microgrids

We depend on it.  Indeed, our daily lives are unimaginable without it.  The trouble is, it’s become unreliable.  Lives have been lost because it wasn’t performing when it needed to be.  It’s built around large facilities that are often decades old.  Parts of it don’t communicate/coordinate well with others.  Its workforce is aging and burnt out.  There is no person or agency charged with ensuring its resiliency. It badly needs to be rethought for the 21^st century.

Credit: Microgrid Knowledge

Oh, you thought I was talking about our nation’s power grid?  I was talking about our healthcare system. 

The parallels are striking, and concerning.  They’re huge industries, based on early 20^th century approaches, and beset by 21^st century challenges to which they may not be easily adaptable.  If we don’t manage their evolution to the 21^st century right, we’re dead.  Literally. 

The power outages in Texas last year caught everyone’s attention.  Texas prides itself on being an energy producer, but its power industry was caught flat-footed by “unexpected” winter weather that many had, in fact, predicted.  People went for days or even weeks without power. 

Oh, that’s Texas, people elsewhere might say. They hate regulations, they love low prices, their power grid isn’t (for the most part) connected to other grids, so the failures were not really surprising. Maybe, but it’s not just Texas.  The Wall Street Journal reported:

Large, sustained outages have occurred with increasing frequency in the U.S. over the past two decades, according to a Wall Street Journal review of federal data. In 2000, there were fewer than two dozen major disruptions, the data shows. In 2020, the number surpassed 180.

In fact, the article says, “Utility customers on average experienced just over eight hours of power interruptions in 2020, more than double the amount in 2013.”  Our power plants and transmission lines are aging badly, we have a phobia of nuclear that is also starting to apply to coal as well, climate change is throwing more extreme weather at us, and many of the renewable options (solar, wind, geothermal) are not quite ready for prime time yet. 

So, get a generator.  In fact, many people are.  That’s fine, if you have the money (often $10,000+), can get the fuel and can keep the generator in working order, and will only need them for limited amounts of time.  That’s a lot of “ifs.”

That’s where microgrids come in.

According to Microgrid Knowledge,

A microgrid is a self-sufficient energy system that serves a discrete geographic footprint, such as a college campus, factory, hospital complex, business center, military installation or neighborhood. Microgrids can operate independently from the grid using power generated on-site; they can also be used for backup power. Microgrids are designed to operate consistently in both “blue sky” and emergency situations supported by a range of energy resources, such as renewable energy, energy storage, combined heat and power or generators.

Their definition somewhat snidely concludes: “It’s easy to know which buildings have microgrids. They are the ones lit up during grid outages, while surrounding buildings remain in the dark.”

Credit: Illinois Institute of Technology

A Chicago neighborhood is about to become “the country’s first neighborhood-scale microgrid” – one that proponents believe “could serve as a model for utilities and communities across the country.”  The US Army plans to have microgrids on all of its 130 bases world-wide by 2035.  Many universities, hospitals, airports, and business parks have already developed microgrids.  They are an idea whose time has come.

Healthcare needs to literally join in.  If there’s a hospital, nursing home, pharmacy, dialysis center, or other health care facility that hasn’t already become part of a microgrid, it’s time.  Those 1960’s-era backup generators are not going to cut it.

Healthcare needs to figuratively join the microgrid movement.  Think of hospitals as the traditional power plants, the loci of the healthcare system.  Everything revolves around them, especially as they’ve bought physician practices, developed more outpatient facilities, and consolidated.  They control how healthcare is practiced and at what cost in their community/region. They power the system.

That’s worked for us, in our dysfunctional U.S. healthcare way, but the cracks are showing. We don’t like how much we’re paying, we’re not seeing that monopolies/oligopolies are getting us higher quality care, and in the pandemic hospitals did not prove to be enough.  Their staffs – which had already been stressed by staffing issues/EHRs/other problems -- were overwhelmed, and started leaving.  Patients stacked up in hallways, there wasn’t enough of some critical equipment/supplies, dead bodies had to be held in refrigerated trucks. 

We’re effectively seeing healthcare’s versions of brownouts, or even blackouts.  If there is one thing our healthcare system is not, it is resilient.

A healthcare microgrid would more effectively keep people out of hospitals.  It would rely less on physicians, especially specialists.  It would be community-based.  It would be available 24/7, and be able to flex capacity as needed.  It would be “smart,” and incorporate as many 21^st century technologies as possible, such as home monitoring.  Unlike actual microgrids (but more like most power grids) and unlike current medical practice, it would freely cross city/state/regional lines.

Credit: Getty Images

Telemedicine is an example of what should be included in microgrids.  The pandemic taught us the value of telehealth, but lots of existing rules had to be waived for that to happen.  Those rules are being reimposed, just as many of us are going back to seeing physicians in person. Some hospitals are bold enough to impose facility fees for telehealth visits. Those are all signs that telehealth is not part of a microgrid; it’s being coopted by the power plants – er, hospitals.

Similarly, are we really taking advantage of nurse practitioners or physician assistants can do?  Why do we even think of nurse practitioners as “nurses” or PAs just as assisting physicians?  Do we give pharmacists as much authority as their training would allow for? 

And, of course, when are we going to get AI that can be our first line of medical advice, and perhaps more?

These are microgrid questions. They’re not questions we should only be considering during times of extreme crisis, like the current pandemic; they are questions we should be answering for the next crisis.   

The analogy is not perfect. I don’t know exactly what a healthcare microgrid would look like.  But, just as I know traditional power grids are not going to be enough for our energy needs, our traditional healthcare system is not going to be enough for our healthcare needs. We need something more resilient and more localized.  We need healthcare microgrids.

Imagining a Different Future

Two articles have me thinking this week.  One sets up the problem healthcare has (although healthcare is not explicitly mentioned), while the other illustrates it.  They share being about how we view the future. 

Credit: Sanofi

The two articles are Ezra Klein’s Can Democrats See What’s Coming? in The New York Times Opinion pages, and Derek Thompson’s Why Does America Make It So Hard to Be a Doctor? in The Atlantic. Both are well worth a read. 

Mr. Klein struck a nerve for me by asking why, when it comes to social insurance programs, Democrats seem so insistent on replicating what has been done before, especially in Western Europe.  He asks: “But what about building here what does not already exist there?”  He worries “that the Biden administration’s supply-side agenda is stuck in the past and not yet imagining the future.”

Those are exactly the right questions we should be asking about healthcare.

Our most ambitious healthcare reform proposals seem to either be the catch-all “Medicare For All” or the simplistic single payor. Both are rooted in the past, and in what has been done elsewhere.  We debate what coverage for which things who should have, how much they should have to pay at point-of-care versus upfront in taxes/premiums, and how much we should pay healthcare providers.  They are the same questions we’ve been debating since the 1940’s. 

They’re not the questions for the 21^st century. 

Mr. Thompson takes on what a mess our medical education and training “system” is, and wonders why on earth we make it so hard for people to become physicians.  It’s harder, longer, more expensive here than almost anywhere else, and we end up with fewer physicians per capita than most other developed countries. We even make it hard for doctors to immigrate. “No matter what the pandemic future holds,” he asserts, “we need more doctors to be part of America’s health-care system.”

I’ve written previous on reforming medical education and on rethinking primary care, so I heartily applaud those aspects of Mr. Thompson’s article, but I stop short of endorsing the call for an “abundance” of doctors.  What we need, as I’ve argued before, is not more doctors but fewer patients. 

Yes, many people have to wait too long to see doctors, while others never get to see them at all, and most of us pay way too much for all kinds of health care.  Certainly our healthcare system is severely flawed, with huge gaps and inequities at every turn. But more Band-Aids, more-of-the-same is not what we need.  We need to be, as Mr. Klein urges, “imagining the future,” not simply patching up our rickety 20^th century healthcare system.

Umm, yes. Credit: Harvard Health

Here are some thoughts:

Data: if the pandemic has exposed anything, it is that we really have no idea what is really going on with our health or in our healthcare system.  We don’t really know how many have contracted COVID, how many have been tested for it, how many have been vaccinated against it, or even how many have died from it.  People have valiantly done their best to estimate all of these and more, but, let’s not kid ourselves, they’re estimates. And COVID is something we’ve been paying a lot of attention to, and spending a lot on. Imagine the rest of our data.

A 21st century healthcare system needs to start with data, at every stage, from self-monitoring at home to everything that happens to us in the healthcare system. It needs to be built to collect that data, to ensure that it flows easily, and that it is collected in ways that are actionable. Data cannot be the afterthought of care; it needs to be built-in at the ground level, designed into the system.

It’s already 2022, and we don’t have the right data, much less the right ways to capture and use it.

Health, not Medical: it has been oft said, but it bears repeating – we don’t have a healthcare system, we have a medical care system. Things that happen outside of a physician’s care are usually outside of the system too.  We talk about social determinants of health, but they mostly remain outside the system.

Public health has taken a beating during the pandemic, after years of benign neglect, but if we were serious about addressing our health needs, we’d be spending a lot more on it and expecting a lot more from it. Most of our health issues start with public health issues. 

The trick will be reinventing public health for the 21^st century, not just grafting 21^st technology on top of 20^th century public health structures, from physical infrastructures to information campaigns to staffing.

DIY: the miracles of 20^th century medicine further elevated physician to near god-like reverence, but the miracles of 21^st health are going to level that playing field, much more than the internet has already done.  Innovations like AI, 3D printing, synthetic biology, and nanoengineering are already showing how radically different our health care can be, and we’re only scratching the surface of what each can do and how they can be applied to healthcare.

Let the biohacking begin! Credit: Yetisen

Each is going to both get more powerful and cheaper, and each will be in the hands of more people.  We’ll know earlier when we have a problem and how to address it, and we’ll usually have the means to “fix” it.  A topside down healthcare system isn’t going to cut it. Moreover, our healthcare spending is going to be significantly different – lower! -- when we’re using what will essentially be consumer goods instead of taking trips to the healthcare system.

The 21st century healthcare system needs to foster/expect DIY.

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Alec Stapp, cofounder of the Institute for Progress, told Mr. Klein: “This isn’t about government controlling the means of production. It’s about government controlling the ends of production. Deciding what we are producing toward, what we are building for.” Those are the decisions we really need to make when thinking about healthcare reform.

E.g., I’d rather the government be building that data infrastructure instead of spending more on graduate medical education.  I’d rather the government be directing more money to public health infrastructure than in bumping up Medicare payment levels.  I’d rather the government be giving tax breaks to biotech companies than to “non-profit” hospitals. 

Be bold.

As long as our healthcare system looks familiar to those of us born in the 20^th century, we’re not thinking boldly enough. We should be imagining a future that does not yet exist, and that will look familiar to people who will still be alive for the 22^nd century.

Take a Tip From Domino's

If you’re already thinking ahead to next Sunday’s Super Bowl, you might be thinking about Domino’s, because, as everyone knows, pizza and football go together like mom and apple pie.  I’m thinking about Domino’s too, but not because I’m planning my order.  It’s about their new program to reward customers who do more of their own work. 

Ahem, healthcare: pay attention.

Credit: Domino's

Last week Domino’s announced that customers who picked up their own orders, rather than using delivery, would earn a $3 tip.  Art D’Elia, Domino’s executive president and chief marketing officer, explained:

It takes skill to get pizza from a Domino's store to your door. As a reward, Domino's is giving a $3 tip to online carryout customers who take the time and energy out of their day to act as their own delivery drivers. After all, we think they deserve it.

The program – Domino’s Carryout Tips – isn’t quite as rewarding as it might sound.  The $3 is actually a credit on your next order, and that credit has to be used by the following week.  There’s a $5 minimum to qualify, and orders have to be online.  The program was announced in time for the expected Super Bowl surge, and is scheduled to end May 22. 

But still.  I don’t like waiting for deliveries, I do like pizza, and if I ordered a lot of Domino’s (which I don’t), the $3 tip would be decent discount, even if I had to order even more Domino’s to actually get it.

Domino’s once was famous for it’s “30 minutes or it’s free” delivery guarantee, until it lost a $78 million lawsuit in the early 1990’s, as the court agreed the promise resulted in reckless driving (and even, it was claimed, multiple fatalities).  Still, during the 1980’s that promise catapulted the chain to be the biggest pizza chain in the U.S., a position it still holds (it now is also the largest in the world).

Although the tip initiative was portrayed as a customer reward program – Mr. D’Elia is, after all, the chief marketing officer – most analysts believe it is more about labor shortages.  Domino’s, like many companies and especially those in the food service industry, is struggling to attract/retain enough workers, including those delivery drivers.  So if customers want to be their own delivery driver – Domino’s ad literally shows that – hey, that’s worth a $3 credit, right? 

In 3Q 2021, Domino’s suffered its first decline in same store sales in over a decade; initially the pandemic had been very good for pizza sales, but the combination of of fewer workers, higher supply prices, and ongoing competition took its toll.  At the time, Chief Executive Richard E. Allison, Jr. noted: “The carryout business will continue to be a focus of ours, given the significantly lower amount of labor involved in those transactions, We’re going to continue pushing there.”

Thus, Carryout Tips.

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Healthcare has its own share of pandemic woes, most of which exacerbated existing problems.  Healthcare workers are burnt out, and many are simply leaving – about one in five, according to some estimates. Patient data continues to be siloed despite huge gains in electronic health records; not only do different EHR vendors not communicate well, different health systems using the same vendor have problems.  Patients not only often don’t have good health habits but a surprising number don’t follow their doctor’s orders, including medication adherence.  Health inequities abound.

Credit: Mighty Casey Media

Somebody needs some $3 tips.  Well, actually, given health care prices, there better be a lot of zeros after the number, and I’m not talking decimal points.  We’re doing way too much of the work, for free.  For example:

·       Have you ever filled out a form in a healthcare office that you’d already filled out previously, either there or in another office?  You get a tip!

·       Have you ever had to carry some of your health care records (either on paper or on a CD) from one healthcare office to another?  You get a tip!

·       Have you ever had to take time off work to sit in a healthcare office or facility, waiting long past your scheduled appointment?  You get a tip!

·       Have you ever had to fight with a healthcare organization about incorrect bills, or with an insurance company over incorrect payments?  You get a tip!

·       Have you ever been a caregiver for someone with acute or ongoing health care issues?  You get a tip!

You get the idea, and you probably have your own suggestions.  We’ve all had encounters with the healthcare system that felt way too hard, during which we felt we were doing more of the work than we should have had to.  Frictionless, it is not. 

The healthcare industry would say, well, nice idea, but there’s no money for that.  We could do that, it might say, but, of course, we’d have to charge more in order to pay for all those tips.  I would say, balderdash.  There’s plenty of money; it’s just going to the wrong places.

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I’m not naïve.  Domino’s is not offering its tips because it truly wants to reward its customers.  It’s doing it mainly because delivery drivers are scarce and too expensive.  If it can persuade more customers to be their own delivery drivers by offering a $3 credit, better for Domino’s, and if the $3 engenders some extra customer loyalty, better still for Domino’s. 

Similarly, healthcare workers are expensive and becoming increasingly scarce.  There weren’t enough of them before the pandemic, and there certainly aren’t not enough of them now.  Given the way they’re leaving the industry, there aren’t going to be enough of them once the pandemic becomes endemic and things reach a “new normal.”

Healthcare better find ways to incent patients to take on more of the work.  Appeals to “more self-service” or even to “managing your own health” aren’t going to be enough.  Healthcare organizations need to be thinking about financial incentives.  Call it a tip, call it a credit, call it a customer loyalty reward, but they should find some way to acknowledge, and reward, patients for the various ways they provide unpaid work in our healthcare system.

A healthcare “thirty minutes or its free” promise wouldn’t be a bad start either.

Maybe healthcare organizations could at least order pizzas for patients…although they’d probably expect them to pick them up.   

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.