How Dare We?

The saying goes, out of the mouths of babes.  Or, in the case of Greta Thunberg, the mouth of a teenager.

I had been vaguely aware of Ms. Thunberg these past few months, but wasn't really sure who she was.  Someone on Game of Thrones, perhaps?  (Which, sadly, shows you how closely I follow either climate change or GoT).  But after her scathing put-down of climate change deniers at the UN this week, I'm thinking: gosh, we need that outrage in healthcare too. 

If you missed her speech, it's worth your five minutes:

"How dare you," indeed. 

For anyone who missed Ms. Thunberg's backstory, she is a 16 year-old student from Sweden, who has made climate change her mission.  She's been leading student protests about inaction on climate change for the past year, leading to a worldwide student protest last Friday that had as many as 4 million people participating.  She was at the UN this week as part of the United Nations Climate Action Summit. 

"Right now we are the ones who are making a difference. If no one else will take action, then we will,” Ms. Thunberg said at the New York City protest.  “We demand a safe future. Is that really too much to ask?"

She excoriated our so-called world leaders while at the UN:  

This is all wrong. I shouldn't be up here. I should be back in school, on the other side of the ocean...you all come to us young people for hope. How dare you?

Noting that thirty years of science have made the dangers climate change "crystal clear," she added:

You say you hear us and that you understand the urgency. But no matter how sad and angry I am, I do not want to believe that. Because if you really understood the situation and still kept on failing to act, then you would be evil. And that I refuse to believe."

As Ms, Thunberg told Robinson Meyer of The Atlantic, about climate change but also applicable to gun violence and a host of other problems, "We are not the ones who are responsible for this, but we are the ones who have to live with these consequences, and that is so incredibly unfair."  

Parkland survivors Credit: Peter Hapak/Time

This is not the first time we adults have been called out for our inaction on important issues that impact not just our health but the health of generations to come.  For example, survivors of the Parkland school shootings have been using their outrage and social media savvy to help mobilize action to finally break the logjam in America about reducing gun violence. 

They've been advocating for a year and a half now, and all we have are more "thoughts and prayers," as well as many more mass shootings.  Young people are speaking up; again, it is adults who are not acting.

Think about some of the many other issues that we are also failing to act on that have intergenerational health impacts:

Anti-Vaxx Movement: If there's something about which the science is even clearer than climate change, it is that vaccines work.  Vaccines save lives, reduce misery, and improve health.  So how is it that, in 2019, we have measles outbreaks?  Kids are supposed to rely on their parents to make good choices on their behalf, especially about their health, and getting vaccinated used to be one.  Now, people don't believe even their doctor's recommendation.  They're basing their decisions on what a friend told them, or the internet, or simply on their faith. 

As Dr. Paul Offit, an infectious disease expert, told The New York Times, "Science has become just another voice in the room.  It has lost its platform. Now, you simply declare your own truth."

Maternal and child health:  We claim to love babies and moms, but you sure couldn't tell it by the state of maternal and child health in the U.S.  We have the worst maternal mortality rates in the developed world, and it isn't any better for childhood deaths.  A Health Affairs study found that U.S. children have a 70% greater chance of dying before adulthood than in other developed countries. 

It's not only mortality but also morbidity.  We shouldn't have, for example, more children who are obese, have diabetes, or have allergies, but we do.  Those are things that will have lifelong consequences. 

Lost Einsteins: a 2017 report lamented how we are producing a generation of "lost Einsteins," children who would never live up to their potential (or survive birth/childhood) due to the socioeconomic situation they are born into.  We live in a country to extreme economic and health disparities.  Be born in the "wrong" place, to the "wrong" race/ethnic group, to the "wrong" parents, and your life choices may be greatly limited.  None of that should matter, but it does.  

It's one thing for an individual to squander his/her own opportunities, but it is something else entirely when our healthcare system is complicit on squandering the opportunities of a significant portion of younger generations.  

Infrastructure: The American Society of Civil Engineers gives the nation's infrastructure a D+ -- not just crumbling roads and bridges, but also schools, drinking water, and waste treatment.  The drinking water crises in Flint  and Newark are neither isolated nor have time limited impacts.  The health of many children is going to be irreparably impacted.

It's going to cost trillions of dollars to improve our infrastructure, money that we're leaving to our children and grandchildren to pay, while adversely impacting their health and ability to pay it in the meantime.  

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Let's not even go into how we fail to fund our social programs like Medicare, CHIP, Medicaid, or the Public Health Service, forcing future generations to deal with them, or how we allow silly but harmful products like vaping to be targeted at teens.  We are failing our children and their yet-to-be-born children.

As Ms. Thunberg said about climate change, our children and our grandchildren are not responsible for the mess we've made of our healthcare system, but they are the ones who will suffer the consequences. 

She's right; it is unfair. 

There should be student protests about the problems with our healthcare system.  We should be joining them.  We all know it is a mess, and still we tolerate it.  Concern and even outrage are not enough.  Action is needed.  How dare we allow our existing inefficient, ineffective, unfair healthcare system to continue to fail us?

It's Not the Health Insurers, Stupid!

After three years of our own government trying to undermine the Affordable Care Act (with the percent of uninsured now rising as a result), it's refreshing to hear politicians talking about getting the U.S. closer to universal coverage.  The debate among the Democratic Presidential candidates is not about the feasibility of universal coverage but about Medicare for All (which as ProPublica explained, is neither really Medicare nor necessarily for all) versus more incremental approaches.

The favorite whipping boy in our current healthcare system is the health insurance industry.  Candidates like Bernie Sanders or Elizabeth Warren decry the industry's profits, arguing that we'd be much better off abolishing private health insurance.  That appeals to many people because, really, who among us -- myself included -- hasn't seen larger deductibles, higher premiums, smaller networks, and perhaps some denied claims?

Credit: The New York Times

As easy as it is to blame the health insurance industry and its profits as the culprit for our system's dysfunction, it's not really fair.  As I'll elaborate: 

• its profits aren't that big;
• many healthcare organizations are making profits;
• our public health coverage programs usually aren't actually;
• why healthcare?

Health insurance profits

When politicians point to the estimated $20b+ in health insurance annual profits, it sounds like a big number.  It is a big number -- except when you are dealing with an industry like healthcare, which has expenditures of over $3.5 trillion.  $20b is barely a rounding error.  

One can rightly criticize the health insurance industry for many things -- its coverage is way too complicated, its decisions often too arbitrary, it has (historically) insulated us from the cost of services -- but the profits per se are not really the issue.  Take all its profits out, and we still don't make a dent in spending.  Instead of health insurance profits, we should be focusing on how to reduce the size of the industry and its administrative costs.

Even in a Sanders-style Medicare for all, some entities would be negotiating payment rates, doing utilization review, processing claims, handling customer service, doing provider relations, and marketing.  Just like health insurers.

Healthcare profits

Many politicians also point out the profits in the pharmaceutical industry, which dwarf that of the health insurance industry.  After all, the pharmaceutical industry has blundered its way into rivaling the health insurance industry as the sector's villains, largely due to its habit of using America as its favorite piggy bank through its aggressive (and mysterious) pricing here.  

But let's be clear: it is not just health insurers or drug companies making money in healthcare.  As Elizabeth Rosenthal recently pointed out, that beloved local institution, the hospital, is often making some pretty nice profits -- whether they are "non-profit" or not.  Even the supposed "non-profit hospitals can act in a very predatory manner, as Kaiser Health News has been exposing.  We're increasingly moving to local hospital monopolies, and those monopolies tend not to improve quality but, rather, increase costs.  

Add in physicians, pharmacies, device manufacturers, dialysis centers, and a host of other health care organizations and professionals, and it's pretty clear that there is a lot of money being made in healthcare.  

Public health coverage programs

Proponents of Medicare For All seem to ignore the facts that our current Medicare program has about a third of its enrollees in a private Medicare Advantage program, all of its Part D enrollees in private plans, and most of the people in "traditional" Medicare opt to have private Medicare supplements in addition to Medicare.  

Our other public health coverage programs, like Medicaid or TRICARE, now have most of their enrollees in private managed care programs.  It is true that the VA has stayed public, and is the closest thing we have to the United Kingdom's National Health Service as a true government-run system, but the biggest recent VA innovation has been to allow choice of private health care options.  

Some Medicare for All proposals claim that there would be no need for private insurance, but history suggests staying purely public would be difficult.

Why healthcare?

Healthcare is important, often essential.  We sometimes get too much of it, but it is hard to argue that most people would be better off without it, and many would be dead.  But that's true about many things in life.

We need to eat to live.  Most of us would miss eating before we'd miss healthcare.  To help ensure that people can afford to eat, we have SNAP (Supplemental Nutrition Assistance Program), which provides financial assistance to about 40 million people so they can purchase food.

What we do not do, though, is to suggest that groceries stores should not make profits.  What we do not do is say the government should be in the grocery business.  We're quite happy to be the financier for lower income persons and to let others make their own food choices, no matter how badly they do it.  

Similarly, most would say housing is an essential component of life, yet we have at least a half million people homeless everyday, with anywhere between six million to thirty million people in substandard/hazardous housing.  A third of us pay more than 30% of our income on housing.  We do offer public housing, but we support more people in private housing through Section 8.   What we do not say is that no one should make money in housing, or that the government should provide all housing.

Even in education, where most students are public, private options remain important to many people, at all levels of education.  

It's hard to see the argument why healthcare is the only essential for which private options should not exist.  

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Profits in healthcare may be a visible sore point to many, but profits in a capitalistic society shouldn't be a thing to be ashamed of.  The problem is usually how those profits are made.

In health insurance -- and in health care generally -- profits have been problematic because they often don't seem to be the result of making us healthy.  We shouldn't just be a conduit to making other people in healthcare richer; they should get richer if and only if they are actually helping us achieve healthier lives. 

We just have a poor understanding of how to achieve that goal, and how to shop for the people, organizations, and services that we need to do so.  If politicians, and everyone else involved in healthcare, would focus on those, we wouldn't need to focus on profits.    

(ICYMI, the title is an homage to Gerry Anderson's It's the Prices, Stupid (as well as David Abernathy's It's the Monopolies, Stupid).  

Our Workarounds Aren't Working

In yet another headline I wish I'd written, Theresa Brown -- nurse, author, clinical faculty member, Ph.D. -- wrote a provocative op-ed for The New York Times: The American Medical System Is One Giant Workaround.  That's a great description, and one that anyone who has ever touched the healthcare system can easily appreciate.

Never mind the insightful but somewhat inside-baseball examples Dr. Brown mentions; who among us in our healthcare journeys has not seen the sticky notes, been asked to send a fax, gotten stuck in a telephone tree, or had to refill (paper) forms?   Those and countless other examples should make us all realize the creaky platform upon which our actual care depends.

To call it a "system" is to give our healthcare system way too much credit.

Not a healthcare workaround, but a metaphor for them

Let's go through the big workarounds about our system.

Coverage
Dr. Brown noted that "Obamacare, though, was never intended to make sure that all Americans had affordable care; it works around our failure to provide health care to all our citizens."  Indeed, ACA was able to cut the percent of people without health insurance in half, but still left some 8% without coverage.  Even worse, that percentage is now rising again.

The big workaround is that we have such a multiplicity of sources of coverage: about 55% with employment-based coverage,18% each for Medicare and Medicaid, 11% with individual coverage, and 4% for military-related coverage (TRICARE, VA, CHAMPVA).  Some people are covered by more than one source.  

ACA finally put some parameters about what (private) coverage had to include and what kinds of cost-sharing were permissible, but few see different plans as easily comparable, or even understandable.  And if you change jobs, gain or lose income, or become old enough or disabled, you may have to also change your source of coverage/plan of benefits.

No wonder why Medicare-for-All has become a rallying point, although few really understand what that might look like or how it would have to be financed.  

If I would wave a magic wand, I'd say that everyone should automatically be covered --period, full stop -- and that we end employment-based coverage.  

Quality
We talk a lot about quality in our healthcare system, often like to brag about it, but the fact of the matter is that we don't even really know what it means, from an empirical standpoint.  We have a hard time defining it, much less trying to measure it.  It is no surprise, then, that we have what has been described as an "epidemic" of unnecessary or inappropriate care, possibly as much as a third of all care.

Healthcare's workarounds are legion.  We have a variety of licensing, credentialing, and accreditation requirements, more regulations than anyone could count, a malpractice system that manages to miss most actual malpractice, and an ever-growing set of "quality" measures that no one really think really do.  We collect data - lots of it -- but are reluctant to share it, even with the patients it reflects and even if sharing would improve our understanding of it.  We are slowly trying to move to "evidence-based medicine," but most of what healthcare professionals do is not.

There are healthcare professionals who are incompetent or motivated by greed.  There are healthcare institutions from which you should not get at least certain kinds of care.  There are mistakes that are made.  There are treatments that don't really work.  We should know who/what they are, and the good healthcare professionals/institutions would benefit by our knowing.   

If I could wave a magic wand, I'd suggest we treat quality not as a largely implicit, intangible aspect of health care but as an indispensable feature, and make defining and measuring it our top priority. Fix this and other problems become more tractable.

Price
I deliberately am using "price" instead of "cost" because, as was pointed out long ago and repeatedly since, "It's The Prices, Stupid."  Our prices for almost everything healthcare related are widely higher than anywhere else in the world.  Worse than that, those prices vary wildly by type of coverage, location of the service, and the person/institution delivering it.  Our healthcare system seems to spend more time, attention and money maximizing billing than getting patient care right. 

We act outraged at surprise billing, patients being hounded by debt collectors, and the murky role of PBMs in prescription drug pricing, to name a few, but they are almost inevitable outcomes of our workaround that allows such a multiplicity of prices.  No one really seems to know what a price for something "should" be, and no one really seems motivated enough to ensure they aren't excessive.  Everyone simply tries to pass the cost of those prices along -- to the taxpayers, to people paying health insurance premiums.

If I could wave a magic wand, I'd suggest a set of fully disclosed, comprehensible prices that do not depend on source of insurance, with variation allowed only to reflect measurable differences in quality. 

Convenience
The U.S. healthcare system is not, and never has been, centered around the patient.  We make sick people go to physician offices or healthcare facilities.  We warehouse even sicker patients in hospitals or nursing homes -- away from their friends and family, out of their familiar settings -- because it is more convenient for the healthcare professions who work in them.  We spend way too much of our time in the healthcare system waiting for someone to help us, usually never sure when that help will happen. 

Sure, healthcare now gives patients online portals (which don't usually talk to other healthcare portals they might use), allows patients to fill out some forms online (which often doesn't seem to preclude having to subsequently fill out more in person), even offers virtual care options (although probably not with the healthcare professional patients know).  The rest of the world is mobile, real-time, and on-demand, and healthcare is still faxes, far-in-the-future, and in-person. 

If I could wave a magic wand, I'd say that where and when a patient gets care and advice needs to be as important in healthcare as it is for other services consumers use.  

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Unfortunately, I do not have a magic wand.  We live in a world of compromises.  But those compromises have led to our current healthcare system, which we can no longer afford and in which we are not achieving the health outcomes we should expect.  We're paying premium prices for mediocre outcomes. 

Our workarounds have failed.  It is time for real fixes.

Here There (Used To) Be Hackers!

You may have missed it -- I know I did -- but this past weekend was Biohack the Planet 2019, the annual conference that celebrates the biohacking movement.  Fortunately the good folks at StatNews were on top of things, reminding us that biohacking is something more of us should be paying attention to. 

Biohackers may like to think of themselves as rebels, even pirates, but, as one of the speakers said, biohacking may be growing up. 

Credit: Biohack the Planet

If you're not familiar with biohacking, Vox did a deep dive earlier this summer. It's about improving your body, sometimes altering it, and can range from meditating to altering your diet to implanting chips to DIY gene editing.  Technology often plays a key role.

Biohacking has had some celebrated successes, like a 15 year old student developing a cheap, fast, 100% accurate test for pancreatic cancer or the Open Artificial Pancreas System project (#OpenAPS). 

MIT Technology Review reported on a biohacked version of Glybera, a $1 million per treatment gene therapy that was introduced in 2015.  A group of "independent and amateur" biologists claim to have developed a simpler, low-cost version of it in two months for about, oh, $7,000. 

Andreas Sturmer.  Credit: MIT Technology Review

Gabriel Licinia, who spoke at the conference, told Technology Review: "This was developed in a shed in Mississippi, a warehouse in Florida, a bedroom in Indiana, and on a computer in Austria."   The team included Andreas Sturmer, an Austrian biologist who thought of reverse engineering Glybera; Licina, a biologist in Indiana, and David Ishee, a Mississippi biohacker. 

For what it's worth, Licinia told Stat that he thinks of himself not as a biohacker but simply as a biologist. 

Glybera treats a very rare blood disorder and, in fact, was pulled from the market in 2017 because manufacturing it wasn't deemed cost-effective.  The new version, which the developers call Slybera, doesn't work in quite the same way, nor has it gone through the same kind of testing.  Mr. Licinia admits," "I’m not saying that we have a completed gene therapy.  Only that we have one piece.” 

The high cost and lack of availability of Glybera make the biohackers' effort more defensible.  Michael Hayden, who led the original research on Glybera and was unhappy about the drug being priced so high, told Technology Review: "The right to access medicine is a social-justice issue.  Any way to provide potential benefits to patients is entirely meaningful, and I would never stand in the way [of biohackers]."

Mr. Licinia said at the conference that they want others to duplicate their work and even to work with the FDA.  Perhaps that illustrates why he told the crowd, "I would like to propose that we grow up a little bit.”

Credit: Biohack the Planet

Stat reported how the conference is edging towards looking like more traditional scientific conferences, including poster presentations and vendor booths.  Speakers debated peer reviewed journals, working with regulators, perhaps even its equivalents of institutional review boards.  Mr. Licinia said: "We’re so busy running away from this terrible thing that we see that we’re not willing to acknowledge that there is value in some of it. What I really want to see is just a middle ground.”

Conference organizer Josiah Zayner, who has been known for some pretty daring biohacking stunts, largely agreed: 

It’s a tough one, right, because if you build the system that you’re trying to break out of, it’s kind of like: Why are you trying to break out of that system? Then you become a gatekeeper of information, you become a gatekeeper of certain things, and I think that’s the opposite of what we all want."

Biohackers may think of themselves as engineers or biologists or simply people trying to use the available technology tools, which increasingly include sophisticated ones like CRISPR.  That's a problem for regulators.  As Vox put it,

Existing regulations weren’t built to make sense of something like biohacking, which in some cases involves risky procedures and stretches the very limits of what it means to be a human being. That means that a lot of biohacking pursuits exist in a legal gray zone: frowned upon by bodies like the FDA, but not yet outright illegal, or not enforced as such. As biohackers traverse uncharted territory, regulators are scrambling to catch up with them.

Earlier this summer California passed a bill -- the first of its kind in the nation -- to outlaw DIY genetic engineering kits.  Similarly, the FDA has warned people against other biohacking efforts like "young blood transfusions" and fecal transplants.  But, as Dr. Carlson told Vox in regards to the California law, "This technology is available and implementable anywhere, there’s no physical means to control access to it, so what would regulating that mean?"

And that, increasingly, is going to be the problem with biohacking generally.  

Credit: Josiah Zayner

Rob Carlson, a longtime advocate of biohacking, told Vox sees the term "hacking" as problematic:

“It’s a way of categorizing the other — like, ‘Those biohackers over there do that weird thing.’ This is actually a bigger societal question: Who’s qualified to do anything? And why do you not permit some people to explore new things and talk about that in public spheres?”

Healthcare has always prided itself on its closed guilds of experts, such as physicians or pharmacists, and for having the opposite of technology's "move fast and break things" mind-set.  And if we were getting the health outcomes we want, at a cost we can afford, that might continue to be fine.  But we're not.  

Some - such as neuroscientist and former MIT president Susan Hockfield -- believe that the 21st century will be the age of biology, with a convergence of biology and engineering.  Physicians are smart, well educated professionals, but they're not (usually) biologists, engineers or, for that matter, computer scientists.  Biohacking may help get us to places that traditional medicine would take much longer -- if ever -- to get to.

It has been all-too-easy for healthcare to regard biohacking as a fringe movement that was, at best amusing and at worst dangerous.  It's also been natural for some biohackers to view what they do as DIY efforts that were their own business.  Neither side can afford to think those ways any longer.

It is time, as Mr. Licinia said, for biohacking to "grow up a little bit," and for "traditional" medicine to recognize that the 21st century is going to include it.  

Trusting in Magical Fairy Dust

This isn't going to be about artificial intelligence (A.I.).  I promise.  There have been a raft of cautionary articles lately about A.I. in general and in healthcare in particular -- David Shaywitz did a nice job of summarizing several of latter in Forbes recently -- but I only want to reference it in order to borrow a great suggestion from Tim Hwang, director of the Harvard-MIT Ethics and Governance of AI Initiative.

In an article in IEEE Spectrum about how to separate hype from reality, Mr. Hwang:

...suggests mentally replacing all mentions of “AI” in an article with the term “magical fairy dust.” It’s a way of seeing whether an individual or organization is treating the technology like magic.

That seems like good advice for lots of claims in healthcare, because healthcare has a lot of magical fairy dust - and not just with A.I. or even technology.

What started me thinking about this, oddly enough, was an expose in The Wall Street Journal about Amazon.  According to the investigation, Amazon has "thousands of banned, unsafe, or mislabeled products" on its site.  It compares Amazon to a flea market, exercising limited control over what third party sellers are selling or how they describe products.  

After calling attention to 4,152 problematic products, Amazon changed or took down the listing for 57% of them, although at least 130 had reemerged within two weeks.  Amazon defended itself in a blog post, citing its various efforts to monitor products on its site and to protect customers, but admitted: "There are bad actors that attempt to evade our systems."  

No kidding. 

The Journal sees this as not a problem for Amazon, but a problem for tech companies generally: 

Amazon’s struggle to police its site adds to the mounting evidence that America’s tech giants have lost control of their massive platforms—or decline to control them. This is emerging as among the companies’ biggest challenges.

The lack of control over tech platforms is why many think we're living in an era of misinformation.  Dr. Claire Wardle, co-founder of First Draft, argues in Scientific American that we're living in a "new world disorder" due to the influence of misinformation.  Technology, she believes, has helped remind us "...that humans are wired to respond to emotional triggers and share misinformation if it reinforces existing beliefs and prejudices."  

Credit: Jen Christiansen, from Wardle/Derakhshan

She distinguishes misinformation, which is false information spread by people who do not realize it is false, from disinformation, which is false information shared to cause harm, or malinformation, which is true information spread in a way designed to cause harm (e.g., leaked emails).  

Dr. Wardle is no Luddite, but she points out: "In a healthy information commons, people would still be free to express what they want—but information that is designed to mislead, incite hatred, reinforce tribalism or cause physical harm would not be amplified by algorithms."

Our world of "disorder" is, unfortunately, our "new normal," Dr. Wardle fears, and suggests: "Understanding how each one of us is subject to such campaigns—and might unwittingly participate in them—is a crucial first step to fighting back against those who seek to upend a sense of shared reality."

And, unfortunately, healthcare is a major victim of misinformation, as the anti-vaxx movement has shown.  We're always looking for that magical fairy dust that will improve our health, and all-too-often we end up trusting misinformation.

People like Dr. Jen Gunter or epidemiologist Gid M-K, Health Nerd spend much of their time trying to debunk health misinformation, Dr. Gunter usually on women's health issues (Goop is a favorite target) and Gid M-K pointing out out flaws in studies/reports of studies.  

Dr. Gunter recently issued a "call to arms" about medical misinformation and the internet, describing her personal journey through misinformation and her subsequent efforts to combat it.  She laments:

It is hard for people to wade through the quagmire that is the medical internet. Bad information is everywhere, fear sells, and the lure of the cure is real. In our 24/7 news cycle a misleading medical story can spawn many erroneous articles. Sometimes the content is actually accurate, but the headlines are incorrect. And let's face it many of us, doctors included, don't always read to the end of a story. 

We also all mistake repetition for accuracy, a phenomenon called the illusory truth effect. And social media, with retweets and reposts, is the very model of repetition.

She urges medical professional to do their part in fixing the medical internet, such as by guiding patients towards good medical information, sharing it on social media, even creating it.  Dr. Gunter urges:

"We in science are the people who developed surfactant, the measles vaccine, and safe blood transfusions...We know how to do great things with science. Helping people have access to quality information so they can make informed decisions is also one of those great things, because you can only be empowered with your health if you are accurately informed.

Credit: Axel Pfaender/The Atlantic

The really scary thing is that misinformation in healthcare is not always easy to discern.  It's not always obviously false, or even widely agreed to be false.  Austin Frakt, of The Incidental Economist fame, reminds us that a 2013 study of thousands of medical treatments found only 40% were had actual evidence to support them.  At least 3% were believed to be ineffective at best and harmful at worst.  Most surprising: "But a whopping 50 percent are of unknown effectiveness. We haven’t done the studies."

They are, in essence, magical fairy dust. 

Professor Frakt says of the fight against this kind of common health misinformation:

It’s an uphill battle. Even when we learn something doesn’t make us better, it’s hard to get the system to stop doing it. It takes years or even decades to reverse medical convention. Some practitioners cling to weak evidence of effectiveness even when strong evidence of lack of effectiveness exists.

It's important to do the science, as Professor Frakt says, to analyze it correctly, as Gid M-K strives to ensure, and to get the word out widely, as Dr. Gunter urges.  It's important not to blindly believe in something that might be misinformation.  But when it's our health, or the health of one of our loved ones, on the line, the temptation to put our faith in unproven claims, new technologies, or alternative treatments is easy to do.  

Just try to make sure you're not believing in magical fairy dust. 

Hey, Healthcare: Just Do the Right Thing

How about that: it appears that big corporations have a social conscience after all. 

The Business Roundtable (BRT), which primarily represents large corporations, issued a statement earlier this week that steers away from its previous stance that a corporation exists to serve the interests of shareholders.  Now, 181 member CEOs agree, corporations must seek to serve all stakeholders.  Corporations must, they say, help promote "An Economy That Serves All Americans."

As soon as I saw this I started thinking about healthcare.

Credit: Getty Images

Jamie Damon, Chairman & CEO of JP Morgan Chase and the current BRT chairman, said:

The American dream is alive, but fraying.  Major employers are investing in their workers and communities because they know it is the only way to be successful over the long term.

The key commitments outlined in the BRT statement are as follows:

1. Delivering value to our customers
2. Investing in our employees
3. Dealing fairly and ethically with our suppliers
4. Supporting the communities in which we work
5. Generating long-term value for shareholders

The Washington Post described the reaction by corporate critics as "cautiously optimistic."  Robert Hockett, a Cornell Law School professor who also advises the Presidential campaigns of Bernie Sanders and Elizabeth Warren (no lovers of corporations!), told The Post: 

It’s almost astonishing.  They’re in effect coming right out and saying, ‘We’ve been wrong for the last 20 years"...some folks in the BRT are recognizing there’s something unsustainable about an economy that’s all about shareholder primacy.

Steven Pearlstein, a professor at James Madison University, told The Post:  "Rather than thinking of them of as bad people with bad motives, it’s probably more correct to think of them as reasonably good people in a bad system."

Credit: Sophia Foster-Dimino

"Reasonably good people in a bad system" may well describe people working in corporations, but it definitely applies to our healthcare system.  Our healthcare system is filled with good people, most of them trying to do the "right thing," but beset by a Kafkaesque system filled with perverse incentives.

It is worth noting that CEOs of for-profit health companies Abbott, Anthem, Baxter, Bayer USA, Bristol-Myers Squibb, Cigna, CVS Health, Johnson & Johnson, McKesson, Medtronic, Pfizer, Stryker, and Walgreens all signed the statement.  It is also worth noting that Kaiser Permanente Chairman and CEO Bernard Tyson was one of only 7 BRT CEOs who did not sign the statement; a spokesperson indicated Kaiser agreed with the principles, but as a non-profit did not have shareholders.

Healthcare is filled with "non-profits," some of whom manage to generate a lot of surplus nonetheless and to pay their executives quite a lot of money, or are small corporations (or LLCs).  It's time for healthcare -- from the smallest solo physician practice to non-profit health systems to the largest for-profit corporations -- to step back and consider a new set of commitments as well.  

Here are my suggestions:

1. It's the patient, stupid: In theory, of course, healthcare has always been about the patient, but that's getting harder and harder to believe.  No one who sits in a waiting room for hours, gets shocked by a large (and usually incomprehensible) bill, has difficulty getting enough time and attention from their healthcare professional, or has to pay more in cases of medical errors or bad outcomes can believe that. 

Healthcare organizations and professionals have to stop being about what they do to patients and focus on what they do for them. 

2. Fair pricing, always.  Drug companies up the prices of longstanding drugs (insulin, anyone), or reformulate them to maximize pricing.  Hospitals maintain chargemasters that have prices that would embarrass defense contractors.  Physicians send out "surprise" bills to patients who had no opportunity to even choose who treated them.  Commercial prices are multiples of Medicare prices, and prices for those without insurance are even higher.

Healthcare organizations and professionals should charge a fair price, one that allows them to make a reasonable return but which does not depend on the kind of insurance one happens to have (or not have) or how skillful they are at upcoding.

3. Share and share alike: Repeat after me -- patient data is theirs.  It is not the property of those treating the patients.  It shouldn't be resold without their explicit consent, and it should be easily accessible to them and to any others they choose to share it with, even if that includes competing healthcare organizations.    

Healthcare organizations and professionals should stop treating patient data as a siloed asset, and look to the business opportunities of interoperability.

4. Health does not happen in a vacuum: Yes, people can be prescribed a pill or given a procedure, but most of what influences their health happens outside healthcare settings.  It matters where they live, how well they eat, what kind of social support they have, how much they exercise.  Sending patients off with instructions they can't understand/can't follow/can't afford, or to settings where they are not safe, just invites bad outcomes and more care.   

Healthcare organizations and professionals need to deal with patients in the world in which they actually live, not in the cloistered healthcare world.

5.  Unhealthy communities mean unhealthy people.  Physicians were once always community leaders, just as hospitals used to exist as community institutions.  Not so much anymore.  Healthcare remains a leading employer in many, if not most, communities, but that is not enough.  Public health matters.  The overall economic health of the community matters.  Taking leadership roles in civic issues matters.  Communities that do not thrive usually have fewer people who thrive.  

Healthcare organizations and professionals must be community leaders with a broad view of the health of that community.

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It's great that the BRT is at least paying lip service to a broader purpose. I'll be more impressed when they do something about executive compensation, tax loopholes, and pollution, or take proactive positions on controversial issues like climate change or gun violence.  Most will not change overnight and some will not change at all.  

But we should expect more from healthcare organizations and professionals.  Lip service to the Hippocratic Oath is not enough, especially when it only is applied to physicians.  We need to stop pretending that too many in healthcare aren't driven primarily by their own economic interests or personal preferences.  We need to start acting with a higher set of principles.

The above five commitments is my proposed set.  What are yours?  

You Want to What?

I love an idea that seems to come out of the proverbial left field.  I love it when an idea seems so novel that you think, "wow, that's an interesting idea."  I especially love it when an idea borrows a practice from one industry and applies it in another. 

Take, for example, the proposal to require liability insurance for gun owners as a solution for gun control. 

Gun control is one of the social issues, much like abortion, where compromise has been increasingly hard to find.  Although a majority of Americans do support some kind of restrictions on gun ownership, a very vocal minority fiercely oppose them, citing their 2nd Amendment rights.  We've wavered through repeated efforts to impose various restrictions, but even in the wake of a number of mass shootings we still don't seem able to get consensus on bipartisan legislation to truly address it.

Mayor Sam Liccardo.  Credit: San Jose Spotlight

San Jose Mayor Sam Liccardo thus got national attention with his recent proposal for a city ordinance to reduce gun violence and its cost on the public.  It's not uncommon for cities to adopt restrictions on firearms, but what makes Mayor Liccardo's proposal newsworthy is the requirement for all gun owners to carry liability insurance (or pay a fee if unable to purchase such insurance). 

Mayor Liccardo says:

We require motorists to carry automobile insurance, and the insurance industry appropriately encourages and rewards safe driver behavior. We tax tobacco consumption both to discourage risky behavior and to make sure non-smokers are not forced to subsidize the substantial public health costs generated by smoking-related illnesses and deaths,

The proposed insurance would apply to any accidental discharge of a firearm, as well as any intentional acts of others who might borrow or steal the gun, but it would not cover intentional discharge. 

Naturally, color the NRA unimpressed.  "Criminals are already ignoring California's more than 800 gun laws, so it's doubtful many of them would rush out and get liability insurance. But, even if they did, liability insurance won't cover criminal acts," said NRA spokesperson Amy Hunter.

The Mayor admits it is not a complete solution and would not end gun violence, but at least it is doing something.  "A mayor doesn't have the luxury of just offering thoughts and prayers... we have to solve problems," he said in a statement.

There have been similar proposals before.  In fact, in early August lawyer Michael Vargas wrote an op-ed in the San Jose Spotlight calling for this very approach, and referenced examples of proposed state and federal legislation that had included it.  Mr. Vargas said:

This raises an important question: why should the cost of gun violence be shifted to gun owners? The answer is simple. Gun owners, like car owners, are the ones who control these dangerous instruments... 

Good public policy demands that we shift the burden of these costs to those who control the instruments (i.e. the guns) of gun violence. Good economic policy demands that we spread the costs among them, so that the costs are born fairly and evenly. 

Mr. Vargas agrees that the proposal would not address illegally obtained guns, but notes that many times guns used in mass shootings are legally obtained. 

Since the analogy to auto insurance is being used, it worth noting that nearly 13% of drivers are estimated not to have such insurance.  And there are drivers who don't register their car, or who drive with no license or on a suspended license.  So having requirements licensing, registration, and insurance only get us so far. 

A bigger problem may simply be that such insurance does not exist and insurers may be reluctant to get into this particular war.  “I would be lying if I said to you that the insurance companies are enthusiastic about this,” Mayor Liccardo told The New York Times.  

Still, to gun control advocates, there must be something delicious about the prospect of gun owners having to deal with the industry that everyone loves to hate.  The insurance industry is already often seen as the bad guys, so let them be the bad guys that strong-arms gun owners.  Those people we especially don't want to have guns probably would not get very good rates from insurers, and owning an assault weapon would be like owning a very expensive sports car when it comes to the cost of its insurance.  

It is financial services solution to a very real public health issue, and that makes it interesting.

Look, I don't think this approach is going to take off.  Nor do I think it would end up being particularly effective even if it did.  But I think it is an audacious approach, an example of non-linear, out-of-the-box thinking applied to a problem that seems to resist more straight-forward approaches.  So, even if it fails, it might help stimulate thinking about approaches around which we might gain consensus.  

Healthcare has developed a wide array of carrots and sticks to try to motivate behavior.  We mandate having insurance (or tried to), we give higher benefits for using preventive services or in-network providers, we charge higher premiums if you smoke or don't participate in wellness programs.  Some of them sort of work, although none of them seem to work anywhere near as well as expected.  

So what's healthcare's version of requiring liability insurance for owning a firearm?

I'm not being literal.  We already have a malpractice liability system that everyone seems to hate, which manages to hamper the way physicians practice without either improving the quality of care or rewarding most of the people who actually suffer from malpractice.  Maybe instead of a liability approach to address sub-standard yet expensive care we should be borrowing from some of the approaches that manufacturers have developed to improve quality, reduce costs, and speed the supply chain. 

You get the idea.

I often write about interesting things happening outside healthcare and then try to apply those lessons to healthcare, because I think too often people in healthcare are too insular.  Most think healthcare is unique, and many tend to look to what others in healthcare are doing for "new ideas.  When it does borrow ideas from elsewhere, its versions rarely delight.  It needs all the outside ideas it can get.

So, to whomever came up with this idea about requiring liability insurance for gun ownership: have you got any other ideas for healthcare?