I Was Wrong

The New York Times had an interesting set of op-eds last week under the theme “I Was Wrong.”  For example, Paul Krugman says he was wrong about inflation, David Brooks laments being wrong about capitalism, and Bret Stevens now fears he was wrong about Trump voters.  Nobody fessed up about being wrong about healthcare, so I’ll volunteer. 

I’ve been writing regularly about healthcare for over a decade now, with some strong opinions and often with some pretty speculative ideas.  I’ve had a lot to be wrong about, and I hope I will be wrong about many of them (e.g., microplastics).  Some of my thoughts (such as on DNA storage or nanorobots) may just be still too soon, but there are definitely some things I’d thought, or at least hoped, would have happened by now.

I’ll highlight three:

I thought we’d care more about our health  

Twenty plus years ago I was an evangelist for what we’d now call digital health.  Give people more, better health information and some useful health tools, then certainly they’d  use them to improve their health. If I’d known about smartphones or wearables I’d have been even more sure.

But, it turns out, not so much. Yes, we’re all pretty good about googling health information, many of us have health apps on our phones, and wearables are cool, but we’d be hard pressed to pinpoint exactly how our health has improved, generally speaking.  Our epidemics of obesity, diabetes, and other chronic conditions continue to grow, and our mortality rates were an embarrassment even before the pandemic’s effects.

The pandemic exacerbated, but did not cause, health disparities that fall along racial, ethnic, and socioeconomic lines, ones that most countries would be embarrassed about but which the U.S. seems to tolerate without much political will around addressing them. ACA helped, but it was only a finger in the dike, and that dike is cracking.

Even worse, the pandemic proved that we care more about politics than our health, to the point many resist taking vaccines that have been proven safe and effective, or following simple public health measures like masking or social distancing. Even worse, many states are weakening public health departments’ powers generally.  How did taking care of our health become a political litmus test?

We’ve also shown that religion also trumps health, as evidenced by abortion restrictions. Some people’s religious views that a fetus is a person, even at conception, outweighs a woman’s rights to her own body, or even her own life. And those so-called “pro-life” believers only seem to care about the fetus during the pregnancy. 

I thought we’d care more about patients than profits

Silly me.

Twenty or even ten years ago seems like such a simpler time.  Hospitals hadn’t, for the most part, consolidated, franchised, or gone overseas.  Physician practices hadn’t been bought up in large numbers.  Private equity didn’t see specialists, air ambulances, nursing homes, or ER docs as huge profit opportunities.  Pharmaceutical companies hadn’t fully mastered how to extend their patents almost indefinitely in order to keep prices high.  Health insurers were happy if they could eke out margins in the low single digits. 

The healthcare system has gone all Martin Shkreli, finding profits anywhere and everywhere, the more the better.  There’s no evidence that hospital consolidation improves patient care and plenty of evidence that it raises prices. Medical school students see the income differentials and are increasingly opting to go into specialty fields.  Everyone has horror stories about prescription drug prices, yet Congress seems powerless to act, no doubt due to the pharmaceutical lobbying clout. No one thinks that private equity is looking to do anything but line their investors’ pockets. Health insurers have become so diversified that they have more revenue streams than we can count.

We’re closing in on health care at 20% of GDP. I remember people being alarmed when it hit 10%; how much more does it have to get before we recognize we’re chasing the wrong things?

I thought someone would figure out how to wreck healthcare

Mark Zuckerberg’s famous motto was “move fast and break things,” and Facebook did both, somewhat to everyone’s chagrin (and, yet, we keep using Facebook…).  That attitude has never caught on in healthcare, ostensibly because it’s too dangerous for patients. But, I’ve come to suspect, it’s more that it is too dangerous for healthcare’s many vested interests.

I’ve been looking for several years for healthcare’s Uber, the entrant(s) that don’t care about how the industry has been structured (or regulated) and want to introduce a new, better consumer experience.  Big Tech was going to come in (especially Amazon). Walmart was going to come in.  Other retail companies, like Best Buy or video game companies, were going to come in. Well, they’re in, but I’m not seeing that much disruption.

We’ve got scores of digital health companies getting ridiculous amounts of money, and many of them are doing interesting things, but I don’t see many industry-wreckers among them.  They’re more in the “if we can just get 0.x% of healthcare spending, we’ll all be rich” mindset.

Again, Uber didn’t come along to improve the taxi industry’s technology or even its rider experience. It said, the taxi industry is a 1950’s model, with very restrictive regulations, so we’ll invent a new industry that replaces it. There’s a lot to criticize Uber for, but most of the “innovators” I see in healthcare are in the “improve taxi industry technology” category, not the blow-up-the-antiquated-healthcare-industry-model(s).

I’m convinced there is a healthcare system out there that is much cheaper, much more effective, much more convenient, and much more equitable.  But continuing to graft on to our healthcare system’s existing edifices isn’t going to get us to that.   

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Barring some sort of miraculous life extension technology, I’m not going to live long enough to se what a 22^nd century healthcare system looks like.  I have high hopes for it, and none of those hopes include it being similar to today’s system.  

I hope that is barely visible to us and that we don’t even necessarily think of it as a health care system (or, at least, a medical care system), because health is so woven into our lives.  I definitely hope that health is no longer a function of your income, race/ethnicity, gender, or location. 

I just hope I’m not wrong about all that too.

Be Careful What You Wish For

I read the Stat News investigative piece “Health care’s high rollers,” by Bob Herman and colleagues, with interest but not much surprise.  I mean, is anyone surprised anymore that healthcare CEOs often make a lot of money, and didn’t let a crisis like the pandemic dampen that?  As Kaiser Family Foundation’s CEO Drew Altman told them, “Health care has become big business. We have a lot of people making a lot of money in health care, and we still have an affordability crisis in health care.”

I periodically see Twitter threads lamenting how little of that healthcare spending actually goes to physicians, yet people often still blame them for that spending.  Physicians make a pretty decent living (an average of $322,000, according to the 2022 Medscape Physician Compensation report), although that compensation depends on specialty, gender, race/ethnicity, and location.  But maybe, just maybe, the problem in healthcare is that we’re not paying physicians enough – not nearly enough. 

I think I know how to fix healthcare.

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There are about a million licensed physicians in the U.S., give or take.  I say, let’s pay each of them a million dollars a year.  No, wait: they’ll have to pay for their staff and other overhead out of that, so let’s say $1.5 million.  Heck, let’s just round it up to $2 million, and I could even see going to $2.5 million if really pushed.  And let’s index that annual amount to overall CPI. 

The caveat, though, is that they’d have to pay for all their patients’ care from that amount.  Order a test, the physician pays. Do a procedure, it comes out of the physician’s pocket.  Prescribe drugs or a medical device, it’s the physician’s responsibility to pay.  Send them to the hospital, same thing.

It’s capitation writ large. It’s global budgets at the physician level.  It’s the opposite of fee-for-service. 

Now, there’s lots of details that would need to be worked out. Many patients have multiple physicians, so deciding which physician has to pay for which care would not be trivial. Also, a physician might have an extraordinarily expensive patient, so some form of stop-loss insurance would be desirable.

And, of course, there’d need to be lots of negotiating.  I don’t picture physicians tolerating the kind of mark-ups on drugs or hospital stays that insurers seem to tolerate, not when those “excess” prices come straight out of their bottom line.  I can see groups of physicians negotiating collectively to drive better deals, sort of like Blue Shield was originally intended to do.

I can also see billing codes getting much simpler. All the current complexity helps maximize their revenue, but would be a cost burden in the new environment.  I would expect many other efforts at administrative simplification for that same reason.

Best of all for physicians and other critics of our current system, I’m not sure we’d need health insurance companies or programs, other than for the stop-loss protection I mentioned above.  No more prior authorizations, no more inexplicable denials, nor more contorted benefit designs, no more incomprehensible fee schedules. If you’re going to have to argue with someone about care you think you need, would you rather that argument be with your doctor than with an insurance company representative?

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Of course, we’d have to somehow ensure physicians continued to see patients at needed levels; they can’t take the money and decide they’re only going to see a couple patients a day, a couple days a week.   We’d need some sort of maintenance of effort or availability measures, so that patients’ access to care is at least as good as now, if not better. They’d have to see patients regardless of income, age, severity of condition, and so on; no discrimination against patients.

But, some will argue, specialists need to make more, in recognition of their skills/training. Yes, we should have that argument. We’ve been undervaluing and underpaying primary care doctors for decades now, and this would be the time to make more rational any differences that might be appropriate. The current income differences are not defensible.

But, others will argue, how does this reward physicians over time? Currently, the longer they practice, the more patients they can see/the more procedures they can do. That’s an asset in a FFS environment, but in this environment we want physicians to learn how to be more judicious, more cost-effective, thus bettering their bottom line while improving patient care.

There’s a danger, of course, that physicians might undertreat patients, would “ration” care, to the point that it has adverse impacts on their health. That is a concern, but if we’re not at least as worried about the current incentives to overtreat, then we’re not being realistic. In both cases, we need to do a better job of measures quality and outcomes of care.

Do the math: 2.5 million dollars for a million physicians is $2.5 trillion, versus our current $4 trillion spending. Throw in perhaps another half a trillion (!) for things like public health and oversight, and we’d still shave 25% of our current spending.

If that’s not worth thinking about, I don’t know what would be.

Physicians decry the diminution of their role, their loss of status, the amount of time spent on paperwork and administrative tasks. Fair enough; let’s put them in charge and see how they do. It’s hard to see that they could do much worse.

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Yeah, I know it’s never going to happen. There are hugely vested interests in our current mess of a system, and they’re not going to give up their incomes without a big fight. It’d be easy to assert (although not correct) that this would be a socialist structure, since presumably the federal government would be the one issuing those big paychecks. And maybe it gives too much power to too few people, even if those people are the ones we ostensibly trust most with our health.

I put this out there not because I think it could happen, or even should happen, but to make the point that if we don’t at least consider “outrageous” ideas like this, we’re not really thinking hard enough about healthcare reform.

Danger Ahead. Good.

I saw a great quote by Alfred North Whitehead the other day: “It is the business of the future to be dangerous.”

Now, I was a math major many years ago, so I know who Alfred North Whitehead was: the coauthor (with Bertrand Russell) of the Principia Mathematica, a landmark, three volume treatise that proved – in excruciating detail -- that all of mathematics (and thus, arguably, all of science) can be reduced to mathematical logic.  I always thought Lord Russell was the eloquent one, but it turns out that Professor Whitehead had a way with words too. 

So, of course, I want to apply a few of his particularly pithy quotes to healthcare.

Few looking at the future of healthcare wouldn’t say it was dangerous.  Our current pandemic has illustrated that no country’s healthcare system was really prepared for it; each struggled.  Sure, we developed vaccines in record time, and our healthcare workers proved, yet again, that they are capable of being heroes, but we also showed that we’re capable of throwing money – lots of it – at healthcare problems without actually solving them.

Even worse, our blithe resistance to following public health/medical advice, and our credulity for misinformation, aren’t unique to the pandemic but are endemic to our attitudes towards health generally. They help account for why our health is getting worse despite all the health care we’re getting and all the money we’re spending on it. 

There’s not going to be enough money for all our health care needs, there’s not going to be enough health care workers to give us the care we want, and the Western lifestyle is gradually undermining our health, assuming climate change and/or microplastics don’t get us first.  The future sure looks dangerous.

Yet we’re not panicking.  We’re not making wholesale changes to our healthcare systems or the way we live.  We’re relying on the familiar institutions to take care of us.  Which brings to mind a second quote from Professor Whitehead: “Familiar things happen, and mankind does not bother about them. It requires a very unusual mind to undertake the analysis of the obvious.”  In fact, he says, “It takes an extraordinary intelligence to contemplate the obvious.”

It is obvious that our current healthcare systems, and our approaches to heath, do not work and, indeed, have never worked.  We got lulled into complacency by some admittedly spectacular medical advances over the years, and grew to assume that, whatever was wrong with us, we would just take a pill or get a procedure to make us better.  

Sometimes, maybe even many times, those pills and those procedures worked, mostly, but we weren’t paying enough attention to the times they didn’t, or to the costs and consequences of them. We weren’t paying enough attention to the opportunity costs, to all the things we weren’t doing because we were doing the “familiar” healthcare things. 

E.g., making sure people don’t live in poverty.

There have been lots of proposals for changing our healthcare system(s), from lots of very smart people, but I’m not sure we’ve had the right “unusual minds,” with the necessary “extraordinary intelligence,” really contemplating the obvious.  We’ve yet to see the breakthrough suggestions about how to change the familiar about healthcare into something that works the way it could/should.

The trouble will be is that, when those suggestions come, we may not recognize their value.  Professor Whitehead warned us: “Almost all new ideas have a certain aspect of foolishness when they are first produced.”  The ideas that we’re going to need aren’t going to be clear solutions at first.  As is usually true with new ideas in science as well, we’ll laugh at them initially, deride them for being foolish, and only over time will they prove their worth.

It starts, as most things do, with asking the right question.  Professor Whitehead’s words of wisdom on this are: “The silly question is the first intimation of some totally new development.”  If we’re not asking “silly” questions, we’re not going to make quantum leaps; we’re just going to keep iterating the present.  That may be safe in the short term, but is doomed to failure in the long term.

People say they like progress, but the truth is that we don’t really like change.  Change upsets our routines; change requires us to do things differently.  “The art of progress,” Professor Whitehead believed, “is to preserve order amid change and to preserve change amid order.” 

We often have to try to preserve order amid change, as change is sometimes forced upon us, but it’s harder to preserve change amid order.  When things are going well, when it seems things are working well enough, we don’t usually go looking for change.  But for there to be progress, we must.  

I have to confess that when I introduced Professor Whitehead’s first quote, I truncated it.  The full quotes is: “It is the business of the future to be dangerous; and it is among the merits of science that it equips the future for its duties.”  Science doesn’t ensure progress, but it enables it, and the changes it brings about are what makes the future dangerous.

So be it.  The technologies that will be pervasive in 2050 are already here -- somewhere, in some form.  It’s the familiar William Gibson (supposed) quote: “the future is already here – it’s just not evenly distributed yet.”  The hard part about envisioning healthcare’s future is not predicting the technologies but in figuring out how we integrate them into our lives, and pay for them.

Me, I don’t see a healthcare future that looks much like today, with huge costs, armies of workers, bloated bureaucracies, numerous middlemen, and oft-ineffective interventions.  It’s obvious that those cannot persist. I just lack the “extraordinary intelligence” to say what comes next.

So, if you’re in healthcare, spend more time contemplating the obvious, and get some really, really bright people to help with that. Ask more silly questions.  Don’t laugh at answers that appear foolish upon first blush.  And make sure that your organization is working at least as hard to preserve change as it is to preserve order.

Yes, the future is going to be dangerous. Bring it on.

We Hold These Truths

It’s July 4^th – Independence Day for those of you who remember your U.S. history.  There’s already too much talk about loss of rights, political tyranny, militias, even succession, and I don’t want to wade any further into those troubled waters.  But I thought I could at least try to reimagine what a Declaration of Independence might look like if it was aimed at the American healthcare system. 

I’m no Thomas Jefferson, or even a Roger Sherman, but here goes:

When in the Course of human events, it becomes necessary for one people to dissolve the system of healthcare which has been responsible for its health, and to design a new such system to which the Laws of Nature and of Nature's God entitle them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation.

We hold these truths to be self-evident, that all people are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, health, and the pursuit of Happiness.

That to help secure these rights, healthcare systems are instituted, deriving their just powers from the consent of the people --That whenever any Form of healthcare becomes destructive of these ends, it is the Right of the People to alter or to abolish it, and to institute a new healthcare system, laying its foundation on such principles and organizing its powers in such form, as to them shall seem most likely to effect their Health, Safety and Happiness.

Prudence, indeed, will dictate that healthcare systems long established should not be changed for light and transient causes; and accordingly all experience hath shewn, that people are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are accustomed. But when a long train of abuses and usurpations, pursuing invariably the same Object evinces a design that hinders their well-being, it is their right, it is their duty, to throw off such healthcare system, and to provide a new one for their future health needs.

Such has been the patient sufferance of the American people; and such is now the necessity which constrains them to alter their former healthcare systems. The history of the present healthcare system is a history of repeated injuries and usurpations, all having in direct object the establishment of an absolute Tyranny over these people.

To prove this, let Facts be submitted to a candid world.

• It has led to declining mortality rates, lagging behind peer countries;
• It trails peer countries on most measures of health outcomes and quality of care;
• It spends much more than other countries, despite the greater mortality and morbidity it achieves;
• It wastes as much of a third of its spending, such as on unnecessary/inappropriate care and excessive administrative costs;
• It causes as many as a third to have medical debt and is a major factor in many bankruptcies;
• It causes as many as half to delay or skip care due to costs;
• It has allowed intolerable health inequities, such as in access, availability, cost, and outcomes of care;
• It causes health to be dictated by zip code, race/ethnicity, employer, age, and legislature(s);
• It does not recognize that almost 40 million of the population are in poverty and are food insecure, and 30 million live in hazardous housing or are homeless, all of which impact current and lifelong health
• It accepts that 80% do not get enough exercise and over half are eating less healthy than twenty years ago, both of which  impact current and lifelong health;
• It has morphed/is morphing into a series of monopolies/oligopolies, in both the provision and payment of care, not for the purpose of better care but for increased profits;
• It has violated our privacy and treated our data as a commodity for its benefit.

In every stage of these Oppressions We have Petitioned for Redress in the most humble terms: Our repeated Petitions have been answered only by repeated injury. A healthcare system whose character is thus marked by every act which may define a defective system.

We, therefore, the American people, do solemnly publish and declare, That these United States are, and of Right ought to have a more effective healthcare system; that we are Absolved from all Allegiance to the existing system, and that the existing healthcare system, is and ought to be totally dissolved; and that as Free and Independent people, we have full Power to create a healthcare system that will support the health of each person, in all aspects of that health and taking into account all the factors that contribute to that health.  

And for the support of this Declaration, with a firm reliance on the protection of divine Providence, we mutually pledge to each other our Lives, our Fortunes and our sacred Honor.

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The American Revolution wasn’t supported by the majority, took years of violence, some strokes of good luck, and a crucial ally, to bring about that Independence.  Its founders created a form of government that was brilliant yet tragically flawed (e.g., slavery, restricted voting rights), and which we are still working through, with progress not always forward (I’m talking to you, Supreme Court, the 116^th Congress, and many state legislatures).  As Winston Churchill said more generally about democracy, it is the worst form of government – except for all the others that have been tried.

Unfortunately, no one can claim that our healthcare system is better than all the other healthcare systems that have been tried.  There’s no perfect healthcare systems, and there are worst ones, but our healthcare system is the envy of no one.  It makes achieving health a matter of random chance, or size of pocketbook.  It takes a narrow definition of health and pours tremendous amounts of effort and money into trying to achieve that, for brief periods, for some people. 

We can do better.  The status quo is not working, and has never worked, not for most people.  On Independence Day, then, while you are watching fireworks, eating hot dogs, and (maybe) thinking of our brave Founding Fathers, try to think about how we can revolt against this very flawed healthcare system – and what a new system might look like. 

We Have a Right to Privacy...Right?

Well, they did it.  We had a warning they were going to do it, from the leaked opinion in May, but it still was a blow to well over half the country when the Supreme Court struck down Roe v. Wade in its ruling on Dobbs v. Jackson Women’s Health Organization. It didn’t rule that abortion was unconstitutional – as Justice Kavanaugh wrote. “On the question of abortion, the Constitution is therefore neither pro-life nor pro-choice” – but, rather, left it to the “voters,” i.e., the states, to decide.  And, boy, the “pro-life” states have been deciding and are ready to do a lot more deciding. 

Hyacinth Empinado/STAT

There has been lots of outrage, many protests, and calls for the Senate to pass a federal law explicitly granting a right to abortion (although that would require changing the filibuster rules).  Aside from the fact that the Democrats probably don’t have the votes to do that, even if they did, as soon as the Republicans retook Congress and the White House, they’d just repeal it and perhaps pass a law outlawing abortion everywhere.  So it goes.

There are going to be many fights about abortion in Congress and in the states, but I think it’s time for a new strategy.  It’s time to amend the Constitution. 

No, we’ll never get an amendment explicitly granting the right to an abortion – but we might get enough consensus on an amendment explicitly assuring the right to privacy.

Many people are surprised to learn that the Constitution does not include a right to privacy.  It has many rights that Supreme Court has ruled “imply” certain rights to privacy.  It did so in 1965’s Griswold, which for the first time gave married couples the legal right to use birth control.  It similarly did so in 1971’s Eisenstadt (contraception for unmarried couples) and in 2003’s Lawrence (gay sex), as well as, of course, in Roe (1973).  The current Court, though, found the Roe decision had been wrongly decided. 

The Court’s majority opinion, and Justice Kavanaugh’s concurring opinion, took pains to clarify that no other precedents were at stake with this ruling, but the dissenting opinions raised the alarm, and Justice Thomas’s concurring opinion sort of exposed the conservatives’ plan by noting: “In future cases, we should reconsider all of this Court's substantive due process precedents, including Griswold, Lawrence, and Obergefell [same sex marriage].”

So, after fifty years of believing they has a right to an abortion, America women suddenly are finding out that, well, it depends on where they live.  Some states are not allowing abortions even in the case of rape or incest, perhaps not even if the woman’s life is at stake.  Some states want to restrict women from traveling to other states to get abortions, or to get abortion medications through the mail.

Strange times.

We’re finding that what happens between a woman and her doctor isn’t private; we’re finding that what procedures she may have or what prescriptions she may get isn’t private.  These are matters for the state; HIPAA is not going to protect you.  We’re being reminded that HIPAA only goes so far, and, in our digital age, that isn’t very far.  Women who might have been using, say, a period tracker now have to worry who else can access their data, and what they can do with it.    

But, of course, I say “women” and I’m talking about pregnancy/abortion, but in 2022 all of us should be wondering who might be accessing our health information, for what purposes.  Our digital footprints and fingerprints are everywhere, and third parties are very interested in them, be they for law enforcement purposes or for more mercenary reasons. 

Hospitals recently got caught selling patients’ health information to Facebook, and you’d think both would know better.  Then again, Facebook is still targeting ads to patient groups on its platform, despite having promised several years ago to do better about that.  If you think there are some responsible parties watching out for our health data, I’d like to know who they are. 

It’s not just health data, of course.  We’re already concerned about data privacy generally, especially when it comes to Big Tech (whomever they might be).  A 2021 KPMG survey found that 86% of respondents had a growing concern about their data privacy, and 78% expressed fears about the data being collected.  Congress is supposedly working on the issue (long after the EU passed GDPR), with the American Data Privacy & Protection Act passing a House subcommittee earlier this week, but that’s a long way from actual passage. 

Congress is not going to be our savior.  Some states are trying, such as California, but that’s only going to go so far.  If we want to assure our privacy, and the benefits that accrue from privacy, we’re going to need to go further – much further.  We’re going to need to amend the Constitution. 

Now, I’m not naïve.  In the hyper-partisan country we live in, getting three-fourths of the states to agree on anything seems like an uphill climb.  Just ask proponents of the Equal Right Amendment, which never passed.  The last Amendment that passed (the 27^th) took 202 years, and all it tried to do was delay Congressional salary increases until after the next federal election. 

No, we’re never going to get three-fourths of states to ratify an amendment granting a right to an abortion.  But we might get enough states to ratify an amendment that codifies our rights to privacy more generally, and, if worded artfully, the right to an abortion should be a consequence.  “Pro-life” advocates are not known to be people who are usually willing to compromise, but neither are they people who typically are comfortable with either the government nor Big Tech “spying” on them. 

A right to privacy might be one thing we could all agree on; maybe not all, but perhaps at least three-fourths of us. 

Pro-choice advocates, and I count myself as one, should still be making our voices heard – going to protests, letting our local, state and federal elected officials know our feelings, advocating to strike down laws restricting access to abortions and/or proposing ones that help assure it, and, most importantly, truly voting as though our rights are at stake, because they are.  Those are all necessary actions, but not sufficient.

Anti-abortion advocates have been playing the long game, and Dobbs is its latest success.  The attack on our rights will continue to fit the conservative, evangelical Christian worldview that now drives the Republican party.  The only way to assure them is a Constitutional Amendment.

An Upside-Down Future for Healthcare

I find myself thinking about the future a lot, in part because I’ve somehow accumulated so much past, and in part because thinking about the present usually depresses me.  I’m not so sure the future is going to be better, but I still have hopes that it can be better. 

Two articles recently provided some good insights into how to think about the future: Kevin Kelly’s How to Future and an except from Jane McGonigal’s new book Imaginable: How to See the Future Coming and Feel Ready for Anything―Even Things That Seem Impossible Today that was published in Fast Company.

I’ll briefly summarize each and then try to apply them to healthcare.

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Mr. Kelly – a founding Executive Editor of Wired (and now “Senior Maverick” there), editor/ publisher of Cool Tools – posits that futurists need to look at the past, present, and future.  “They look carefully at the past because most of what will happen tomorrow is already happening today,” he notes.  “The past is the bulk of our lives, and it will be the bulk in the future.”  

As for the present:

It is often said that most futurists are really predicting the present. It turns out that the present is very hard to see…So a good futurist spends a lot of time trying to decipher the present and to try to see it through the mask of present-day biases…I sometimes think of “seeing the present” as trying on alien eyes; looking at the world as if I were an alien from another plane.

As for the future, he says, “I find it helpful to unleash the imagination and trying to believe in impossible things…there is an art to believing in impossible things well. It’s more like being open to possibilities, to listening to what is possible.” 

Mr. Kelly suggests trying to picture the “history” of an imagined future, the steps required to get to X in year YYYY, so that we can understand “What kinds of technology and laws and social expectations needed to be in place year by year in order to arrive at that state.” However, he warns: “Most important, the main job is to think about the consequences of X arriving. What would we do if X was true? How do we manage it? How do we regulated it? How does it change us as humans?”

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Dr. McGonigal – a game designer, Director at The Institute for the Future, and co-founder of health app/game SuperBetter – shares five tips for imagining the future:

Take a Ten Year Trip to the Future: “Ten years because that is enough time for society, and your own life, to become dramatically different. It’s enough time for new technologies to scale up and achieve global impact. It’s enough time for social movements to achieve historic victories. It’s enough time for big new ideas to take root, gain traction, and change the world.”

Be Ridiculous – At First: “Any useful statement about the future should at first seem ridiculous…We need to prepare our collective imagination for “unimaginable” possibilities…If something feels unimaginable, that’s the tip-off that it is an essential future to start thinking about.”

Look for Clues: “To find future clues, you need to develop a way of observing the world in which you spot weird stuff that others overlook.  You must constantly home in on things you haven’t previously encountered, things that make you say, “Huh…strange,” and “I wonder why that’s happening.”

Turn the World Upside-Down: “If your imagination feels stuck in the present, then rewrite the facts of today. Make a list of up to a hundred things that are true today, then flip them upside-down…Turning the world upside-down can help clarify what changes you want in society and your own life.”

Build Urgent Optimism: “Urgent optimism is a highly motivating, resilient mindset made up of three key psychological strengths: mental flexibility, realistic hope, and future power.’

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In healthcare, the past is, for better and for worse, always with us.  For example, the central role of hospitals and doctors is certainly over a century old, that of pharmaceutical companies almost that old; the pervasive presence of employer-provided health insurance goes back to the 1940’s and that of Medicare/Medicaid to the 1960’s.  None of them seems likely to go anywhere anytime soon.

The present of our healthcare system is, as Mr. Kelly warns, is harder to see.  It has proved dangerously fragile in this pandemic.  It never has offered equal care, or even equal access to care, to everyone.  And, most scary of all, in 2022 it turns out that we still don’t know if most medical treatments work, much less cause harm. 

It’s not a “system” in any meaningful way, and I’m honestly hard pressed to think of for whom it works well; even the people getting ridiculously compensated by it complain.  “Alien eyes” looking at it might not even recognize it as health care, especially considering we keep paying more and more yet are increasingly in worse health.

So we need to think of ridiculous futures, filled with impossible things.  We need to turn healthcare upside-down, as Dr. McGonigal might say.  Ten years isn’t going to be enough; we need to be thinking about 2050, or 2100. 

In my upside-down healthcare world, we don’t have doctors and hospitals.  Care is done at home, supported by assistive/supportive technology and overseen by artificial intelligence.  Health is monitored in real-time and any necessary adjustments are made almost as quickly, such as through the nanobots swimming within us or in the medications/devices we 3D print at home.  Care decisions and treatments are based on evidence, collected and analyzed on an ongoing basis, not on intuition, tradition, or personal preferences.  Technology has lowered costs so much that insurance is not necessary.

We acknowledge that health starts with how we live – what we eat, where we live, what we breathe, how much income we have, how we earn our living, to name a few.  We need massive savings in healthcare to invest in those. 

Where are all the healthcare workers in this future?  I don’t know, but healthcare isn’t supposed to be a jobs program.  It’s supposed to be about maintaining/improving our health.

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Sound ridiculous?  Good; that’s how we know we’re trying hard enough. 

I’m going to keep looking for clues to that future, be they improvements in AI, turd robots, or RNA computers – “weird stuff that others overlook,” as Dr. McGonigal says.  I want to be open to the possibilities that healthcare can become, not limited by our expectations about what it is now.

We need more urgent optimism about fixing healthcare.

What's Up, Docs?

Here’s how I’ll know when we’re serious about reforming the U.S. healthcare system: we’ll no longer have both M.D.s and D.O.s.

Now, I’m not saying that this change alone will bring about a new and better healthcare system; I’m just saying that until such change, our healthcare system will remain too rooted in the past, not focused enough on the science, and – most importantly – not really about patients’ best interests.

Let me make it clear from the outset that I have no dog in this hunt.  I’ve had physicians who have been M.D.s and others who have been D.O.s, and I have no indication that there have been any differences in the care due to those training differences.  That’s sort of the point: if there are no meaningful differences, why have both? 

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Chances are, your physician is an M.D.; M.D.s make up around 85% of all U.S. physicians.  You don’t see many D.O.s on television shows either; it wasn’t Marcus Welby, D.O. for example.  Gregory House was an M.D., as is Meredith Grey.  However, the number and percentage of D.O.s is increasing; 25% of U.S. medical students are in osteopathic medical schools. 

The distinction between allopathic medicine (M.D.s) and osteopathic medicine (D.O.s) has long historical roots.  The first osteopathic medical school was founded in 1892, by Dr. Andrew Taylor Still, as an effort to reform the highly variable medical education of the time.  The medical establishment was not thrilled with the new movement, but it took until 1910 for the Flexner Report to similarly try to reform allopathic medical education (and, by the way, to recommend elimination of osteopathic medical schools). 

For decades, D.O.s were a small and disadvantaged minority.  It wasn’t until 1969 that D.O.s could join the AM.A.  It wasn’t until 1973 that D.O.s were eligible for licensure in all 50 states and the District of Columbia.  It wasn’t until 2014 that allopathic and osteopathic medicine agreed to a single accreditation system for graduate medical education.  Today, the general consensus is that training is “virtually identical,” and even the distinction of an “osteopathic hospital” has, for the most part, been lost.   There are, though, still some 38 osteopathic medical schools.   

Advocates of osteopathic medicine sometimes assert that it is more holistic and more “hands-on,” but it is getting harder and harder to argue such distinctions. 

Credit: AOA

It is interesting to note that U.S. trained D.O.s have full practice rights in 45 other countries, and restricted rights in several others, but in most other countries, osteopaths are not physicians.  They can get Bachelors, Masters, or Ph.D.s in osteopathy, but these are considered non-medical degrees.  Osteopaths in those countries focus more on physical manipulation techniques that were part of the original osteopathic training (and which, in theory, D.O.s still are taught).

The U.S. is the outlier in considering D.O.s physicians. 

Again, I’m not saying the U.S. has it wrong.  I’m not saying D.O.s are not fully equivalent to M.D.s.  What I’m saying is: who does it serve to have both M.D.s and D.O.s? 

It’s hard for patients to find good physicians.  We usually rely on proximity, who is in our network, maybe some word of mouth from friends and family.  If we’re diligent, we might look at where a physician we are considering went to medical school, did their residency, had their fellowship, and got their board-certification in.  But it’s one thing to try to evaluate the importance of going to, say, Harvard Medical school versus a Caribbean medical school, but how is a patient to evaluate osteopathic versus allopathic training and licensure? 

When you’re picking a lawyer, you might care about what law school he/she went to, but at least you don’t have to think about what kind of law school it was.  That’s not true with physicians.  That doesn’t make sense, and it doesn’t help patients get the right physician and/or the best care.

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I started thinking about this issue a few years ago, when I was thinking about how we should train “A.I. physicians” (be they fully independent ones, or a additional resources for human physicians).  We’d want to give them the best data, the latest research, and the most up-to-date training.  So, would that be allopathic or osteopathic? 

If we can’t answer that question, and I don’t think we currently can, then we should be very cautious about training A.I. in medical care at all.  If we don’t understand what the biases, shortcomings, or advantages that come with each type of training, we’re imposing needless human handicaps on future A.I. capabilities.  

As I wrote in my earlier piece:

…if we don’t want our AIs to be either “M.D.” or “D.O.,” but rather a combination of the best of both, then why don’t we want the same of our human doctors? Why do we still have both? 

House, MD versus AI, What?

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Separation of D.O.s and M.D.s is a historical artifact.  The separation predates what we even think of modern medicine; prior to the Flexner Report, medical education was neither rigorous nor consistent.  Both allopathic and osteopathic medical education have changed greatly over the years, and, not coincidently, have grown more similar.  But, still, the separation remains. 

We still have those distinct medical schools, each with its own oversight organization (AACOM and AAMC).  We still have separate licensing (COMPLEX and USMLE), each overseen by its own board (NBOME and NBME).    We still have separate professional organizations (AOA and AMA).  This is no way to run a railroad, as the saying goes – much less a healthcare system.

As I often lament, it’s 2022.  We’re almost a quarter of the way through the 21^st century.  We need to figure out the best way to educate, train, license, and oversee physicians.  Maintaining a split that dates from the 19^th century is not just foolish, but downright dangerous. 

The question we should always be asking is: what is best for patients?  Not “how have we always done it?”

So, no, until I see a concerted effort to take the best from the osteopathic and allopathic schools in order to develop a 21^st approach to what a physician should be, I’m not going to take any purported healthcare reform seriously.