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.