Nanoparticles On My Mind

Nanoparticles are everywhere!  By that I mean, of course, that there seems to be a lot of news about them lately, particularly in regard to health and healthcare.   But, of course, literally they could be anywhere and everywhere, which helps account for their potential, and their potential danger.

Let’s start with one of the more startling developments: a team at the University of Miami’s College of Engineering, led by Professor Sakhrat Khizroev, believes it has figured out a way to use nanoparticles to “talk” to the brain without wires or implants.  They use “a novel class of ultrafine units called magnetoelectric nanoparticles (MENPs)” to penetrate the blood-brain barrier. 

Credit: University of Miami

“Once the MENPs are inside the brain and positioned next to neurons, we can stimulate them with an external magnetic field, and they in turn produce an electric field we can speak to, without having to use wires,” Professor Khizroev explained.  A special magnetic helmet would communicate with the MENPs, in real-time. 

Other efforts, such as Elon Musk’s Neuralink, have been looking at using implants to achieve the brain-computer interface, but Dr. Khizroev is skeptical of this kind of approach:

Other efforts have used external instruments like microelectrodes to try to solve the mysteries of the brain, but because of its complexity and difficulty in accessing, such methods can only go so far.  There are 80 billion neurons in the human brain, so imagine how difficult it would be to attach 80 billion microelectrodes to access every single neuron. The only way to truly tap in is wirelessly—through nanotechnology.

Credit: Darpa

Professor Khizroev has been working on the technology for over a decade, and has received funding from Darpa as part of its Next Generation Non-surgical Neurotechnology (N³) program (also known as BrianSTORMs), the goal of which is “to develop high-performance, bi-directional brain-machine interfaces for able-bodied service members.”    The team got Phase II funding last November in order to build working devices. 

“Right now, we’re just scratching the surface,” Dr. Khizroev says.  “We can only imagine how our everyday life will change with such technology.”  Some of what he does imagine, though, is:

We will learn how to treat Parkinson’s, Alzheimer’s, and even depression. Not only could it revolutionize the field of neuroscience, but it could potentially change many other aspects of our health care system.

Last December, a Battelle team lead by Ping Liang, a former research partner of Dr. Khizroev, also received Phase II funding, for their work using magnetoelectric nanotransducers (MEnTs).  “Our current data suggests that we can non-surgically introduce MEnTs into the brain for subsequent bi-directional neural interfacing,” Patrick Ganzer, a Battelle researcher and the principal investigator on the project, said at the time.

Lest anyone think this is either an easy or a solved problem, Darpa points out: “N³ researchers are working to develop solutions that address challenges such as the physics of scattering and weakening of signals as they pass through skin, skull, and brain tissue, as well as designing algorithms for decoding and encoding neural signals that are represented by other modalities such as light, acoustic, or electro-magnetic energy.” 

These challenges kind of put Facebook’s new muscle movement-reading wristband in perspective, don’t they? 

But that’s not all the nanoparticle news from just this week.  In no particular order:

• Researchers from Cleveland Clinic and Chungbuk National University tested a COVID-19 vaccine (on ferrets) using antigens attached to nanoparticles.  The researchers concluded: “This approach has proven to have higher efficacy at a lower dose than traditional protein subunit vaccines,” and pointed out that it does not require cold storage. 
• Another research team, from Scripps and Temple, also tested using nanoparticles to deliver antigens for COVID-19, using three self-assembling protein nanoparticle (SApNP) platforms.  They concluded: “our study provides promising COVID-19 vaccine candidates for evaluation in clinical trials.”
• A research team at the University of Manchester used nanoparticles to discover previously unseen blood markers: “The nano-tool we developed allowed us to see deeper into the blood proteome, identifying proteins of interest that are directly associated with neurodegeneration processes in the brain, among thousands of other blood-circulating molecules.”  This might allow earlier and more definitive diagnoses of Alzheimer’s.
• A research team at the University of Science and Technology China are testing “acid-responsive nanoparticles composed solely of membrane-disruptive macromolecules” to treat pancreatic cancer.  The nanoparticles were more effective in penetrating the stroma surrounding the cancer cells. 
• Russian and Israeli researchers “have developed hybrid nanostructured particles that can be magnetically guided to the tumor, tracked by their fluorescence and pushed to release the drug on demand by ultrasound. This technology can help make cancer chemotherapy more targeted.” 

• Another Chinese research team is using nanoparticles to deliver antimicrobial peptides (AMPs) for the treatment of deep infections.  Normally AMPs are too toxic, but they believe “the development of intelligent nanocarriers can achieve selective activation and active target in the infectious sites, thus improving the therapeutic efficacy against bacterial infection and reducing the toxicity against normal tissues.”
• An international team of researchers assert: “The potential of nanotechnology in fighting this deadly disease [COVID-19] has not only been realized in context of developing a nano-vaccine but by delivering the nano-based anti-viral agents.  They propose several “nano-carriers” for various COVID-19 treatments, using “nanoencapsulation.” 
• Spanish researchers have been able to observe autonomous nanobots in vivo – inside the bladders of a living mouse -- using Positron Emission Tomography (PET).  “The possibility to monitor their activity within the body and the fact that they display a more homogeneous distribution could revolutionize the way we understand nanoparticle-based drug delivery and diagnostic approaches,” one of the researchers said. 

Nanobots in the liver over time   
Credit: Pedro Ramos, Cristina Simó / CIC biomaGUNE, IBEC, UAB

Again, that’s just this week, and only health-related nano news. 

I’m no expert on nanoparticles, or any kind of nanotechnology.  I understand that the technology has a long way to go yet.  I realize that there are risks, included unintended health effects, to using nanotechnology.  All that being said, too much of our health treatments are “shotgun” approaches that often cause as much collateral damage as beneficial impacts.  Nanoparticles offer the promise of “rifle” approaches that offer precise targeting – like using smart bombs instead of carpet bombing.   

Within my lifetime, and hopefully within the decade, we’ll have nano-delivered drugs that will greatly increase their efficacy.  We’ll have nanobots swimming around in us, for a variety of therapeutic purposes.  And we should have nanoparticle mediated brain-computer interfaces too.

Exciting stuff.   

Roblox and Healthcare's Metaverse

As neither a gamer nor the parent of a gamer, I’ve been proud that I’ve stayed even mildly in touch with the cultural phenomenon that gaming is.  I’ve written about, for example, the Metaverse, Fortnight, and e-sports.  Still, I somehow managed to be completely oblivious to the existence of Roblox, until they went public this week and was valued at $45b, larger than Electronic Arts (which I had heard of). 

Once again, I think there are lessons for healthcare.

Credit: Roblox

P.J. McNealy, CEO of Digital World Research, described Roblox to NPR as: “Minecraft meets Nintendo, which meets Lego and mobile phones enable a whole bunch of it.”  Whatever the metaphor, Roblox is booming.  It was valued at $4b a year ago, but the pandemic was very, very good for it. 

Credit: Quartz

Half of America children use Roblox.  Two thirds of its users are 16 and younger, and most of them were spending lots of time at home last year.  It is now estimated to have 37 million unique daily users, spending some 30 billion hours on the site last year.  It is available in 180 countries, in 11 languages.

What makes Roblox particularly unique is that it is not a game developer; it is a platform where users develop the “experiences”.  Roblox describes its mission thusly:

Roblox’s mission is to bring the world together through play.  We enable anyone to imagine, create, and have fun with friends as they explore millions of immersive 3D experiences, all built by a global community of developers.

It claims 8 million developers have created 20 million experiences -- and that it paid over $300 million to them.  The games are free but users can buy and spend an in-game virtual currency (Robux), which can be exchanged for actual money (Roblox shares 30% of the revenue with developers).  At least one developer made over $1 million in a single year; over 1200 made at least $10,000, with over 300 making over $100,000. 

Mr.  McNealy believes the IPO will allow Roblox significant expansion:

This money will either give them an opportunity to build more content for the for the platform or to go to adjacent platforms like music or partnering with Spotify or movie service.  That's where this is going to go.

CEO and co-founder David Baszucki isn’t content with the younger market, wondering: “So how do we make it possible for Roblox to connect with everyone in the world?”  Alex Hicks, cofounder of Roblox studio Red Manta, sees such potential, telling Polygon: “Lots of kids already know what Roblox is, but they’re just scratching the surface with the older audience.” 

In a February company blog post, Mr. Baszucki outlined some of the vision:

We see a future where tens of thousands of people can gather in a single instance to join a virtual business conference, attend a movie premier, or watch their favorite artists perform live.  We are working to make this vision a reality, innovating towards new technologies such as spatial audio and high-fidelity avatars with lifelike facial expressions.

Microsoft (Teams), Google (YouTube), and Facebook (Live) should all be looking over their figurative shoulders.  

Mr. Baszucki told Wired last year:

We will see a shift in the way people play, work, learn or simply hang out in 2021. Some of these connections will move into the Metaverse, a digital place where people seamlessly get together and interact in millions of 3D virtual experiences...[it is] arguably as big a shift in online communications as the telephone or the internet.

 Ah, the metaverse again. 

Credit: Roblox

To recap: a platform that relies on -- and rewards -- on user-generated content, thrives on shared immersive experiences, appeals to young people, and is fun.   Let’s see, which of those also apply to our healthcare system?  That’s right: none.

Healthcare is at least talking about platforms (e.g., Mayo Clinic Platform), but the closest thing the U.S. healthcare system has to a platform is probably Epic, which is renowned for poor usability and lack of interoperability.  Companies like AmWell would love to be the new platform, but are only slowly moving out from telehealth roots.  Optum is many things to many people, but not anywhere near being a platform.

Peer-to-peer support/advice is becoming more important in healthcare, but usually despite the healthcare professionals and institutions, not because of them.  Professional advice and treatment is still considered the “gold standard.”  Paying for patient-created “experiences” is unheard of. 

As for fun, well, when people use “Hunger Games” to describe what it is like to score COVID-19 vaccination appointments, it isn’t intended to convey any fun.  Healthcare may be allowing some games/gamification, but it is much too serious to take the importance of fun seriously.

Where is the healthcare platform that is built upon user-created content, paying those creators for how they engage other users in immersive 3D experiences?  “Participatory medicine” means simply allowing patients a say in their own care, which is a low bar Roblox wouldn’t even recognize.

Online gaming is a new industry compared to healthcare, but we’re already seeing the battle of its old guard and newer models.  In Venture Beat, Dean Takahaski contrasts Roblox’s IPO with Microsoft’s blockbuster acquisition of video game publisher Bethesda:

I see it as a contest between a promising part of the industry, as represented by the potential of the user-generated content of Roblox, and the old part of the industry, where Microsoft’s purchase of Bethesda is a new step in consolidation.

The way Techcrunch’s Luke Matney sees it:

The gaming industry has entered a very democratic stride as cross-play tears down some of the walls of gaming’s platform dynamics…While massive publishers have tapped cloud gaming as the trend that will string their blockbuster franchises together, they all wish they were in Roblox’s position.

Healthcare needs a Roblox.  It needs a platform that user created content and tools, among other things, can be built upon.  It needs a platform that engages users, using the latest technologies.  It needs a healthcare Metaverse. 

Such a company probably won’t come from within healthcare; e.g., Epic Games is more likely to create a healthcare Metaverse than Epic. 

I don’t know what a healthcare Roblox would look like; to be honest, I don’t really even know what Roblox looks like.  But I hope that there are some younger, smarter, more gaming-oriented people who can imagine what it might be, and that they make it happen. 

Your Health Data May Be a NFT

I must admit, after I wrote about digital currency last week, I did not expect to be writing about crypto anytime soon. Then I heard about “non-fungible tokens” (NFTs) and got a sense of the hype they were causing -- how I could I resist?

There may even be a connection to health care. 

You may have seen the Nyan Cat (pictured below), which is not new; it turns 10 in April.   What is new is that last month its creator “sold” it.  You may be thinking, wait, the GIF is everywhere, anyone can download it, so in what sense could he “sell” it?   

That’s where NFTs come in.  As you may know, “fungible” means that two things can be interchanged; one dollar is just like any other dollar, one bitcoin is like any other bitcoin, one electron is like any other electron.  Non-fungible, then, means the item in question is unique, and this is where the “token” comes in.  Basically, NFTs use digital certificates via blockchain to mark that something is one-of-a-kind, a claim of digital ownership.

Nadya Ivanova, chief operating officer of research firm L’Atelier explained NFTs to The Wall Street Journal: 

Think of it like a digital passport that comes with an asset.  They allow for this trust and authenticity to be established in a way that we haven’t been able to do before, whether it’s with physical assets or digital assets.

Artists have been using NFTs for a few years now, and auction house Christie’s is auctioning off the “First Purely Digital NFT-Based Work of Art Ever Offered by a Major Auction House,” featuring the digital artist Beeple (aka Mike Winklemann).  Christie’s promises:

…the buyer receives the artwork file containing a digital signature from the artist and all vital details including time of creation, edition size and a record of any prior sales. These details are permanently attached to the artwork, providing an enduring guarantee of value. 

NFTs have gone beyond art.  The NBA is all over this, with NBA Top Shot selling highlight clips; one of Lebron dunking just went for $200,000.  Maverick’s owner Mark Cuban is a big proponent.  “The tech is real,” he told CNBC. “The impact is real, and permanent.” 

Kings of Leon is releasing their new album as an NFT, believed to be the first group to do so.  Jack Dorsey is selling his first ever tweet as an NFT, and bids are already in excess of $2.5 million.  Singer Grimes has made $6m selling her mixed media artwork as NFTs.  Even Lindsay Lohan is cashing in. 

If you’re having a hard time discerning the underlying theme, join the club.  We’re in early days yet, and what NFTs prove best for remain to be seen.  As Kate Haun, a partner at Andressen Horowitz, admitted to NPR: "At the time the iPhone was created, nobody would've thought that one of the killer apps was going to be hailing a ride."

She went on to add:

Remember those days where people would line up for the newest Nike Air Jordan sneakers at the physical store? This is the new digital equivalent.  It's everything that brings together culture, and it's also a bet on the future of e-commerce.

Luke Heemsbergen, a professor at Deakin University. wrote in The Conversation:

NFTs are a cultural answer to creating technical scarcity on the internet, and they allow new types of digital goods… [they] bring code and culture together to create a form of control that doesn’t rely on the law or sabotaging existing systems. They create a unique kind of “authenticity” in a[n] otherwise shareable world.

All this means that NFTs are potentially revolutionary.  Bloomberg’s Leonid Bershidsky points out:

You could also see it as a new concept of property, which communist dreamers of centuries past would have found to their liking: It’s communal in all practical applications even as it feeds the creator and honors the supporter.

Anybody hooked by the news of (pretty unremarkable) videos and collages selling for lots of money will quickly find out that the NFT concept can be applied to property rights on everything under the sun (or, as the community would hope, that Bitcoin moon).

 A new concept of property, applied to property rights on everything…yeah, I’d call that revolutionary.

What makes NFTs even more intriguing is that some content creators are specifying that, as the NFT is resold, they get paid, giving them a future revenue stream and a share in any appreciation in value. 

So, what might this have to do with healthcare?

There are undoubtedly lots of potential applications, but my thoughts immediately went to health data.  It has long been a bitter fight in healthcare: whose data is it, anyway?  Patients believe it is theirs, but they don’t hold it, don’t always have access to it, can’t control it from being shared or even sold, and generate no economic value from it even as it produces real economic gains for companies using it.   

All of that is maddening, yet not much of it is likely to change under the existing paradigms.     

If our health data was an NFT, we could have more control when it was shared.  We could auction it off.  We could ensure that we benefit financially as others use it or resell it.  And, by the way, all the parties using it could have more assurance that the data was authentic.

There has been much talk about use of blockchain in healthcare, as in many other industries.  Mr. Cuban says, speaking specifically in reference to NFTs, “[B]lockchain and smart contracts and marketplaces are here to stay.”  NFTs could be blockchain’s killer app in healthcare.

A big drawback to NFTs, as with blockchain and cryptocurrency more generally, is that they require a lot of computing power.  NPR points out: “By some estimates, one crypto transaction could gobble up more power than the average U.S. households uses in a single day.” 

But, as Dr. Heemsbergen points out: “Other than their tonnes of CO₂ emissions, what’s real about NFTs is how their creation of technical scarcity enables a new cultural agreement about how something can be authentic and who controls that authenticity.” 

We can use NFTs to do that with digital art and dunk highlights, or we can do something meaningful by applying them to our health data.  If anything needs a “new concept of property,” it’s health data. 

Wanna Buy Some Bitcoin

To healthcare organizations, digital currency is the thing you’re forced to deal with when your systems are held for ransomware.  To the rest of the world, it’s increasingly starting to look like the future.

Credit: Getty Images

Tesla caused somewhat of a stir last month when it disclosed that it had bought $1.5b of bitcoin.  It also said it would start accepting bitcoin payments for its cars.  CEO Elon Musk added to the furor, saying: "I do at this point think bitcoin is a good thing. I'm late to the party, but I am a supporter of bitcoin.” 

Most of us are late to the digital currency party. 

Credit: FamZoo Staff

Bitcoin’s market cap hit $1 trillion in mid-February, although it now hovers just over $900b, with Ethereum another almost $200b.  Tesla is making more money from its bitcoin investment than from its core businesses.  In the scheme of global financial markets, digital currencies are still small, but are not something any CFO should be ignoring.   

Tesla is not the only major company accepting digital currencies; Overstock, Starbucks and Twitch do, as three wildly different examples.  Twitter is thinking about paying vendors or even employees with bitcoin.  Facebook expects to launch its own cryptocurrency this year. 

I’m not aware, though, of any major healthcare companies accepting or paying with digital currencies.  No Tesla-type breakthroughs in healthcare.   

Banks recognize the threat that digital currencies could pose to them.  Just today, Citi allowed that bitcoin could “become the currency of choice for international trade.” Its research note went on:

Bitcoin’s future is thus still uncertain, but developments in the near term are likely to prove decisive as the currency balances at the tipping point of mainstream acceptance or a speculative implosion.

Bank of New York MellonCorp announced last month that it would hold, transfer and issue bitcoin and other cryptocurrencies for its asset management customers.  “Digital assets are becoming part of the mainstream,” said Roman Regelman, chief executive of BNY Mellon’s asset-servicing and digital businesses.  JP Morgan isn’t there yet, but last week said it would allow investors to hold up to 1% of their portfolio in cryptocurrencies. 

PayPal announced last October: “Beginning in early 2021, PayPal customers will be able to use their cryptocurrency holdings as a funding source to pay at PayPal's 26 million merchants around the globe.”  Dan Schulman, president and CEO, said:

The shift to digital forms of currencies is inevitable, bringing with it clear advantages in terms of financial inclusion and access; efficiency, speed and resilience of the payments system; and the ability for governments to disburse funds to citizens quickly.

Mastercard and Visa are also already bowing to that inevitable. 

One of the aspects of bitcoin and other cryptocurrencies that holds much appeal is that they bypass central banks, unlike so-called “fiat currencies” issues by nations’ central banks.  Those central banks are recognizing that they risk being left out of the future, and are determined to have their say. 

Credit: Ledger Insights

A recent Bank for International Settlements survey found that more than 86 central banks were exploring a central bank digital currency, with more than 60 countries already testing the concept.  Countries like the Bahamas (Sand Dollar) and Sweden (e-krona) are already far along in their testing; the Swedish central bank (Riksbank) wants making e-krona payments to be “as easy as sending a text.”

Even the U.S. is finally coming around to the idea, with Treasury Secretary Janet Yellen allowing that digital currency was “absolutely worth looking at” because it “could result in faster, safer and cheaper payments,” although she also expressed some concerns.  Fed Chairman Jerome Powell told Congress that such a currency is a “high priority project for us…This is something we're investing time and labor in, across the Federal Reserve system”

But, as Frederick Kempe, President & CEO of the Atlantic Council, wrote in a CNBC op-ed: “Yet while the Fed consults, China executes.”

China is, indeed, not late to this party.  It is aggressively working on a national digital currency.  The New York Times reported: “no major power is as far along as China. Its early moves could signal where the rest of the world goes with digital currencies.”   

Mr. Kempe worries:

Chinese officials have made no secret that their greatly accelerated efforts at introducing and distributing the digital yuan are an opening move in their long-term strategy to undermine the dollar’s global supremacy and expand their influence.

If the U.S. loses the high ground of financial technological innovation, combined with a weakening of the dollar’s global dominance, the benefits for Beijing would be considerable.

An article in the magazine of China’s central bank admitted: “The right to issue and control digital currencies will become a ‘new battlefield’ of competition between sovereign states.” 

I’ve written before about how China is threatening America’s lead in emerging technologies, social media, and AI healthcare, but I hadn’t thought much about losing “the high ground of financial technological innovation” to China as well.  It’s a battlefield we’re not prepared for.

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In the best case, digital currencies could make payments “as easy as sending a text,” as Rikbank hopes.  They should make processing those payments faster, more secure, and less impacted by national boundaries.  They’d open up electronic payments to the unbanked; anyone with a smartphone could use them. 

KHYLIN WOODROW/BLOOMBERG BUSINESSWEEK

In the worst case, though, they could further erode privacy; all those anonymous cash or bitcoin payments could be tracked, such as through a central bank.   Yaya Fanusie, a fellow at the Center on Economic and Financial Power, told The New York Times:  “This is about more than just money.  It’s about developing new tools to collect data and leverage that data so that the Chinese economy is more intelligent and based on real-time information.”   China won’t be the only country with such interests.

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The Digital Currency Initiative at MIT Media Lab says its mission is “to create a future in which moving value across the Internet is as intuitive and efficient as moving information.”  That just makes me smile; when it comes to healthcare, moving information is still neither intuitive nor efficient.   

Healthcare has lots on its plate right now, with a host of legacy issues that have only been exacerbated by the pandemic.  I get that.  Incorporating digital currencies is not on the front burner.  But ignoring them won’t make them go away; it will only make the “inevitable” transition harder. 

Need Care, Should Travel

As tempting as it is to write about the parallels to healthcare of the Texas power/water debacle, or about IBM’s rumored desire to sell off its Watson Health division, I find myself thinking once more about our inability to distinguish quality in our health care. 

I live in Cincinnati (OH).  The metro area has five hospital systems, including an academic medical center (University of Cincinnati), plus a renowned children’s hospital (Cincinnati Children’s) and a VA hospital. Most Cincinnati residents go their entire lives getting all their medical care here. 

That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  Most people have some nationally ranked hospitals within a few hours drive, and everyone is within a few hours flight from some, but all-too-few actively pursue them, despite “centers of excellence” programs that many health plans have used to encourage such travel.  Even people living in cities with such hospitals don’t always choose to get their care from them. 

There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally; it’s harder on the patient, harder on the family, and those travel expenses/time are usually not reimbursed. 

What, me travel?

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine.  If you have a cold or the flu, chances are you can get pretty good care for it locally.  Even if you have a more serious condition like diabetes or asthma, local physicians and hospitals can usually help you manage it well.  But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling.   

The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care?  I can get a heart transplant locally; I can get almost any kind of cancer care I might need here, and, if not, certainly in Columbus.  When is that care likely to be not good enough?

I don’t know, you don’t know, and even “experts” are likely to disagree. 

I wish all the hospital advertising I see spent at least a little time telling me when I shouldn’t go there, instead of telling me why I should always go there.  The facts are that outcomes aren’t the same, that doctors in different hospitals don’t have the same experience/expertise, and that all-things-to-all-people is not the best recipe for best-in-class.  

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

E.g., outcomes for colds are likely to be similar no matter where/from whom you get treatment, but chances that you’ll survive a heart transplant (and have high quality of life afterward) are heavily dependent on where/from whom you get the transplant.   

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

I’m not intending to do business development for The Cleveland Clinic, or, for that matter, for USN&WR.  I’m just using them to make the point.  Pick your preferred hospitals, pick your preferred rating mechanism, but the fact remains that all care is not the same.  Some hospitals are better for some things than others.  We just don’t act as though that was true.

Of course, there would be non-trivial financial implications to such a change.  Hospitals that are not nationally ranked aren’t likely to be willing to give up those more severe patients; instead, they’ve been investing over the past few decades to bring more & more services within their walls.  Whether that results in better outcomes for patients, though, is at best unclear. 

Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  For the most part, we pay regardless of the quality.  Value-based programs are, to date, more for show than for effect. 

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. 

All politics, as they say, is local, but all health care shouldn’t be. 

Healthcare Needs Its Mary Barra

With all that has been going on, I’ve been remiss in reflecting on General Motor’s big announcement a couple weeks ago: it is going to have an all electric, zero emissions fleet of “light duty” vehicles (cars, SUVs, pickups) by 2035, and be carbon neutral by 2040.  One of the largest manufacturers of internal combustion vehicles for over a hundred years is recognizing that its past is not its future.

Of course, I immediately wondered what the equivalent move in healthcare would be, and from whom. 

GM's Mary Barra Credit: GM

 In the announcement, GM Chairman and CEO Mary Barra declared:

General Motors is joining governments and companies around the globe working to establish a safer, greener and better world.  We encourage others to follow suit and make a significant impact on our industry and on the economy as a whole.

You can just imagine Henry Ford fuming in his grave.

GM has had electric vehicles for some time, but they remain a small percentage of its business, as they do among the auto industry generally (Tesla’s market cap notwithstanding).  GM had supported the Trump Administration’s policies efforts to rescind emission standards, which benefited internal combustion engines, but quickly changed course in light of Biden Administration priorities on climate change.

GM now plans to spend some $27b on electric and autonomous vehicles over the next few years.  “We’re committed to fighting for EV market share until we are No. 1 in North America, Ms. Barra said at an investor’s conference.   “EVs are core to creating GM shareholder value.”

None of the major auto manufacturers immediately matched GM’s move, although all have introduced electric vehicles and Ford, in particular, vowed to invest $29b in electric/autonomous vehicles through 2025. A Ford spokesperson said the company was “committed to leading the electric vehicle revolution in the areas where we are strong.” 

Although there are, not surprisingly, skeptics, most observers praised GM’s announcement.  Paul Bledsoe, a climate expert at the Progressive Policy Institute, told The Washington Post: “When America’s most iconic manufacturer commits to carbon neutrality, that’s a huge signal to the rest of the economy.” Erik Gordon, a business professor at the University of Michigan, told The New York Times:

This is a guardedly bold move.  It’s not that risky. Fifteen or 20 years from now, who knows where we might be? Mary Barra won’t even be C.E.O. But right now it’s hugely symbolic. This is very forward-looking.

To be sure, the 2035 emissions deadline is a goal, not a commitment.  Mike Ramsey, a vice president at Gartner told Sierra: “I think GM is serious in the sense that it is an aspirational goal. If the market doesn’t move that way fast enough, they aren’t going to stop making engines and gas tanks just because they said they would.”

“The central point is that we made a firm commitment to carbon neutrality by 2040,” Jessica James, assistant manager of sustainability communications at GM, explained. “That is happening. But some things need to come together to meet the 2035 deadline—it’s out of our direct control.” 

I don’t know if GM will live up to its announcement, or even if GM will still be around in 2035, but I love bold promises from otherwise stodgy companies.  If Microsoft can become a leader in open source software, who’s to say that GM can’t reinvent itself?  More power to them.

So what are some equivalent things healthcare organizations might do, changing core parts of how they’ve operated to better serve society?  Here are a few suggestions:

• Epic could promise that data in its EHRs will be fully interoperable with other EHRs, with a consolidated patient record across health systems.  “Patient data belongs to patients.  Our job is to use that data to help patients and all of their health care professionals make better health decisions.”
• Sutter Health could announce it is getting rid of its chargemaster.  “Medicare payments shall be our base payment level, and no payor will have rates more than 120% of that."
• UVA Health could vow to stop suing its patients.  “We’re here to help patients, not go after them during vulnerable times in their lives.  Any billing/collection disputes will be worked out through third party arbitration.”
• UPMC could agree to pay local property taxes.  “We are committed to helping improve the health of our community, and we recognize that paying our fair share of local taxes is an important part of that goal.”
• TeamHealth and Envision Healthcare, both owned by private equity firms, could put an end to their surprise billing practices.  “We commit that all of our professionals will be in-network for all major health insurers, or will accept the payment level from the largest health insurer in the given market as our charge.” 
• Pfizer and Eli Lilly could put an end to pricing practices that make their drugs much more expensive in the U.S. than in other countries, especially for such necessary products as Epipen and insulin (respectively).  “We can no longer drive our profits from U.S. customers.  Our U.S. prices will be consistent with prices charged in G20 countries.”
• The AMA and the medical specialty societies could agree to give up control of the Relative Value Scale Update Committee (RUC), which determines changes to RBRVS weights.  “We recognize that, in this era of transparency, our involvement in helping set payment levels that our members may benefit from is no longer appropriate.” 
• The Association of America Medical Colleges and The American Association of Colleges of Osteopathic Medicine could agree to merge.  “Over 110 years after the Flexner report, we believe it is long past time that the historical differences between M.D.s and D.O.s be eliminated, in favor of a single system of education, training, licensing and oversight of physicians that will best serve patients in the 21^st century.”

One difference between these promises and GM’s: we shouldn’t have to wait until 2035.  These are things that can and should be done within a few years.

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 Almost seventy years ago, GM President Charles Wilson made his famous (mis)quote: “what’s good for GM is good for America” (although his actual quote was “I thought what was good for our country was good for General Motors, and vice versa.”)  Healthcare is a much bigger portion of our economy than auto manufacturing is or ever was, and anything that is good for healthcare but bad for the people using it cannot really be good for either healthcare or the country.

Healthcare has a chance to re-stake its future.  It should make, and keep, some bold promises.  If doing so is good for GM, it should be good for healthcare as well.  Where are its Mary Barras?