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Tuesday, May 23, 2017

"Assuming / Despite / If / Then / Therefore / Else..." Could AI do "argument analysis?"


When I was a kid in grade school, back prior to indoor plumbing, it was just broadly referred to as "reading comprehension" -- "What was the author's main point?" Did she provide good evidence for her point of view? Do you agree with the author's conclusion? Why? Explain..."

The oral equivalent was taught in "debate teams" prep.

Now along comes the part of "AI" technology R&D (Artificial Intelligence) known by its top-level acronym "NLP" (Natural Language Processing). We see increasing discourse on developments in "Machine Learning," "Deep Learning," "Natural Language Generation" (NLG) and "Natural Language Understanding" (NLU).
There's been a good bit of chatter of late in the Health IT news about the asserted utility of NLP. See here as well.
I am interested in particular in the latter (NLU), most specifically as it pertains to rational "argumentative" discourse (mostly of the written type). e.g., "Critical Thinking" comes to mind (I was lucky to get to teach it for a number of years as an adjunct faculty member). I was subsequently accorded the opportunity to teach a graduate seminar in the higher-level "Argument Analysis."

From my grad seminar syllabus:
We focus on effective analysis and evaluation of arguments in ordinary language. The "analysis" part involves the process of getting at what is truly being argued by a proponent of a position on an issue. Only once we have done that can we begin to accurately assess the relative merits of a proposition—the "evaluation" phase. These skills are essential to grasp if we are to become honest and constructive contributors to debate and the resolution of issues.

Our 24/7 global communications civilization is awash in arguments ranging from the trivial to grand themes of moral import. Advocates of every stripe and theme pepper us relentlessly with persuasion messages ranging from the "short and sweet" to the dense and inscrutable. We have more to consider and evaluate than time permits, so we must prioritize. This we often do by making precipitous snap judgments—"Ready-Shoot-Aim"—which then frequently calcify into prejudice. The sophistication and nuance of language enables a savvy partisan to entice us into buying into an argument perhaps not well supported by the facts and logic...
I first encountered "Argument Analysis" in the fall of 1994 as an "Ethics & Policy Studies" graduate student myself. I chose for my first semester paper an analytic deconstruction of the PNHP 1994 JAMA paper "A Better-Quality Alternative: Single-Payer National Health System Reform."

The first two opening paragraphs:
MANY MISCONSTRUE US health system reform options by presuming that "trade-offs" are needed to counter-balance the competing goals of increasing access, containing costs, and preserving quality. Standing as an apparent paradox to this zero-sum equation are countries such as Canada that ensure access to all at a cost 40% per capita less, with satisfaction and outcomes as good as or better than those in the United States. While the efficiencies of a single-payer universal program are widely acknowledged to facilitate simultaneous cost control and universal access, lingering concerns about quality have blunted support for this approach.
Quality is of paramount importance to Americans. Opponents of reform appeal to fears of diminished quality, warning of waiting lists, rationing, and "government control." Missing from more narrow discussions of the accuracy of such charges is a broader exploration of the quality implications of a universal health care program. Conversely, advocates of national health insurance have failed to emphasize quality issues as key criteria for reform, often assuming that we have "the best medical services in the world." They portray reform primarily as extending the benefits of private insurance to those currently uninsured, with safeguards added to preserve quality.
For the "analysis" phase I undertook to examine and "flowchart" the subordinate arguments' logic of the 49 paragraphs of assertions comprising the PHNP article, numbering every argument statement as "paragraph(n), sentence(n.n), and sub-sentence truth-claim clause(n.n.n) where warranted" as evident by close reading of the text. My full (pdf) copy of the paper is parked here.

Click to enlarge.
Dotted lines denote a "despite" (a.k.a. "notwithstanding") statement, whereas solid lines depict "because-therefore" premise-to-conclusion movement in the direction of the arrowheads.

It was tedious. The bulk of the first 25 pages of the 56 page paper comprised this analytic "flowcharting" visualization helpful for what the late Steve Covey would characterize as a crucial "seek first to understand" effort. The remaining 31 pages subsequently focused on my (in large measure subjective) critical evaluation of the logic and evidence provided by the authors.
BTW: I'm certain I didn't get everything exactly right on the "analysis" side (or the eval side, for that matter). It was my first run at this type of thing. And, I had a second course to deal with at the time ("History of Ethics," 11 required texts) and was still working full-time at my Medicare QIO job.
I have a good 100 hours or so in that one paper. Imagine trying to do that to an entire book.

Hmmm...


Could we develop an AI NLU "app" for that? (I don't underestimate the difficulty, given the myriad fluid nuances of natural language. But, still...)

Logic visualization software is not exactly news. In the late 80's I developed an instrumentation statistical process control program for the radiation lab where I worked in Oak Ridge -- the "IQCstats" system (pdf). Below is one page of the 100 or so comprising the logic flowcharts set included in my old 2" bound "User and Technical Guide" manual.

Click to enlarge

The flowchart set was generated by an "app' known as "CLEAR," which parsed my source code logic and rendered a complete set of flowcharts.

While "critical evaluation" of arguments proffered in ordinary language might not lend itself to automated digital assessment (human "judgments"), mapping the "Assuming / Despite / If / Then / Therefore / Else" logic might indeed be do-able in light of advances in "Computational Linguistics" (abetted by our exponentially increasing availability of ever-cheaper raw computing power).

Below, my graphical analogy for the fundamental unit of "argument" (a.k.a. "truth claim").

Click to enlarge



Any complex argument arises from assemblages of the foregoing "atomic" and "molecular" "particles" (once you've weeded through and discarded all of the "noise").
I should add that most of what I'm interested in here goes to "informal/propositional logic" in ordinary language. Formal syllogistic logic (e.g., formal deductive "proofs") comprise a far smaller subset of what we humans do in day-to-day reasoning.
English language discourse, recall, beyond the smaller "parts of speech," is comprised of four sentence types:
  1. Declarative;
  2. Interrogative;
  3. Imperative;
  4. Exclamatory.
We are principally interested in the subset of declaratives known as "truth claims" -- claims in need of evaluation prior to acceptance -- though we also have to be alert to the phony "interrogative" known as the "loaded question," i.e., an argument insinuation disingenuously posed as a "have-you-stopped-beating-your-wife" type of query.

NLP AND LINGUISTICS

It occurs to me that, notwithstanding my longstanding chops on the verbal/written side, I've never had any formal study in "linguistics," much less its application in NLP. Time to start reading up.

Introduction
Natural languages are the languages which have naturally evolved and used by human beings for communication purposes, For example Hindi, English, French, German are natural languages.  Natural language processing or NLP (also called computational linguistics) is the scientific study of languages from computational perspective. natural language processing (NLP) is a field of computer science and linguistics concerned with the interactions between computers and human (natural) languages. Natural language generation systems convert information from computer databases into readable human language. Natural language understanding systems convert samples of human language into more formal representations such as parse trees or first order logic that are easier for computer programs to manipulate. Many problems within NLP apply to both generating and understanding; for example, the computer must  be able to model morphology (the structure of words) in order to understand an English sentence, and a model of morphology is also needed for producing a grammatically correct English sentence, i.e., natural language generator.

NLP has significant overlap with the field of computational linguistics, and is often considered a subfield of artificial intelligence. The term natural language is used to distinguish human languages (such as Spanish, Swahili, or Swedish) from formal or computer languages (such as C++, Java, or LISP).  Although NLP may end comp us both  text and speech, work on speech processing is conventionally done in a separate field.

In NLP, the techniques are developed which aim the computer to understand the commands given in natural language and perform according to it. At present, to work with computer, the input is required to be given in formal languages. The formal languages are those languages which are specifically developed to communicate  with computer and are understood by machine, e.g., FORTRAN, Pascal, etc. Obviously, to communicate with computer, the study of these formal languages is required. Understanding these languages is  cumbersome and requires additional efforts to understand these. Hence, it limits their applications in computer. As compared to this, the communication in natural language will facilitate the functioning and communication with computer easily and in user-friendly way.

 Natural language processing is a significant area of artificial intelligence because a computer would be considered intelligent  if it can understand the commands given in natural language instead of C, FORTRAN, or Pascal. Hence, with the ability of computers to understand natural language it becomes much easier to communicate with computers. Also the natural language processing can be applied as a productivity tool in applications ranging from summarization of news to translate from one language to another. Though, the surface level processing of natural languages seems to be easy the deep level processing of natural languages, understanding of implicit messages and intentions of the speaker are extremely difficult avenues...
Ya have to wonder whether that was written by a computer. Minimally, a non-native English speaker/writer.

I've also just read up on "linguistics" broadly via a couple of short books, just to survey the domain.


The real meat comes here:


801 pages of dense, comprehensive detail.
Introduction
The field of computational linguistics (CL), together with its engineering domain of natural language processing (NLP), has exploded in recent years. It has developed rapidly from a relatively obscure adjunct of both AI and formal linguistics into a thriving scientific discipline. It has also become an important area of industrial development. The focus of research in CL and NLP has shifted over the past three decades from the study of small prototypes and theoretical models to robust learning and processing systems applied to large corpora. This handbook is intended to provide an introduction to the main areas of CL and NLP, and an overview of current work in these areas. It is designed as a reference and source text for graduate students and researchers from computer science, linguistics, psychology, philosophy, and mathematics who are interested in this area.
The volume is divided into four main parts. Part I contains chapters on the formal foundations of the discipline. Part II introduces the current methods that are employed in CL and NLP, and it divides into three subsections. The first section describes several influential approaches to Machine Learning (ML) and their application to NLP tasks. The second section presents work in the annotation of corpora. The last section addresses the problem of evaluating the performance of NLP systems. Part III of the handbook takes up the use of CL and NLP procedures within particular linguistic domains. Finally, Part IV discusses several leading engineering tasks to which these procedures are applied...

(2013-04-24). The Handbook of Computational Linguistics and Natural Language Processing (Blackwell Handbooks in Linguistics) (p. 1). Wiley. Kindle Edition.
Interesting. BTW, nice summation of Computational Linguistics on the Wiki.
Computational linguistics is an interdisciplinary field concerned with the statistical or rule-based modeling of natural language from a computational perspective.

Traditionally, computational linguistics was performed by computer scientists who had specialized in the application of computers to the processing of a natural language. Today, computational linguists often work as members of interdisciplinary teams, which can include regular linguists, experts in the target language, and computer scientists. In general, computational linguistics draws upon the involvement of linguists, computer scientists, experts in artificial intelligence, mathematicians, logicians, philosophers, cognitive scientists, cognitive psychologists, psycholinguists, anthropologists and neuroscientists, among others.

Computational linguistics has theoretical and applied components. Theoretical computational linguistics focuses on issues in theoretical linguistics and cognitive science, and applied computational linguistics focuses on the practical outcome of modeling human language use...
"applied computational linguistics focuses on the practical outcome of modeling human language..."

Like, well, NLU Argument Analytics?

After getting up to speed on the technical concepts and salient details, perhaps the next step would involve learning Python.

"This book offers a highly accessible introduction to natural language processing, the field that supports a variety of language technologies, from predictive text and email filtering to automatic summarization and translation. With it, you'll learn how to write Python programs that work with large collections of unstructured text. You'll access richly annotated datasets using a comprehensive range of linguistic data structures, and you'll understand the main algorithms for analyzing the content and structure of written communication.

Packed with examples and exercises, Natural Language Processing with Python will help you:
  • Extract information from unstructured text, either to guess the topic or identify "named entities"
  • Analyze linguistic structure in text, including parsing and semantic analysis
  • Access popular linguistic databases, including WordNet and treebanks
  • Integrate techniques drawn from fields as diverse as linguistics and artificial intelligence
This book will help you gain practical skills in natural language processing using the Python programming language and the Natural Language Toolkit (NLTK) open source library. If you're interested in developing web applications, analyzing multilingual news sources, or documenting endangered languages -- or if you're simply curious to have a programmer's perspective on how human language works -- you'll find Natural Language Processing with Python both fascinating and immensely useful."
apropos of this topic generally, a couple of prior posts of mine come to mind. See "The Great A.I. Awakening? Health Care Implications?" and "Are structured data now the enemy of health care quality?"

So, could we use digital NLU technology to passably analyze natural language arguments, rather than just turning lab data and ICD-10 codes into SOAP narratives (and the converse)?

Me and my crazy ideas. Never gonna make it into any episodes of "Silicon Valley" (NSFW).

UPDATE: RECENT NLG REPORTAGE

From Wired:
What News-Writing Bots Mean for the Future of Journalism
Joe Keohane, 02.16.17

WHEN REPUBLICAN STEVE King beat back Democratic challenger Kim Weaver in the race for Iowa’s 4th congressional district seat in November, The Washington Post snapped into action, covering both the win and the wider electoral trend. “Republicans retained control of the House and lost only a handful of seats from their commanding majority,” the article read, “a stunning reversal of fortune after many GOP leaders feared double-digit losses.” The dispatch came with the clarity and verve for which Post reporters are known, with one key difference: It was generated by Heliograf, a bot that made its debut on the Post’s website last year and marked the most sophisticated use of artificial intelligence in journalism to date.

When Jeff Bezos bought the Post back in 2013, AI-powered journalism was in its infancy. A handful of companies with automated content-generating systems, like Narrative Science and Automated Insights, were capable of producing the bare-bones, data-heavy news items familiar to sports fans and stock analysts. But strategists at the Post saw the potential for an AI system that could generate explanatory, insightful articles. What’s more, they wanted a system that could foster “a seamless interaction” between human and machine, says Jeremy Gilbert, who joined the Post as director of strategic initiatives in 2014. “What we were interested in doing is looking at whether we can evolve stories over time,” he says...
More and more examples abound on the NLG side of things. Just Google "written by AI."

UPDATE: SPEAKING OF NEWS

I cited this excellent book a while back.


Re: Chapter 8, "Computational Journalism"
In 2009, Fred Turner and I wrote: “What is computational journalism? Ultimately, interactions among journalists, software developers, computer scientists and other scholars over the next few years will have to answer that question. For now though, we define computational journalism as the combination of algorithms, data, and knowledge from the social sciences to supplement the accountability function of journalism.”

Hamilton, James T. (2016-10-10). Democracy’s Detectives (Kindle Locations 10750-10753). Harvard University Press. Kindle Edition.
NLP seems an obvious fit, 'eh?
____________

More to come...

Wednesday, May 17, 2017

An "Innovation" Oopsie


So, I got a new Twitter Follow, and, as is my custom after just a quick bit of relevance and authenticity vetting, I reciprocated.


OK, I'll bite. Curious, despite knowing that the requisite "registration" form meant that I'd be getting pitched thereafter, despite my being a mere solo independent ankle-biting health care space blogger.

Corporate "Change Management" (remember that?) is by now long passe. We need Disruptive, Transformational Innovation Management.


Suppressing just a slight waft of a Jim Kwik Moment, I attempted to register.


Okeee-dokeee, then.

Below: at the outset of this encounter (after they got the registration form to work), This was rich.


Whatever, bro's. I thereupon substituted an email alias that bounces off one of my websites to my Comcast ISP inbox, and that worked, notwithstanding that it's the same destination.

Didn't matter (see above). Zip. Zilch. Nada. Nyet.

I expect they'll fix this mess straight away. I had other stuff to tend to.

My Twitter relationship with these peeps may well quickly go the way of my short-lived ZIPcode Wilmington mutual hang. They dropped me like a broken radioisotope container.

BTW: This Jeremiah Owyang fellow is all over YouTube.


OK, my Jim Kwik Moment is allayed. Notwithstanding the profuse Silicon Valley jargon.

It will not surprise me one whit to soon see an Irony-Free Zone pitch for "Creativity Management Software."

BTW: On "disruption," see my 2017 New Year's Day post.
__

OTHER STUFF

Trying to get back on pace with my reading.



The "Handbook of Computational Linguistics..." in particular will make your head spin.

Specifically interesting in potential apps for "NLU" (Natural Language Understanding). The "Natural Language Generation" part of NLP is way further along (e.g., turning "data" into narrative text/language via "AI").

May have to dust off my ancien coding chops and learn Python.


Stay tuned.
____________

More to come...

Monday, May 15, 2017

The dx from Hell: ICD-10 code C25.9

Pancreatic Cancer
Pancreatic cancer (PC) has the highest case-fatality rate of any of the major cancers, both in the US and worldwide. The disease is difficult to detect, rapidly metastatic, resistant to treatment, and often results in death. Pancreatic adenocarcinoma is also one of the most difficult cancers to study. Case-control studies may be inaccurate because patients with PC often die within weeks of their diagnosis. At the same time, prospective studies of PC are challenging due to the relative rarity of this type of cancer (~ 1% lifetime risk) and low prevalence due to short life expectancy. Consequently, PC etiology is often investigated by analyzing data from large-scale prospective studies or clinical trials for diseases other than PC, but limited numbers of cases and methodological heterogeneity (e.g., no or incomplete histological verification) affect the validity of these results.

The etiology of PC is widely acknowledged to be multi-factorial. The incidence of PC is greater in males than in females, and higher in Blacks than Whites. According to SEER 17 areas data, the age-adjusted incidence of PC in 2006 per 100,000 individuals was 11.61 (95%CI 11.34-11.88) for Whites and 15.57 (95%CI 14.57-16.62) for Blacks, with 16.56 for Black men (95% CI 15.08-18.61). Environmental or host risk factors shown to be associated with PC include cigarette smoking, obesity, type II diabetes mellitus, chronic pancreatitis, physical inactivity and blood groups A or B. Dietary risks may be related to low fruit and vegetable intake and increased intake of high-heat cooked meats (i.e., grilled/fried animal protein sources). Two separate, recent studies linked pancreatic cancer to high consumption of carbohydrates and alcohol. Unfortunately, these common risk factors have small effect sizes, so it is difficult to produce highly accurate risk models. For example, smoking yields a risk ratio of approximately 2. The risk of developing PC is recognized as being exceptionally elevated in certain genetically predisposed families (e.g., hereditary pancreatitis,), but only about 10% of all PC cases can be attributed to genetic causes...
From pancreas.org

Lightening strikes yet again. I've alluded briefly to this new circumstance here and there in prior posts.

On March 29th, the radiologist's report from a CT scan done at a Kaiser Permanente facility indicated that my younger daughter Danielle is afflicted with Stage IV metastatic pancreatic cancer, a finding confirmed by a subsequent liver biopsy. (She's given permission to go public with this horrific news.)

Our world has been turned upside down ever since. My KHIT efforts have been significantly hamstrung. Danielle started Folfirinox chemo (after first being accepted into and then, in the wake of some subsequent disqualifyingly elevated adverse labs, excluded from a UCSF clinical trial). Her severe side-effects reaction to the first chemo round landed her in the hospital, where my wife and I spent all of last week by her bedside in shifts.


Above, Sissy (top) and Danielle (bottom) in 1974 in Seattle, the year I got a divorce and custody of both of them. The backstory on my salt and pepper kids.

Needless to say, we are all reeling. One of her friends started a crowdfunding page for her, for which we could not be more grateful. She will need every dime. Danielle's out-of-pocket expenses to date alone are mind-boggling (KP membership notwithstanding). If her illness doesn't kill her, it will most certainly bankrupt her -- in relatively short order. She will shortly be the former Executive Director of The Stepping Stones Project (they've generously given her extended "medical leave," which, though, necessarily runs out by month's end).

We've moved her back home, and I will be breaking her lease and packing up and stowing her apartment shortly, and tending to the myriad piling-up logistical and legal assistance details.
And, get excused from the jury duty summons I just got.
So, yeah, I'm a bit behind the curve. My life the past seven weeks has been an endless recursion of "oh, SHIT!" moments.

Prior to this news. I'd been trying to finish out my "One in Three" book. Gonna have to scrap the title and cover photo and broaden the scope.

1980, Knoxville
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More to come...

Monday, May 8, 2017

#HealthIT and the American Sickness

Elisabeth Rosenthal:
CHAPTER 18
BETTER HEALTHCARE IN A DIGITAL AGE

In the last twenty-five years, nearly every aspect of our day-to-day lives has been made easier by digital technology: banking, watching films, traveling, communicating with loved ones near and far away, purchasing a new home. But healthcare is an exception to the rule.

That’s not because of a lack of investment. Silicon Valley is hot on healthcare. Even though tech funding in general has fallen off lately, digital health funding went up 13 percent in the first quarter of 2016, with investment for the quarter reaching nearly $ 1 billion. Every week I get more than a half-dozen pitches from start-ups touting new machines or claiming that their algorithms and apps will empower consumers and solve the healthcare cost crisis.

The problem is that these huge investments and the products they spawn are of highly variable benefit to patients. Health technology can be deployed for enormous patient good, but often all it offers up are useless, but profitable, services. If a company exists to untangle or parse the data in our convoluted system, the real answer is not to add another layer designed by entrepreneurs looking for profit, but to make the system simpler.

Consider the five largest healthcare start-up deals in that first boom quarter of 2016: $ 175 million for a start-up that describes itself as a “clinical intelligence platform for cancer care providers” (funded largely by drug companies that want to mine the data for faster approvals); $ 165 million for a company that develops and sells wearable wrist monitors that provide “personalized insights into how [users] sleep, move and eat; $ 95 million for an (or “another”) online platform that offers “intelligent health information” to patients; $ 70 million for a company that promises to “warehouse” healthcare data; $ 40 million for an outfit that developed a kiosk to deploy in drugstores and malls that can screen for blood pressure, weight, pulse, and body mass index. (Automated measurements are notoriously inaccurate; there are simpler ways to measure these parameters and no medical reason to regularly monitor some of them anyway.)

With our purchases and our votes, we should make sure that new technology serves patients before investors’ profits...


Rosenthal, Elisabeth (2017-04-11). An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (pp. 321-322). Penguin Publishing Group. Kindle Edition.
Hashtag #anamericansickness.

She goes on to discuss in more detail the relative (and sometimes dubious) merits of digital stuff such as "wearables," "telehealth," and "interoperability/patient data access." She also brings up the still-contentious federal "Meaningful Use" initiative, which gave birth to this blog in 2010.

apropos of all of this, excellent interview with the author:
Why are American health care costs by far the highest in the world? Journalist and former practicing physician Elisabeth Rosenthal chronicles how we got here in her new book, "An American Sickness." Economics correspondent Paul Solman talks with Rosenthal about the forces driving high prices and what could be done to bring costs down.

Again -- and particularly given the recent narrow House passage (by a 1-vote margin) of the controversial "AHCA" bill -- I find this book a must-read (though I have to admit to my concerns going to the viability of her "How You Can Take It Back" assertions, in light of the powerful forces aligned against patients).

UPDATE

I tweaked the crude little "Health Care UTIL" graphic I'd rendered.


Click to enlarge. Again, what am I missing?
Every health care stakeholder on the provider side -- physicians, clinics, hospitals, pharma, biomed, insurors, etc -- claims to be losing money and needs higher prices, or it will exit its respective market space. Yet, to our "Repeal and Replace" "conservatives," the ostensible beneficent magic of (inexorably margin-minimizing) "free market competition" will somehow leave them better off and happier (The Monopolism Wisdom of Peter Thiel notwithstanding) -- accepting lower returns in order to "bend the cost curve" significantly and durably down for the benefit of patients (and our chronically ballooning NHE). I'm not sure we're ever gonna get coherent, productive consensus dialogue on this maddening perplex.
On the subject of UTIL and costs, see my prior post "Rationing by 'Price'."

On health care "pricing,"

Ahhh... the lovely buzzword "transparency." My phrase above, "inexorably margin-minimizing" could not be more apt. Margin is inescapably to a significant degree a function of opacity (plus, of course, barriers to entry of competitors). "Conservative" politicians love to bloviate euphorically regarding the ostensible unalloyed virtues of "free markets" and "competition" until transparency erodes (their donors') margins, at which point they invariably whine and stomp about "predatory competition."
Again, read An American Sickness.
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More to come...

Tuesday, May 2, 2017

An American Sickness, continued


Hashtag #anamericansickness.

MAY 6TH UPDATE: I finished this book. EVERY member of Congress (and his/her staff) should have to read it and take a test on its contents. Every taxpayer should also read it closely.
__

Continuing on from my prior post. The book's Dedication page:
Dedicated to all the patients, doctors, and other healthcare professionals who so generously shared their stories and experiences to bring this book to life. Waiving privacy concerns, they agreed to have their real names appear in print. In the hope of contributing to change in our healthcare system, they spent hours digging up copies of their bills, insurance statements, correspondence, and other documents to provide verification. I’m deeply grateful for their help, commitment, and courage.

They—and all Americans—deserve better, more affordable healthcare.
Interesting. Candid disclosures of (US) HIPAA-protected "PHI" (Protected Health Information) in the service of larger, socially beneficial goals. I can't help but recall my post citing Gideon Burrows' excellent, courageous (UK) book back when I finished my own cancer tx in November 2015.


My own family revelations began in the late 1990's with my posts recounting my late elder daughter's illness and death. Now, we are struggling to come to terms with her younger sibling's recent shocking dx of Stage IV metastatic pancreatic cancer. We got a 2nd opinion consult at UCSF (she's a Kaiser enrollee), and Danielle signed the Consents for enrollment in a clinical trial now getting underway.

Then some adverse, worryingly elevating labs came in, and she was declared ineligible for the RCT (owing to hepatoxicity risk). Back to Plan A (at Kaiser) -- Folfirinox.

Suffice it to say that my wife and I are reeling. I struggle to find any motivation to do much of anything (beyond yet again my requisite next-of-kin caregiver duties).

PERSONAL DISCLOSURE - STEVE BRILL

CHAPTER 1. LOOKING UP FROM THE GURNEY

I USUALLY KEEP MYSELF OUT OF THE STORIES I WRITE, BUT THE ONLY way to tell this one is to start with the dream I had on the night of April 3, 2014.

Actually, I should start with the three hours before the dream, when I tried to fall asleep but couldn’t because of what I thought was my exploding heart.

THUMP. THUMP. THUMP. If I lay on my stomach it seemed to be pushing down through the mattress. If I turned over, it seemed to want to burst out of my chest.

When I pushed the button for the nurse, she told me there was nothing wrong. She even showed me how to read the screen of the machine monitoring my heart so I could see for myself that all was normal. But she said she understood. A lot of patients in my situation imagined something was going haywire with their hearts when it wasn’t. Everything was fine, she promised, and then gave me a sedative.

All might have looked normal on that monitor, but there was nothing fine about my heart. It had a time bomb appended to it. It could explode at any moment— tonight or three years from tonight— and kill me almost instantly. No heart attack. No stroke. I’d just be gone, having bled to death.

That’s what had brought me to the fourth-floor cardiac surgery unit at New York– Presbyterian Hospital. The next morning I was having open-heart surgery to fix something called an aortic aneurysm.

It’s a condition I had never heard of until a week before, when a routine checkup by my extraordinarily careful doctor had found it.

And that’s when everything changed.

Until then, my family and I had enjoyed great health. I hadn’t missed a day of work for illness in years. Instead, my view of the world of healthcare was pretty much centered on a special issue I had written for Time Magazine a year before about the astronomical cost of care in the United States and the dysfunctions and abuses in our system that generated and protected those high prices.

For me, an MRI had been a symbol of profligate American healthcare— a high-tech profit machine that had become a bonanza for manufacturers such as General Electric and Siemens and for the hospitals and doctors who billed billions to patients for MRIs they might not have needed.

But now the MRI was the miraculous lifesaver that had found and taken a crystal clear picture of the bomb hiding in my chest. Now a surgeon was going to use that MRI blueprint to save my life.

Because of the reporting I had done for the Time article, until a week before, I had been like Dustin Hoffman’s savant character in Rain Man— able and eager to recite all varieties of stats on how screwed up and avaricious the American healthcare system was.

We spend $ 17 billion a year on artificial knees and hips, which is 55 percent more than Hollywood takes in at the box office.

America’s total healthcare bill for 2014 is $ 3 trillion. That’s more than the next ten biggest spenders combined: Japan, Germany, France, China, the United Kingdom, Italy, Canada, Brazil, Spain, and Australia. All that extra money produces no better, and in many cases worse, results.

There are 31.5 MRI machines per million people in the United States but just 5.9 per million in England.

Another favorite: We spend $ 85.9 billion trying to treat back pain, which is as much as we spend on all of the country’s state, city, county, and town police forces. And experts say that as much as half of that is unnecessary.

We’ve created a system with 1.5 million people working in the health insurance industry but with barely half as many doctors providing the actual care. And most do not ride the healthcare gravy train the way hospital administrators, drug company bosses, and imaging equipment salesmen do.

I liked to point out that Medtronic, which makes all varieties of medical devices— from surgical tools to pacemakers— is so able to charge sky-high prices that it enjoys nearly double the gross profit margin of Apple, considered to be the jewel of American high-tech companies.

And all of those high-tech advances— pacemakers, MRIs, 3-D mammograms— have produced an irony that epitomized how upside-down the healthcare marketplace is: This is the only industry where technology advances have increased costs instead of lowering them. When it comes to medical care, cutting-edge products are irresistible; they are used— and priced— accordingly...
Yeah. Goes directly to Elisabeth's book, 'eh?

From An American Sickness:
10. THE AGE OF HEALTHCARE AS PURE BUSINESS

Our healthcare system today treats illness and wellness as just another object of commerce: Revenue generation. Supply chain optimization. Minimization of tax liability. Innovative business modeling. Things sold. Services rendered. Bills to be paid. “As a consumer (formerly ‘patient’ or ‘sick person’) how cool it must be to find oneself on the innovative, enrollment-optimized upper specialty drug tier when sickness strikes and you face 20 to 30 percent coinsurance,” quips Uwe Reinhardt, a Princeton economist who has been challenging the financial underpinnings of the American healthcare system for years.

Helen, a real estate professional in a major eastern city, had a history of ruptured disks in her back that required surgery. So when she developed severe pain in her neck and numbness and tingling in her hand and arm she knew she would likely need another operation. An MRI showed a piece of bone pushing on a nerve.

The first surgeon she consulted said he wouldn’t see her because her Oxford Premium plan paid fees that were too low. The second, a surgeon she’d used twice before, agreed to take her on. His office would negotiate with Oxford to obtain a reasonable rate. “I begged them to get me on the schedule as soon as possible— I was in unbearable pain,” she said. With neurological deficits that merited urgent intervention, he scheduled the surgery for a fortnight later. She drugged herself, canceling all work appointments.

But five days before surgery, the doctor’s office called to inform her that Oxford wouldn’t agree to more than $ 58,000, less than half the $ 130,000 the doctor usually charged. The office biller asked Helen to send in $ 23,000 to help make up the difference, in addition to the $ 12,000 co-payment. If she couldn’t come up with the money, the surgery would be canceled, the biller explained: “We can’t do the surgery for what your insurer’s willing to pay.”

From about 2010 on, new types of medical charges multiplied, just as priority boarding fees and fees for window seats appeared on airline bills. Doctors who considered themselves good diagnosticians began charging longtime patients annual retainers of $ 2,000 to remain in the practice, or $ 150 a month extra for customers who wanted same-day answers to medical questions, or $ 20 just to write each prescription. Some parents of children in New York City public schools began receiving $ 300 explanation of benefits statements generated for a child’s trip to the school nurse’s office (which had been outsourced to a contracted medical provider), even if for a scraped knee on the playground or a stomachache born of test anxiety.

Doctors and medical centers, who two decades ago might have worked hard to figure out an affordable payment, now rapidly turned over patient accounts to billing services and collection and credit rating agencies. By 2014, 52 percent of overdue debt on credit reports was due to medical bills and one in five Americans had medical debt on their credit record, impacting their ability to get a mortgage or buy a car.

There was money, money everywhere . . .

In my own years of medical school and practice, I never saw a single patient with hemophilia, whose victims lack an essential clotting factor (most commonly factor VIII) and so suffer from repeated internal bleeding. Treating this rare condition certainly didn’t seem like a profitable proposition. So I was surprised to hear a medical marketing consultant I interviewed refer to hemophilia not as a devastating, debilitating illness if left untreated, but instead as a “high value disease state.”...
"There was money, money, money everywhere."

A couple of observations recur, circa the time of my birth. First, an interesting quote from one of the patron saints of "libertarianism," followed by the opinion proffered by the WWII era British Prime Minister:
"Nor is there any reason why the state should not assist individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance, where, in short, we deal with genuinely insurable risks, the case for the state helping to organise a comprehensive system of social insurance is very strong. There are many points of detail where those wishing to preserve the competitive system and those wishing to supersede it by something different will disagree on the details of such schemes; and it is possible under the name of social insurance to introduce measures which tend to make competition more or less ineffective. But there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom."

- Friedrich Hayek, The Road to Serfdom, 1944

“The discoveries of healing science must be the inheritance of all. That is clear: Disease must be attacked,  whether it occurs in the poorest or the richest man or woman simply on the ground that it is the enemy; and it must be attacked just in the sane way as the fire brigade will give its  full assistance to the humblest cottage as readily as to the  most important mansion… Our policy is to create a national health service in order to ensure that everybody in the country, irrespective of means, age, sex, or occupation, shall have equal opportunities to benefit from the best and most up-to-date medical and allied services available.”

- British Prime Minister Winston Churchill, 1948
“You’re going to have such great health care, at a tiny fraction of the cost—and it’s going to be so easy.” -- Donald Trump, October 2016 Florida campaign rally


Then there are people like the smugly arrogant and ignorant Alabama GOP congressman Mo Brooks:
Rep. Mo Brooks (R-Ala.) told CNN’s Jake Tapper that sick people should pay more for health insurance ― an opinion reflected in the newest proposed version of a Republican health care bill.

Brooks, who is one of the more than 30 congresspeople who make up the so-called Freedom Caucus, a far-right contingent within the House of Representatives, made his comments in response to a claim by President Donald Trump. Trump stated Monday that he wanted to carry over Obamacare policies that protect people with pre-existing conditions.

But the newest version of the bill wouldn’t do that, a fact Brooks emphasized.

“My understanding is that it will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool,” he said, “thereby reducing the cost to those people who lead good lives.”

Of these people who live “good lives,” he then added, “They’re healthy, they have done the things to keep their bodies healthy, and right now those are the people who have done things the right way and are seeing their costs skyrocket.”
 I guess Jimmy Kimmel's newborn's then-brief life wasn't a "good" one.

And, I have no doubt that Congressman Mo Brooks will continue to take his 70% taxpayer-subsidized FEHB health plan benefits.
"Pricing sick people out of insurance coverage is abuse. It will make them go to the doctor less often, meaning less early detection and more early death.

And discrimination against sick people is as morally wrong as discrimination against people because of the color of their skin. High-risk pools are American Sowetos in a system of medical apartheid."
ERRATUM

We're at the Kaiser facility in Vallejo. And so it begins...


____________

More to come...

Thursday, April 27, 2017

An American Sickness

Elisabeth Rosenthal, MD, former ER physician and subsequently New York Times reporter of lengthy, considerable note, is now Editor-in-Chief at Kaiser Health News.

Elisabeth Rosenthal, Editor-in-Chief, joined KHN in September 2016 after 22 years as a correspondent at The New York Times, where she covered a variety of beats from health care to environment to reporter in the Beijing bureau. While in China she covered SARS, bird flu and the emergence of HIV/AIDS in rural areas. Libby’s 2013-14 series “Paying Till it Hurts” won many prizes for both health reporting and its creative use of digital tools. Her book, “An American Sickness: How Healthcare Became Big Business And How You Can Take it Back,” is being published by Penguin Random House in April 2017. She is a graduate of Stanford University and Harvard Medical School and briefly practiced medicine in a New York City emergency room before converting to journalism.
I am deep into her new book. A sobering, riveting, and at times infuriating read. I'm already well aware of of lot of what she writes, but it at once raises my BP and validates my own take on this morally untenable aspect of health care. I'm not crazy (or naive) after all.


Hashtag #anamericansickness.

The more I read, the more the word "Pultizer" repeatedly wafts up in my mind.
INTRODUCTION
Complaint: Unaffordable Healthcare

In the past quarter century, the American medical system has stopped focusing on health or even science. Instead it attends more or less single-mindedly to its own profits.

Everyone knows the healthcare system is in disarray. We’ve grown numb to huge bills. We regard high prices as an inescapable American burden. We accept the drugmakers’ argument that they have to charge twice as much for prescriptions as in any other country because lawmakers in nations like Germany and France don’t pay them enough to recoup their research costs. But would anyone accept that argument if we replaced the word prescriptions with cars or films?

The current market for healthcare just doesn’t deliver. It is deeply, perhaps fatally, flawed. Even market economists themselves don’t believe in it anymore. “It’s now so dysfunctional that I sometimes think the only solution is to blow the whole thing up. It’s not like any market on Earth,” says Glenn Melnick, a professor of health economics and finance at the University of Southern California.

Nearly every expert I’ve spoken with— Republican or Democrat, old or young, adherent of Milton Friedman or Karl Marx— has a theoretical explanation as to why the United States spends nearly 20 percent of its gross domestic product on healthcare— more than twice the average of developed countries. But each one also has a story of personal exasperation about the last time a family member or a loved one was hospitalized or rushed to an emergency room or received an incomprehensible, outrageous bill.
Stephen Parente, Ph.D., a health economist at the University of Minnesota and an adviser to John McCain in the 2008 presidential election, believes that studies overstate the excessive healthcare spending in the United States. But when he talks about the hospitalization of his elderly mother, his dispassionate academic tone shifts to one I’ve heard thousands of times, brimming with frustration:
There were a dozen doctors all sending separate bills and I couldn’t decipher any of them. They were all large numbers and the insurance paid a tiny fraction. Imagine if a home contractor worked this way? He estimates $ 125,000 for your kitchen and then takes $ 10,000 when it’s done? Would anyone ever renovate?
Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants. That’s how the healthcare market works. In no other industry do prices for a product vary by a factor of ten depending on where it is purchased, as is the case for bills I’ve seen for echocardiograms, MRI scans, and blood tests to gauge thyroid function or vitamin D levels. The price of a Prius at a dealership in Princeton, New Jersey, is not five times higher than what you would pay for a Prius in Hackensack and a Prius in New Jersey is not twice as expensive as one in New Mexico. The price of that car at the very same dealer doesn’t depend on your employer, or if you’re self-employed or unemployed. Why does it matter for healthcare?

We live in an age of medical wonders— transplants, gene therapy, lifesaving drugs, and preventive strategies— but the healthcare system remains fantastically expensive, inefficient, bewildering, and inequitable. Faced with disease, we are all potential victims of medical extortion. The alarming statistics are incontrovertible and well known: the United States spends nearly one-fifth of its gross domestic product on healthcare, more than $ 3 trillion a year, about equivalent to the entire economy of France. For that, the U.S. health system generally delivers worse health outcomes than any other developed country, all of which spend on average about half what we do per person.

Who among us hasn’t opened a medical bill or an explanation of benefits statement and stared in disbelief at terrifying numbers? Who hasn’t puzzled over an insurance policy’s rules of co-payments, deductibles, “in-network” and “out-of-network” payments— only to surrender in frustration and write a check, perhaps under threat of collection? Who hasn’t wondered over, say, a $ 500 bill for a basic blood test, a $ 5,000 bill for three stitches in an emergency room, a $ 50,000 bill for minor outpatient foot surgery, or a $ 500,000 bill for three days in the hospital after a heart attack?

Where is all that money going?


Rosenthal, Elisabeth (2017-04-11). An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (pp. 1-3). Penguin Publishing Group. Kindle Edition.
My contextual triangulation will eventually extend to a number of others I've previously cited. e.g.,


to wit,
In spite of the clear and recent data, the United States stumbles when addressing these social determinants of health. Although Americans do not like being mediocre in national health outcomes, they have been even less enthusiastic about facing the complex web of social conditions that produce and reinforce these outcomes. They continue to pay top dollar for hospitals, physicians, medications, and diagnostic testing yet skimp in broad areas that are central to health, such as housing, clean water, safe food, education, and other social services. It may even be that Americans are spending large sums for health care to compensate for what they are not paying in social services— and the trade-off is not good for the country’s health.

ROUGHLY FIVE YEARS AGO WE started thinking that there might be a connection between soaring health costs and meager social service spending, when we were musing about theoretical roots to the so-called health care paradox in the United States. To explore whether our hypothesis would hold up, we examined ten years of spending and health outcome data from thirty OECD countries that collected data using comparable methodologies. The results confirmed our suspicions.

Our comparative study, published in the academic literature in 2010, broadened the scope of inquiry about health and health spending to include spending on social services as a potential determinant of population-level health outcomes. For the purposes of our study, social services expenditures included public and private spending on old-age pension and support services for older adults, survivors benefits, disability and sickness cash benefits, family supports, employment programs (e.g., public employment services and employment training, unemployment benefits, supportive housing and rent subsidies), and other social services that exclude health expenditures. Health expenditures included public and private spending on curative care, rehabilitative care, long-term care, laboratory and diagnostic services, outpatient and preventive care, and public health services.

The study found that if we counted countries’ combined investment in health care and in social services, the United States was no longer spending the largest percentage of GDP— far from it. In 2007, for example, the United States devoted only 25 percent of gross domestic product to health and social services combined, while such countries as Sweden, France, Austria, Switzerland, and Denmark dedicated about 30 to 33 percent of their respective GDP to the combination. In 2007, while the United States ranked highest in health spending, it ranked only thirteenth in spending on health services and social services combined (see Figure 1.4).

Moreover, the study revealed that America was one of only three industrialized countries (the other two were Korea and Mexico) to spend the majority of its total health and social services budget on health care. On average in the OECD countries other than the United States, for every dollar spent on health care, an additional two dollars was spent on social services. Yet in the United States, for every dollar spent on health care, less than sixty cents was spent on social services. Most important, we found that less spending on social services relative to spending on health services was statistically associated with poorer health outcomes in key measures, such as infant mortality and life expectancy, and this result held even when the United States was removed from the analysis...


Bradley, Elizabeth H.; Taylor, Lauren A. (2013-11-05). The American Health Care Paradox: Why Spending More is Getting Us Less (Kindle Locations 420-448). PublicAffairs. Kindle Edition.
And, Steve Brill's compelling take on the evolution of our health care system (and which recounts his own frustrating experience with acute care), culminating in his analysis of the enactment of the ACA ("ObamaCare").
From its historical roots, to the mind-numbing complexity of the furiously lobbied final text of the legislation, to its stumbling implementation, to the bitter fights over it that persist to this day— the story of Obamacare embodies the dilemma of America’s longest running economic sinkhole and political struggle.

It’s about money: Healthcare is America’s largest industry by far, employing a sixth of the country’s workforce. And it is the average American family’s largest single expense, whether paid out of their pockets or through taxes and insurance premiums.

It’s about politics and ideology: In a country that treasures the marketplace, how much of those market forces do we want to tame when trying to cure the sick? And in the cradle of democracy, or swampland, known as Washington, how much taming can we do when the healthcare industry spends four times as much on lobbying as the number two Beltway spender, the much-feared military-industrial complex?

It’s about the people who determine what comes out of Washington— from drug industry lobbyists to union activists; from senators tweaking a few paragraphs to save billions for a home state industry to Tea Party organizers fighting to upend the Washington status quo; from turf-obsessed procurement bureaucrats who fumbled the government’s most ambitious Internet project ever to the selfless high-tech whiz kids who rescued it; and from White House staffers fighting over which faction among them would shape and then implement the law while their president floated above the fray to a governor’s staff in Kentucky determined to launch the signature program of a president reviled in their state.

But late in working on this book, on the night of that dream and in the scary days that followed, I learned that when it comes to healthcare, all of that political intrigue and special interest jockeying plays out on a stage enveloped in something else: emotion, particularly fear.

Fear of illness. Or pain. Or death. And wanting to do something, anything, to avoid that for yourself or a loved one...


Brill, Steven (2015-01-05). America's Bitter Pill: Money, Politics, Backroom Deals, and the Fight to Fix Our Broken Healthcare System (Kindle Locations 131-146). Random House Publishing Group. Kindle Edition.
There will be many more books to cite pertaining to this topic (the byzantine economics and policy perplex of health care). Stay tuned.
The Bradley/Taylor "Paradox" book is particularly interesting, putting per capita and aggregate "health" spending in a deservedly broader context. Think about the "Upstream."
BTW, see also my 2015 reporting on Steve Brill's excellent series "America's Most Admired Lawbreaker."
__

I wrote my first blog post musing about our health care "system" on another of my blogs eight years ago. See "The U.S. health care policy morass."
Some reform advocates have long argued that we can indeed [1] extend health care coverage to all citizens, with [2] significantly increased quality of care, while at the same time [3] significantly reducing the national (and individual) cost. A trifecta "Win-Win-Win." Others find the very notion preposterous on its face. In the summer of 2009, this policy battle is now joined in full fury. I will try to add some constructive argument to the fray.

This likely will be a lengthy post that will accrue over time, given the complexity and importance of the topic, but,


FIRST, A PREFATORY STORY

In the mid-late 1990s, while caring for my terminally ill daughter in Hollywood, I recall reading that there were more MRI machines deployed in the Los Angeles area than in the entire nation of Canada, the inference being that the American economics of hugely expensive sense-extending diagnostic imaging technologies such as MRI units, CAT scanners, cardiac dynamic stress test machines, etc tended toward the economically problematic. Every medical institution feels compelled to have them to be credible, competitive Players in the market, but everyone also needs to keep them all profitably humming, with viable billable payers at the end of the back office line. And, every additional install exacerbates the billable utilization problem. Damned if you do, damned if you don't...


THE U.S. "HEALTH CARE" "SYSTEM"?

I will by no means be the first to note that our medical industry is not really a "system," nor is it predominantly about "health care." It is more aptly described as a patchwork post hoc disease and injury management and remediation enterprise, one that is more or less "systematic" in any true sense only at the clinical level. Beyond that it comprises a confounding perplex of endlessly contending for-profit and not-for-profit entities acting far too often at ruinously expensive cross-purposes...
See also my more recent take on what I call the "shards" of our fragmented, crazed non-"system."


I frequently say "if you're not confused, you've not been paying attention."

One of the most maddening implications of "An American Sickness" is that the leading GOP "health care reform / repeal ObamaCare" proposals are virtually certain to make things materially worse.

Elisabeth concludes,
EPILOGUE 
The Fate of Empires describes an age of decadence into which all great societies— Rome, Greece, Persia, Great Britain— descend before they finally fall for good. The decadence, according to the author, Sir John Glubb, is due to a period of wealth and power, selfishness, love of money, and loss of a sense of duty. Does this sound familiar? Societies, it says, typically take over two hundred years to get to the age of decadence. American healthcare has arrived far faster. 

The fathers of modern medicine— doctors and scientists like Frederick Banting, who pioneered insulin treatment; Jonas Salk, who discovered the polio vaccine; Albert Starr, who invented a lifesaving artificial heart valve; and Thomas Starzl, who fathered modern organ transplant— helped usher in a new era of scientific healing. They are the reason for medicine’s lofty reputation. But the respect they earned through their noble efforts has been squandered in the past quarter century. The treatments we get and the prices we pay are governed as much by commerce as by humanism or science. The mission of this book is to advocate for a return to a system of affordable, evidence-based, patient-centered care. 

No one player created the mess that is the $ 3 trillion American medical system in 2017. People in every sector of medicine are feeding at the trough: insurers, hospitals, doctors, manufacturers, politicians, regulators, charities, and more. People in sectors that have nothing to do with health— banking, real estate, and tech— have also somehow found a way to extort cash from patients. They all need to change their money-chasing ways. 

To make that happen, however, we patients will need to change our ways too. We must become bolder, more active and thoughtful about what we demand of our healthcare and the people who deliver it. We must be more engaged in finding and pressing the political levers to promote the evolution of the medical care we deserve. 

I hope the book you have just finished has made you not just outraged but also better prepared for these tasks. Now you understand that the free coffee and artwork display in a hospital’s marble atrium aren’t free at all. That what’s sold to you as the newest drug or device to treat your illness may not be, in fact, the best. That the anesthesiologist who comes in to say “hi” before a procedure is perhaps not being kind, but making an appearance so that he and/ or his extender can bill for a consult. You’re wise to the heist and emboldened with new tools and ideas about how to take back your health and our medical system. 

Medicine is still a noble profession. There are many great doctors, nurses, pharmacists, and others working their hearts out, even in these troubled and troubling times. Even as the healthcare sector faces a future of great financial uncertainty and humiliating bureaucracy, many of the best and brightest students are flocking to medical school. They’re doing it because they want to take care of patients, to heal using some of the time-honored tools in the doctor’s black bag as well as the miraculous scientific innovations of the last twenty-five years. That is, after all, the only really compelling reason to go into medicine. 

They want to deliver patient-centered, evidence-based care at a reasonable price. We, the patients, need to help, to rise up and make that possible. We have to remind everyone who has entered our healthcare system in the past quarter century for profit rather than patients that “affordable, patient-centered, evidence-based care” is more than a marketing pitch or a campaign slogan. 

It is our health, the future of our children and our nation. High-priced healthcare is America’s sickness and we are all paying, being robbed. When the medical industry presents us with the false choice of your money or your life, it’s time for us all to take a stand for the latter. [An American Sickness... pp. 328-329]
Between the Introduction and the Epilogue lies a ton of spot-on (albeit frequently aneurism-inducing) detail. It's also the kind of book you can roam around in effectively (which I am still doing; eventually I'll report on her Chapter 18 take on digital health IT).

Chapter by chapter, she recurrently relates her details back to her take on fundamental health care market "rules."


All excellent stuff. Do yourself a favor it you're still on the fence, go to Amazon, read the extensive "Look Inside" preview excepts.

ERRATUM

A comment I recently posted under an article at THCB.
ALL stakeholders in health care, with the exception of patients, argue that they are all “losing money” and need higher prices, or they will pull out of their service domains. Yet somehow “competitive market forces” will make them all happy earning even LESS as we “bring down the cost of health care” for the benefit of patients (who have ZERO individual market leverage, and are ACTUALLY losing money).
CODA 

From my Facebook page,


Noteworthy in this regard, Elisabeth's American Sickness book dedication:
Dedicated to all the patients, doctors, and other healthcare professionals who so generously shared their stories and experiences to bring this book to life. Waiving privacy concerns, they agreed to have their real names appear in print. In the hope of contributing to change in our healthcare system, they spent hours digging up copies of their bills, insurance statements, correspondence, and other documents to provide verification. I’m deeply grateful for their help, commitment, and courage.

They—and all Americans—deserve better, more affordable healthcare.
I will have more to relate shortly on my daughter's worsening circumstance, in the hope that it (like other personal disclosures I have posted over time) will help others.

Speaking of "affordable healthcare," I just did a quick 'n dirty graphic in Illustrator.




What am I missing?
____________

Much more to come. Meanwhile, buy Elisabeth's book...