2019 in the health care space?

"I never make predictions, especially about the future." - Yogi Berra

"The great thing about being a health care futurist is that you never have to update your slides." - Health Care "Futurist" Ian Morrison

LOL. Ian also once quipped during a Health 2.0 Conference Keynote "I've got slide decks older than some of my clients."

Below: this is an actual thing.

"APF." Not kidding. Hmmm... Wonder if Ian is a member? (As well as my equally cool Futurist friend Joe Flower? And, how about Jacob Ward?)

From the APF website: "What is a Futurist? A professional futurist is a person who studies the future in order to help people understand, anticipate, prepare for and gain advantage from coming changes." Okeee-dokee, then. "studies the future"? (Wiki page on "Futurist.")

Michael Burry MD, now there was "Futurist" ("The Big Short" guy).

Stay tuned. Just got home from a Christmas trip back to the Baltimore area to see our son Matt. Met the most gracious, spectacular people in his circle. Stayed silent about being gone on social media, for what should be obvious reasons.

First, some random stuff in the waning 2018 days.

Finished this book while gone:

Highly recommended. A comprehensive, scholarly, accessible (and non-partisan) history of the evolution of the space. From the Amazon blurb:

Written for nonexperts, this is a brisk, engaging history of American healthcare from the advent of Medicare and Medicaid in the 1960s to the impact of the Affordable Care Act in the 2010s. Step by step, Jonathan Engel shows how we arrived at our present convoluted situation, where generic drugs prices can jump 1,000 percent in a day and primary care physicians can lose 20 percent of their income at the stroke of a Congressional pen.

Unaffordable covers, in a conversational style punctuated by apt examples, topics ranging from health insurance, pharmaceutical pricing, and physician training to health maintenance organizations and hospital networks. Along the way, Engel introduces approaches that other nations have taken in organizing and paying for healthcare and offers insights on ethical quandaries around end-of-life decisions, neonatal care, life-sustaining treatments, and the limits of our ability to define death. While describing the political origins of many of the federal and state laws that govern our healthcare system today, he never loses sight of the impact that healthcare delivery has on our wallets and on the balance sheets of hospitals, doctors' offices, government agencies, and private companies.

I'm already rather well-read up on this type of material, but Jonathan's was thoroughly enjoyable and instructive nonetheless. I would encourage everyone to read it, health care professionals and lay people alike.

Gonna be starting his latest release shortly.

Again, the Amazon blurb:

The diet and weight-loss industry is worth $66 billion – billion!! The estimated annual health care costs of obesity-related illness are 190 billion or nearly 21% of annual medical spending in the United States. But how did we get here? Is this a battle we can’t win? What changes need to be made in order to scale back the incidence of obesity in the US, and, indeed, around the world? Here, Jonathan Engel reviews the sources of the problem and offers the science behind our modern propensity toward obesity. He offers a plan for helping address the problem, but admits that it is, indeed, an uphill battle. Nevertheless, given the magnitude of the costs in years of life and vigor lost, it is a battle worth fighting.

Fat Nation is a social history of obesity in the United States since the second World War. In confronting this familiar topic from a historical perspective, Jonathan Engel attempts to show that obesity is a symptom of complex changes that have transpired over the past half century to our food, our living habits, our life patterns, our built environments, and our social interactions. He offers readers solid grounding in the known science underlying obesity (genetic set points, complex endocrine feedback loops, neurochemical messengering) but then makes the novel argument that obesity is a result of the interaction of our genes with our environment. That is, our bodies have always been programmed to become obese, but until recently never had the opportunity to do so. Now, with cheap calories ubiquitous (particularly in the form of sucrose), unwalkable physical spaces, deteriorating rituals and norms surrounding eating, and the withering of cooking skills, nearly every American daily confronts the challenge of not putting on weight. Given the outcomes, though, for those who are obese, Engel encourages us to address the problems and offers suggestions to help remedy the problem.

Hmmm... this quote comes to mind:

“Medicine is supposed to be about helping you through the accidents — the misfortune of a genetic disease, the misfortune of a trauma, the misfortune of some pathogen. Nobody went to medical school to babysit someone through a life of self-inflicted misery because of two deadly habits: sedentarism and excessive consumption of refined carbohydrates.” — Greg Glassman, CEO, CrossFit Health

Glassman has a point, but I think things are a good bit more complex than that.

Like I said, stay tuned. lots to ponder and write about (still dragging my butt finishing up several other books in chronic, halting progress). We got home about 1 a.m. Gotta go fetch the dogs from vet/boarding. Can't wait to see that bill. Ranger is still having persistent ear infection problems.

UPDATE ERRATUM

From my latest hardcopy snailmail edition of Science Magazine:

apropos of my prior riffs on climate change,

…[T]he deeper cause of the ecological crisis: a pervasive worldview that imbues the trends of more with a cachet of inevitability and legitimacy. This worldview esteems the human as a distinguished entity that is superior to all other life forms and is entitled to use them and the places they live. The belief system of superiority and entitlement—or human supremacy—manifests in a range of anthropocentric commonplace assumptions, linguistic constructs, institutional regimes, and everyday actions of individual, group, nation-state, and corporate actors. For example, the human is invested with powers of life and death over all other beings and with the prerogative to control and manage all geographical space. The all-encompassing manifestation of the belief system of human supremacy is precisely what constitutes it as a worldview…

From "Reimagining the human."

Beyond Human Dominance
The dominant framework of technofixes, technological schemes, and fine-tuning efficiencies is by itself no match for the tidal wave of human expansionism expected in this century. Looming before us is the imminent escalation of food, energy, materials, and commodities production, and resulting increases in wildlands destruction, species extinctions, wildlife extirpations, freshwater appropriation, ocean degradation, extractionist operations, and the production of industrial, pesticide, nitrogen, manure, plastic, and other waste—all unfolding amid climate-change ordeals.

In the face of this juggernaut, a singular focus on a techno-managerial portfolio seems fueled by a source other than pragmatism alone. That portfolio—which would include such initiatives as climate geoengineering, desalination, de-extinction, and off-planet colonization—is in keeping with the social rubric of human distinction. The prevalent corpus resonates with a Promethean impulse to sustain human hegemony while avoiding the most expeditious approach to the ecological predicament—contracting humanity's scale and scope by means that will simultaneously strengthen human rights, facilitate the abolition of poverty, elevate our quality of life, counter the dangers of climate change, and preserve Earth's magnificent biodiversity.

To pursue scaling down and pulling back the human factor requires us to reimagine the human in a register that no longer identifies human greatness with dominance within the ecosphere and domination over nonhumans…

 Good luck scaling back our speciocentric hubris.

See all the articles under Tomorrow's Earth.

BELOW, NEWS HEADLINE TODAY

UPDATE

Interesting, in light of the foregoing on "reimagining the human." From The Atlantic:

An Elephant’s Personhood on Trial
A legal case involving a famous solitary elephant poses a fundamental question about animals’ rights.

"Personhood?" Yeah. Some of us want to bestow it on human zygotes.

BTW, see EO Wilson's "Half Earth."

MORE FROM SCIENCE MAGAZINE DEC 14TH ISSUE

This issue is jammed with great stuff. to wit,

Revealing the brain's molecular architecture
The PsychENCODE Consortium

The brain, our most complex organ, is at the root of both the cognitive and behavioral repertoires that make us unique as a species and underlies susceptibility to neuropsychiatric disorders. Healthy brain development and neurological function rely on precise spatiotemporal regulation of the transcriptome, which varies substantially by brain region and cell type. Recent advances in the genetics of neuropsychiatric disorders reveal a highly polygenic risk architecture involving contributions of multiple common variants with small effects and rare variants with a range of effects. Because most of this genetic variation resides in noncoding regions of the genome, establishment of mechanistic links between variants and disease phenotypes is impeded by a lack of a comprehensive understanding of the regulatory and epigenomic landscape of the human brain…

Man, I've been reading all day. My brain is tired...

Developments in the neuroscience area will likely enhance progress in AI/ML, I would think. Expect significant advances in the coming year.

BUT, WAIT! THERE'S MORE!

This book was reviewed in this foregoing cited issue of Science Magazine:

"Off topic?" Nah.

...Maybe it’s a tinkerer’s curiosity that turned me into a scientist. Early on, physics allowed me to explore the sprockets and gears of the universe and the very forces that control our lives. Looking for more challenges, I turned later to the complexities of networks and data. For a vigilant asker-of-questions, I’ve chosen the right corner of the scientific world to call home. As long as a line of inquiry is based on numbers—the more the merrier—I can pursue it doggedly, following its scent through the maze of data now available to researchers in our hyper-connected, technological world. Hunting down an answer inevitably leads to more questions, new possibilities that hover like gnats on the periphery of any research I conduct. I try to swat them away and stay focused on the task at hand, but I’m not that different from the kid I once was, stubbornly asking “Why?” in response to… well, pretty much anything. It is the quest for answers that gets me up in the morning and keeps me up at night.

These days I run the Center for Complex Network Research, in Boston, where my job is exploring the “why” behind topics as varied as how people or molecules interact, where and how links form, and what our interconnectedness can tell us about society or our biological origins. We’ve examined the topology of the World Wide Web. We’re looking at how tiny hiccups in our genetic networks lead to disease. We’re exploring how our brains control their billions of neurons and how molecules in food attach to our proteins, ensuring our long-term health.

I love this kind of stuff—the math behind our social fabric, the way numbers provide a framework for understanding the essence of our connectedness. When I use models and tools to delve into unlikely topics for scientific analyses, these frameworks inevitably deepen our knowledge…

Barabási, Albert-László. The Formula (pp. 4-5). Little, Brown and Company. Kindle Edition.

So much to learn, so little time.

OK, TAKE IT BACK TO THE TOP...

Stay tuned. For openers, Forbes' "Top 8 Healthcare Predictions for 2019." Not sure that I'm buyin' a lot of that at first blush.

Erratum: BobbyG on "The Future of Science" in 2016.

JOE FLOWER'S YEAR-END THOUGHTS

It’s December 30, 2018.

Healthcare is complex. Simple solutions are useless. Any simple picture of the future is a lie. Simple techno-optimism or innovationist neophilia get us nowhere…

Simple futurism is entertainment. It points at each shiny thing—AI, contractual blockchain, virtual worlds, augmented reality, cell transformation, haptic rebuilds—and says, “Wow! Look at this.” It’s a Jetsons way of looking at the future, as real as using the Flintstones as a guide to the past.

Thinking about the future is a complex business. It requires clarity, penetration, a broad view, and the insights of complexity science. Futurism based on the insights of complexity is a tool for thinking, planning, strategizing…

These skills can be learned…

A futurism based on complexity looks at every element, shiny, dull, or invisible, and asks:

• “What is it for?”
• “How does it get its energy?”
• “How does it affect other elements?”

Complex futurism can connect the dots and the 3-D networks of dots building out over time to paint the pictures of future scenarios, of ways the future could really turn out, what will take us there, and what strategies we might employ to meet them…

Healthcare is changing — consolidation, new tech, political chaos, a vast and growing IT overburden, shifting rules, ever-rising costs, new solutions, business model experiments. And it will continue to do this for some time...

'eh?

NEWS YEAR'S EVE ADDENDUM

Via STATnew:

What will 2019 bring for science and medicine? We asked the experts

PERSONAL HEALTH CARE ERRATUM

Just got what will likely be my last 2018 Humana EoB statement in the mail. Year-to-date (thru 12/24) "total billed charges," just a tad more than $544,000 (those BS "chargemaster" prices). Mostly evrything having to do with a minor surgery (large inguinal hernia) and a major one (open heart aortic valve replacement).

I have no way to know which providers actually got how much (the Medicare, Humana, and Silverscripts EoBs across the year each run to many pages of obtuse FFS detail). And, I've not really tallied up my own 2018 OoP (out-of-pocket). It was plenty.

Suspect that in the aggregate, reimbursements have been on average perhaps ~25% of "list." Fair?
_____________

More to come...

"Overcharged?" Paying for health care

The publisher (CATO Institute), at the request of one of the authors, graciously gave me a pre-pub comp copy to study and review. The book is to be released on July 3rd.

"Why is the American health care system so dysfunctional and expensive? Why does the EpiPen, containing $1 worth of medicine, cost $600? Why do hospitalized patients receive bills laden with inflated and surprise charges that come out of the blue from out-of-network providers, or that demand payment for services that weren't delivered? Why is more than $1 trillion―one out of every three dollars that passes through the system―lost to fraud, wasted on services that don't help patients, or misspent? What are the causes of spiraling costs, mediocre quality, and limited access?

Overcharged details how the answers to these questions are connected and reveals a system that performs as if it had been designed to spend as much money as it can, and to be as confusing and unfriendly as possible, with no accountability. Overcharged then exhaustively details real reforms―showing how health care can become more efficient and pro-consumer when it is subjected to the competitive forces that apply to the rest of the economy, and will only get better and cheaper when consumers exert pressure from below."

It's a serious (if partisan) book, deserving of serious study and critical analysis. A bargain at $7.99 Kindle price. I find in it much to both agree with and to be skeptical of.

I recently underwent a coronary angiogram px, dx preparatory to my upcoming SAVR px (open heart aortic valve replacement surgery). My "chargemaster" invoice and EoB statement numbers:

Cardiology:  $31,004.00
Laboratory:  $$615.84
Med/Surg Supplies & Devices:  $4,624.00
Pharmacy:  $1,391.20
----
Total:  $37,635.04

Medicare paid $2,667,29 (it's considered a Medicare Part-B outpatient encounter), my residual balance owed was $1,209.44, for a total paid of $3,876.73. Roughly 10.3% of the (BS) "retail."

I was there for about 4 hours, so, roughly a grand an hour, for all of that technology and expertise.

Did I "overpay" to comfortingly learn from my cardiologist that I "have the arteries of an 18 year old?"

"SAVR"

Sometime in the next couple of months, a highly respected and experienced local cardiac surgeon and his team will sedate and anesthetize me, render me deeply unconscious, emplace a breathing tube in my throat, slice open my chest, spread out my rib cage, stop my heartbeat, put me on a heart-lung machine, cut my heart open, remove my seriously stenotic aortic valve, replace it with a sutured-in prosthetic (pig or bovine tissue) valve, close the heart back up and re-start it, close my chest back up, and send me off to Recovery.

One hopes.

The Healthcare Bluebook pegs the current "fair price" for the SAVR px in my area at about $90k.

"Reasonable?"

Back to Overcharged. Per Covey, I "begin with the end in mind."

CONCLUSION
For the last half century, the chief object of American health policy has been to ensure that consumers pay the smallest possible fraction of the cost of medical care at the point at which treatments are delivered. Obamacare, the State Children’s Health Insurance Program, Medicare, Medicaid, the U.S. Veterans Health Administration (VHA), and tax-advantaged private insurance arrangements— along with the long list of coverage mandates that go with them— all reduce direct financial responsibility for medical services to a minimum. As explained in Chapter 15, the evil genius of third-party payment is that it encourages consumption and drives up costs by making medical services cheap for patients at the point of sale.

The public officials, insurers, and health care providers who benefit from all this spending defend third-party payment arrangements by arguing that health care is too complicated and too expensive for consumers to manage on their own, and by contending that people who are directly responsible for health care costs will use medical services less often than they should. Better that government bureaucrats spend tax dollars and that private insurers spend premium dollars, they argue, than that consumers pay for medical services themselves. They don’t want consumers to consider the possibility that market mechanisms might remediate excessive costs and complications as successfully in health care as they have in other sectors. This is to be expected. Widespread reliance on third-party payment arrangements benefits insurers and health care providers, so they want nothing to interfere with it…

…An abundance of evidence, including everything from peer-reviewed academic studies of the impact of Medicare and tax breaks on costs to news reports about surprise bills, retail outlets, and frauds, makes it clear that the politicized third-party payment system is the main culprit. Instead of expanding the reach of that system, as Obamacare did, we should face facts and start paying for health care the same way we pay for everything else. When hundreds of millions of people spend their own money on health care, they will behave differently, and health care providers will too. Consumers will look for services that offer better value for the dollar, and doctors, hospitals, drug companies, and other medical outlets will try to provide them. Prices will fall and both the availability and the quality of medical treatments will improve.

Many health care providers won’t like this new world in which they must compete for business. They benefit from existing arrangements, which pay them whatever they ask and send them more dollars year after year. We should stop indulging them, and we should stop listening to their apologists and lobbyists too. Markets do a good job of supplying food, clothing, housing, transportation, and other essentials. They can help us meet our needs for medical treatments.

One of the most wonderful things about markets is that they automatically reward sellers who treat consumers well and automatically punish those who don’t. Both the carrot and the stick are important. For American health care to improve, providers that deliver high-quality services at reasonable prices must be rewarded and inferior providers must fail. There must be turnover and opportunities for new entrants. A near-death experience made the American automobile industry more efficient and pro-consumer, and decades later, innovators like Tesla are still forcing existing manufacturers to do better by deploying new technologies and business models. If and when the businesses that operate in the American health care sector are subjected to intense competition, they will respond the same way. And if they don’t, they will fall by the wayside and new businesses will emerge that will offer Americans cheaper and better health care.

Change won’t come easily. Old-line health care companies have rigged the game in their favor. They benefit from a guaranteed flow of dollars and massive subsidies. They control market entry. And they have convinced the American public that they should not have to operate like other businesses…

Charles Silver & David A. Hyman. Overcharged: Why Americans Pay Too Much for Health Care (Kindle Locations 7253-7295). CATO Institute. 

That is the crux of their argument.

Which begins thus:

PREFACE
The problems with America’s health care system are many and varied. That’s why there is no general guide to all of them. Instead, there are thousands of books and articles about specific difficulties, such as the mistreatment of prostate cancer in men, the politics of health care reform, outrageous hospital charges, or fraud in the prescription drug business.

Although many of these writings are excellent, they fail to convey a sense of the whole. An intelligent person wants to know, at the most general level, why our health care system is so dysfunctional. What are the root causes of spiraling costs, mediocre quality, and limited access? Why is more than $ 1 trillion— one out of every three dollars that passes through the system— lost to fraud, wasted on services that don’t help patients, or otherwise misspent? Why do hospitalized patients receive bills that are laden with inflated charges, that come out of the blue from out-of-network providers, or that demand payment for services that weren’t delivered? Why does the EpiPen, an old technology that contains $ 1 worth of medicine, cost $ 600? Do questions like these require separate answers? Or are the answers connected? Are there core drivers of the health care system’s many pathologies?

We believe that an array of the American health care system’s most important shortcomings stem from a few root causes. We also think that it is important to lay these fundamental drivers bare for everyone to see... [ibid, Kindle Locations 43-53]

 Between these bounds lie 22 chapters fully laying out their argument and supporting evidence. to wit:

The United States is “the most expensive place in the world to get sick.” 1 Why? One big reason is that providers routinely game the payment system. Drug companies are experts at this. Chapter 1 describes how they first gain strangleholds on supply. Chapter 2 describes how they then charge whatever they want, knowing the payment system imposes no restraint on prices. Chapter 3 shows that shady conduct occurs at every point in the drug distribution chain and often involves the willing participation of pharmacists and physicians who profit by exploiting existing payment arrangements. It is easy to see why spending on prescription drugs, new and old, has gone through the roof.

Doctors game the payment system too. As Chapters 4 and 5 show, they deliver an ocean of services that patients don’t need, such as excessive numbers of stents and cesarean deliveries. Chapter 6 describes how doctors regularly perform treatments that haven’t been proven to work, many of which are found to be ineffective or harmful when they are finally studied with care.

Chapter 7 explains how public officials get in on the action. In return for sizable campaign contributions from health care providers and their lobbyists, they let the flow of cash into the health care sector continue and look for ways to increase it. When the campaign contributions are large enough, elected officials even go to bat for corrupt providers who face fraud investigations.

Some hospitals and doctors aren’t satisfied with excess payments for garden-variety overuse and unnecessary care, and they turn to a life of crime— or at least abuse. Chapter 8 explains how hospitals “upcode” treatments, invent secondary conditions that patients don’t have, and concoct phony bills. Chapter 9 shows how hospitals also conspire with doctors to maximize their revenues by capturing differences in payments based on the site of service, tacking on absurd charges, and gouging patients who are uninsured or treated by out-of-network physicians at their facilities. Chapter 10 describes how hospices, nursing homes, and home health care services play similar games and frequently charge for services that were never delivered.

Chapter 11 shows how some doctors operate pill mills that supply the street with dangerous drugs— likely contributing to the rising death toll from overuse of prescription narcotics. Ambulance companies and durable medical equipment suppliers cheat the system regularly too, as do domestic and international criminal gangs. As Chapter 12 explains, there are far too many malefactors for the police to catch. For every one police put away, two more pop up. That is why the same types of fraud succeed again and again and again.

Chapter 13 explains that the quality of health care is often dangerously low because the payment system pays providers regardless of how well or poorly their patients fare. In fact, it often doles out more money to providers when patients experience complications than when they get well. Chapter 14 explains how incumbent health care providers have stifled competition so successfully that the government has to pay them extra to improve. In other industries, competition forces existing business to bear the costs of improving their products.

Although there have been repeated attempts to address these problems, all have failed because they have not changed the core incentives driving the system. We address that problem in Part 2... [ibid, Kindle Locations 542-570]

And so on.

I found this interesting:

Academic research on health care, of which there is an enormous amount, presented other challenges. In a book of this type, which is intended to provide a coherent, high-level account of the entire health care system for a general audience of intelligent readers, we can discuss only general themes and the leading works that develop them. And we cannot go into even those works in much detail. We therefore strove to set out the basic insights and most important findings, and to do not much more than that. Readers who want to read the literature in greater depth are welcome to begin their journey by using the many citations we provide. [ibid, Kindle Locations 95-100]

Yeah.

Candidate Trump: "You're going to have such great health care, at a tiny fraction of the cost, and it's going to be so easy."
 
President Trump: "Who knew health care could be so complicated?"

I am reminded of a number of other health care policy writings I've studied across the years,
beginning with my 1994 grad school "argument analysis and evaluation" semester paper of the JAMA Single Payer proposal article (pdf). More on that paper here.

More stuff:

Ugliest book cover "art" ever. See this post.

More...

Steve Brill, Elisabeth Rosenthal.

Bradley and Taylor, and my friend Joe Flower.

Dave Chase.

And, multiple cites of Einer Elhauge -- the "Allocating health care morally" guy (pdf).

Health law policy suffers from an identifiable pathology. The pathology is not that it employs four different paradigms for how decisions to allocate resources should be made: the market paradigm, the professional paradigm, the moral paradigm, and the political paradigm. The pathology is that, rather than coordinate these decisionmaking paradigms, health law policy employs them inconsistently, such that the combination operates at cross-purposes. 

This inconsistency results in part because, intellectually, health care law borrows haphazardly from other fields of law, each of which has its own internally coherent conceptual logic, but which in combination results in an incoherent legal framework and perverse incentive structures. In other words, health care law has not-at least not yet-established itself to be a field of law with its own coherent conceptual logic, as opposed to a collection of issues and cases from other legal fields connected only by the happenstance that they all involve patients and health care providers. 

In other part, the pathology results because the various scholarly disciplines focus excessively on their favorite paradigms. Scholars operating in the disciplines of economics, medicine, political science, and philosophy each tend to assume that their discipline offers a privileged perspective. This leads them either to press their favored paradigm too far or to conceptualize policy issues solely in terms of what their paradigm can and cannot solve.

Instead, health law policy issues should be conceived in terms of comparative paradigm analysis. Such analysis focuses on the strengths and weaknesses of the various decisionmaking paradigms, determining which is relatively better suited to resolving various decisions, and then assigning each paradigm to the roles for which it is best suited. It is from this comparative perspective that this Article analyzes the promise and limits of the moral paradigm for allocating health care resources…

I have more cites, but those are enough for these purposes. Again, a macro-level health econ policy SME I'm not. My relative expertise, as I've noted before, is principally limited to domains such as InfoTech, workflow/process QI (big-time Lean advocate), and HIPAA.

We rightfully expect (and get) continuous improvements in health care / bio-med technology. We know dispositively that scientific process QI methods such as Lean continue to bear significant fruit (notwithstanding being confined within a chaotic health care economic environment). Were we to apply such methodical "customer-value-add" thinking to the administrative / financial side, what might we accomplish? Is the only way to get there removal of payor intermediaries?

Defining "customers" is a significant sand-in-the-gears obstacle, I know. So many "stakeholders" (as the authors and numerous others point out) beyond patients, many of them with inordinate incumbent market clout -- abetted by (margin-correlated) opacity and barriers to entry.

SOME RANDOM "OVERCHARGED" BULLET POINT THOUGHTS

• I have long irascibly asserted that "no amount of calling 3rd-party (mostly for-profit) intermediated, dubious value-add pre-payment plans 'insurance' will make them so." These authors give that assertion a good confirmatory airing. Insurance is properly a risk-vetted hedge against catastrophic loss. It maked me crazy that so many don't get this.;
• I have abiding skepticism that the (conflated phrase) "free markets" comprise a uniformly beneficent way to structure socioeconomics. For one thing, let's not confuse "private markets" with "free markets." All human activity gets regulated one way or another. On this point, Google "Gresham's Dynamic." Anyone still recall the 2008 financial crash? Central to the argument here is that assertion here is that the health care space is "just another consumer market" and will function optimally without "government meddling." I have serious skepticism that a direct-cash-pay price for my upcoming heart surgery would be materially less than the ~$90k Bluebook "fair price" any time soon -- and all I have at this point is "soon.";
• Also in that regard, the authors recommend that people might "finance" big-ticket acute care encounters beyond their cash-on-hand means (such as, e.g., say, my pending SAVR px -- though I actually, luckily could pay for it OoP). What could possibly go wrong there? As someone who did a lengthy stint in subprime risk management, I have some views on that idea. (apropos, not too long ago, at WinterTech, some VCs were speaking of indeed looking at opportunities in the private "medical financing space.");
• The authors tout the potential of "medical tourism." Interesting. I seriously looked at going to Germany or Switzerland to pay cash for a "TAVR" px rather than the open-heart valve job I've decided on; 
• Two dozen cites regarding "EHRs," almost all of them negative (largely re: "Meaningful Use" so despised by "conservatives");
• "Singapore" as an exemplar? Seriously? Dunno; never been there. Neither have I been to Scandinavia (often cited as universal coverage successes), in fairness;
• Really didn't care much for the "intergenerational 'warfare' / reverse Robin Hood" assertions. Is a "commonwealth" really only legitimate within the confines of short-term transactionalism?
• When did it become a "conservative" idea to simply give people "vouchers" via which to buy private market health care? (Or, "school choice," etc?). Central to the CATO Liturgy is that "subsidies distort markets." And, yeah, lots of truth there broadly. The "benefit" of my home mortgage deductability has to be (invisibly) baked into the house's "market value." It has to really be a net wash;
• But, tangentially related to the foregoing point, the writers cite the comparative examples of Social Security vs, Medicare. I'm am now a Social Security and Medicare bene. I get a fixed SS amount each month, and it's up to me to decide how to spend it. Overcharged posits that Medicare should be no different. Any problems there? 'eh?

I find the authors' assessment of the core dysfunctions of our "fragmented" health care "system" rather spot-on (a lot of it is not exactly news to me; see my other book cites, and prior postings). Nonetheless, I have to have concerns about the broad ("equal access") viability of their proposed "market solutions." But, I'm still burrowed deep in the book -- which I heartily recommend, irrespective of your policy positions. More as this Grasshopper learns more.

I'd love to have reactions from my pal, medical economist J.D. Kleinke on this stuff.

 

JULY 8TH UPDATE

Do poor people have a right to health care?
NY Times Editorial Board

The 16 Kentuckians who recently won a lawsuit challenging the legality of Medicaid work requirements include a law student with a rare heart condition, a mortician with diabetes, a mother of four with congenital hip dysplasia and a housekeeper with rheumatoid arthritis. It’s a mixed bunch, united by two grim facts: They live at or below the federal poverty level, and they’re caught in the cross hairs of a debate over what society owes its neediest members.

Their lawsuit argued that insisting that people work a certain number of hours a month in order to receive Medicaid benefits, like other requirements the state was planning to demand, is illegal because it runs counter to Medicaid’s purpose — to ensure that low-income people have access to decent care. The lawsuit also contended that such requirements would imperil the plaintiffs’ health by depriving them of the only medical insurance they could afford. The new rules, which would have stripped recipients of their benefits if they failed to meet monthly hours-worked quotas and strict reporting standards, were simply oblivious to the realities of low-wage living in Kentucky, and America in general…

…the latest salvo in a protracted national reckoning over Medicaid, a program that has been in place for more than half a century and now insures one in five Americans, or roughly 74 million people. In January, the federal government announced that it would reverse decades of precedent and allow states to tie Medicaid coverage to work requirements. The move is part of a wider conservative-led campaign to restrict the number of people who benefit from social safety-net programs. It also reflects persistent national ambivalence over the question of whether health care is a human right or an earned privilege — and, if the latter, how “earned” should be defined…

…the basic ideological argument for work requirements — that people should earn their government benefits — collapses under scrutiny. Numerous analyses have indicated that a clear majority of Medicaid recipients who can work already do work. Of the 9.8 million working-age Medicaid recipients who are not employed, the vast majority have physical limitations or provide full-time care to young or elderly family members; just 588,000 of them are able to hold jobs but are currently unemployed, according to a 2017 report. And most of those are actively looking for work…

…it would seem that the Trump administration’s push to enact work requirements is aimed not at improving health, or even at cutting costs — there are more effective ways to do both — but rather at stigmatizing Medicaid, a program that has become less maligned in recent years, as more Americans have become insured under it. In one 2017 poll, 74 percent of respondents said they had a favorable view of Medicaid.

But while most Americans agree that poor people should have health insurance, they also believe that people of all income levels should earn their benefits — the same poll from last year found that 70 percent of respondents supported Medicaid work requirements. That paradox, of increasing support for Medicaid amid lingering suspicion toward Medicaid recipients, underscores persistent questions about how Americans view those in need…

"[O]ne peculiarity of our present climate is that we care much more about our rights than about our 'good'."  -- Simon Blackburn, Being Good

And, a chronic difficulty lies in determining where the two are not mutually exclusive, no?

UPDATES

From STATnews: "As Atul Gawande steps into a risky health CEO role, here are five challenges he faces."

Notes many of the same issues as Overcharged.
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Modern Healthcare, July 11th:

Is private equity helping or hurting healthcare?
By Harry Gamble  | July 10, 2018

Some view third-party investment in physician practices as a vital trend that offers economies of scale that make healthcare more efficient. Others believe it fosters monopoly control while driving up prices. But nearly everyone agrees that further consolidation within the U.S. healthcare market is coming.

The Chicago-based American Medical Association is in the midst of a yearlong effort to quantify the impact that venture capitalists, private equity firms and other outside entities have on the way doctors treat their patients. The study rolls on as the number of physicians who work for themselves continues to shrink. According to a report by Accenture, the share of U.S doctors in independent practice has plummeted to 33 percent in 2016 from 57 percent in 2000.

"The days of Marcus Welby are behind us," said Anthony LoSasso, professor of health policy and administration at the University of Illinois at Chicago's School of Public Health. "The uncertainty over healthcare policy in Washington is probably driving the integrated healthcare delivery systems and large hospitals to bulk up almost as a counterweight to the uncertainty they face. They know that if you are bigger, you are in a better position to survive whatever may come your way.”…

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More to come...

Caregiver and nascent care recipient

This button was on my press pass to the Fall 2017 Health 2.0 Conference. I thought at the time, 'yeah, nice, that's pretty cool' given my ailing daughter's situation after her March 29th dx of Stage IV pancreatic cancer. She just had her second chemo round of a new 2-drug chemo regimen after 9 months of her first Folfirinox chemo cocktail. Folfirinox works until it no longer does -- roughly 9-12 months. We are now there.

Danielle also had to go in for an interventional radiology ovarian cyst drainage px this week, as if there wasn't enough to deal with. It was a "success," albeit another long day.

Below, the entrance to our weekly Kaiser-Permanente schlep.

Luckily for us, this K-P facility is merely 7-8 minutes from our house.

I lost my first-born (Danielle's elder half-sister) to cancer 20 years ago this July 1st. I thought nothing would ever be more difficult than that.

I was wrong. On so many levels.

Not the least of which being that a year of unremitting stress (commencing with the election of the brutish Donald Trump) has caught up with me.

"SEVERE AORTIC STENOSIS"

My late Dad had his aortic valve replaced (along w/ a bypass px) in 1996 at age 80. My late Mother had chronic CAD as well, eventually having to have a pacemaker implant.

So, cardiovascular disease is in my bloodline genetics. I've been on relatively low-dose statins and BP meds for years. I do what I can: sparse with the red meat and fats and junk foods, gym rat devotee, not obese (5'10," 174 lbs at age 71). I did a cardiac treadmill about a dozen years ago, and never did get up to "heart rate." Barely broke a sweat (those were my heavy full-court hoops days).

Continuing delusions of grandeur, 2016

 Nonetheless...

I ended up in the hospital with sepsis in early April 2015 in the wake of my prostate cancer biopsy. Wrote about that lovely entire experience here. While admitted, I had a cardiac echo px. Nothing ever came of it until my new Primary noticed a "heart murmur" during a subsequent exam quite some time later. He looked in my chart (Epic) and quickly found the earlier Muir Medical Center cardiac echo report. It had been deemed of "non-clinical" import. Which is probably why no one brought it up, and, admittedly, I'd not looked via the patient portal. I had other things to deal with at the time.

After Danielle fell ill, I saw my Primary again, and asked for several referrals, worried about my persistent daily stress levels, and the potential impact on my renewed "caregiver" duties.

Among the docs I subsequently saw was a cardiologist (whom I really like). I had a full workup, including bloodwork, static EKG, treadmill EKG, and another cardiac echo.

My EKGs were fine. My bloodwork panel assays were all in the normal range, my BP is "normal range," my BMI is normal.

My new cardiac echo, however, indicated a worrisome decline in my aortic valve viability ("stenosis"), and, while my "ejection fraction" was normal, prudence would dictate "active surveillance" follow-ups.

In December I had yet another cardiac echo px.

Further worsening of stenosis, and a drop in ejection fraction (the latter getting closer to the line). Time to discuss action.

"TAVR?"

Transcatheter Aortic Valve Replacement. A "non-invasive" alternative to "SAVR," (the onerous traditional open-heart surgery). Sedation and a Local, and you go home a day later with a sore groin.

Dr. Chang (my cardio doc) had mentioned it, saying that it's becoming the "standard of care" outside the U.S. But, while the TAVR px is done in the states, it's only approved here for "high" or "prohibitive surgical risk" patients (i.e., older and sicker patients).

And, that cohort restriction problematically biases the relative TAVR vs SAVR outcomes stats, making it difficult to make a fully-informed choice under the pressure of time.

Given that the TAVR option appears to not be an unalloyed outcomes blessing in any event (to the extent we can truly know, via the relative paucity of current data), I am likely to opt for the SAVR px, and will soon meet with a recommended cardiac surgeon to discuss it. I suppose I could go all "Medical Tourist," fly to Germany or Switzerland, pay cash (~$100k), and do a TAVR.

Probably not. I could pay for it (ugh), but, probably not, all things considered.

Beyond the well-known patient post-op adversities of the SAVR px per se, my daughter's relentlessly worsening condition dictates that I address this sooner rather than later.

So if this blog goes increasingly dark for a while, you'll know why.

If this blog goes away, I guess you'll know why as well.

LOL.

Next up, HIMSS 2018. Given all of the foregoing, I rather doubt I'll be there, notwithstanding that it's again being held in my old Las Vegas stomping grounds.

In 2012, just on a lark, I applied for a HIMSS Conference press pass. To my utter surprise, they approved it!

Why do I continue this ankle-biting effort?
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UPDATE

Interesting.

Planning to have open heart surgery anytime soon? You might want to ask your cardiologist to book an afternoon slot in the OR.

New research shows that heart operations performed in the afternoon produced better outcomes than those done in the morning.

Because afternoon heart surgery syncs with the body's circadian clock (the internal body clock that controls when people sleep, eat and wake up), it reduces the risk of heart damage, the French researchers said.

"Currently, there are few other surgical options to reduce the risk of post-surgery heart damage, meaning new techniques to protect patients are needed," said study author Dr. David Montaigne, a professor at the University of Lille.

In one part of the study, his team tracked the medical records of nearly 600 people who had heart valve replacement surgery for 500 days, to identify any major cardiac events such as a heart attack, heart failure or death from heart disease. Half had surgery in the morning while the other half had it in the afternoon.

The risk of a major cardiac event was 50 percent lower among patients who had surgery in the afternoon than in those who had surgery in the morning. That would work out to one less major cardiac event per 11 patients who have afternoon surgery, the researchers said…

Link here.

ERRATUM

My friend the Health Care Futurist Joe Flower and his wife Jennifer are selling their Sausalito live-aboard tug.

I've been on it, it's magnificent. I'd buy it in a heartbeat had I the money. I've had my eye on this one up on Vancouver Island, BC. Seriously.
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FEB 3RD UPDATE

I met with the referral cardiac surgeon, really like him. I am totally comfortable doing the SAVR under him ("open heart"). He wants to evaluate a "cardiac echo stress test" first, and sees no dire exigency, given my total picture.

My daughter's cancer, however, has taken a significant turn for the worse. She spent M-W in the hospital, and we've had to buy a bunch of "DME" for her return home. They want us to get a "hospital bed," too. Talk of "Palliative Care Unit" and "hospice" is in the air.

The stress, man...
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More to come...

2017 Health 2.0 Conference photo gallery recap

Running way behind this year. First, the Las Vegas mass shooting took the air out of my soul, given my long connection there (none of my many friend were hit, but everyone I know there is traumatized). Then, I encountered WiFi hassles in my Hyatt room, which kept me offline Tuesday night. Turns out they'd taken down their login interface and replaced it with a new one. No more "last name + room number." The new login page, which asks for your full name and email address, finally came up yesterday morning. Too late. Whatever. I'll catch up from home.

My Sunday pre-conference Provider Symposium post is here.

So, I'm home. Left the Convention Center at 1:32 and beat the 680 crush. Home by 3, too tired to do anything.

Gonna now triage my myriad shots and begin uploading them. Then I'll review my copious notes and post my conference takeaways. Lots of great stuff.

Indu set the "looking ahead" agenda at the outset, citing "Five Drivers" going forward:

1. FHIR and Blockchain;
2. New modalities and analytics;
3. New entrants into healthcare, large and small;
4. Incumbents adopting new stripes;
5. New environments for health care.

In the interim, before I riff on more detail, I recommend to everyone this poignant THCB post. Reminds me of this one. I totally personally relate to the latter one, given my daughter's Stage IV pancreatic cancer dx.

Stay tuned. Hundreds of shots to review.

But, first, a divergence apropos of HIT, breaking news from STAT:

IBM to Congress: Watson will transform health care, so keep your hands off our supercomputer

To the public, IBM trumpets its Watson supercomputer as the next big thing in medicine, a new kind of machine that melds human expertise with digital speed to give patients personalized treatment advice.

Meanwhile, in the halls of Congress, company executives have been delivering a blunter message: We will revolutionize patient care, so please get out of the way.

Like any new technology, Watson poses unknown risks; for example, what if its advice is wrong and harms a patient? But IBM argues that its machine doesn’t need to be regulated because it’s different from other medical devices. It’s not like a pacemaker or a CT scanner, so the company shouldn’t have to prove to the government that it’s safe and effective.

Now, as federal regulators prepare to weigh in on that issue, a STAT examination shows the lengths to which IBM has gone to shield its prized machine from government scrutiny.

The company’s fingerprints are all over legislation passed last year that exempted several types of health software from FDA jurisdiction…

See my prior post "Watson and cancer." FierceHealthIT is also on the story.


MORE PICS...

HIMSS in the House, Hal Wolf and Stephen Lieber.

HLA Global in the House, Jon Patrick and son.

Triple threat opening Keynotes: Bruce Greenstein, Aneesh Chopra, and David Brailer.

More pics...

Gil Addo, CEO, RubiconMD

Amy Abernethy, MD PhD, CMO, Flatiron

Sandra Hernandez, MD, President & CEO, California Health Care Foundation

BTW, no, I don't have names for everyone I've shot. Stuff goes by too fast, and there's no way to consistently link up names in my notes to shots in the camera, given the volume of shots. More photos on the way...

CONTINUING

Major Underachiever

Indu interviews RWJF's Dr. Michael Painter

I got invited to the Tuesday evening Aetna private reception. Nice. Thanks.

A long day. A ton to assimilate. More shots below coming shortly.

UPDATE

The shutter clicks continue.

I have more, LOL, but you get the idea. Yet another great Health 2.0 Conference. Gotta now spend some time pondering my notes.

UPDATE

MobiHealthNews has excellent comprehensive coverage up.

In-Depth: News and views from Health 2.0 2017

This year was the 11th anniversary of Health 2.0, a yearly health tech conference that explores the newest in digital health with eyes for what’s still to come. This year marked the first Health 2.0 conference since the show was acquired by HIMSS, MobiHealthNews's parent company.

With the four-day event come and gone, MobiHealthNews has collected all of its coverage from the Santa Clara Convention Center below, along with extra conference announcements and speaker discussions that might not have made it to the front page…

I can't top that. Read all of it. Kudos.

See also:

Health 2.0 Fall Conference Startup Pitch Competition: Meet the Companies

This week, healthcare technology innovators, thought leaders, and business owners convene in Santa Clara, California for Health 2.0’s 11th Annual Fall Conference. While this year’s event runs from October 2-4, Medgadget was able to participate in the Sunday pre-conference and the annual Startup Pitch Competition.

Evaluating eight “Series A ready” companies, organized into professional solution (B2B) and consumer solution (B2C) tracks, were six judges…

Be up with some of my own conclusions shortly. Of particular interest to me were "Interoperability," 'Big Data & Analytics," "NLP," health care "policy," and "workflow."

UPDATE

Another fine recap, from the PoV of one of the Provider Symposium Day panelists:

Key Takeaways from Another Great Health 2.0
Rasu Shrestha MD MBA

The Health 2.0 Conference gets better every year. I’m so grateful to have engaged with so many industry leaders – both familiar faces and new friends. What a wonderful opportunity to speak on the “Innovation to Implementation to Transformation” panel on Sunday and connect with people behind some of the most up-and-coming health care technology companies at MarketConnect Live. I also really enjoyed engaging with a ballroom full of enthusiastic attendees leading a lunch and learn discussion with my colleagues where we discussed best practices in marrying the competencies of a digital health company with the realities of patient care.

Sunday night’s Traction 2017 pitch competition was a highlight. I saw some promising startups that are using technology to solve long-standing health care problems. From skin cancer detection to new uses for 3D-printers, I saw innovations that reinforce UPMC Enterprises’ belief that technology can be an enabler of better, more efficient, and more affordable care.

While at Health 2.0, I thought a lot about where our industry is going and what each person’s role is in redefining the health care trajectory. I left the conference with three key takeaways I’d like to share with you…

Below, cool, someone had a fish-eye lense. Click the pic to enlarge,

Hmmm... I may need to buy one of those.

Also of note, from Joe Flower's opening Keynote:

"Six Assertions on Knowing the Unknowable Future of Healthcare"

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CODA

I've been mostly offline for a week, under the weather and dealing with my ailing daughter while my wife was in Florida on business. I don't have a lot to add the the assessments of the Conference, except to say that my irascible dubiety toward "interoperability" has been attenuated. I retain some misgivings, but it seems that the FHIR crowd is indeed making significant headway. Beyond that, my skeptical view of "NLP" pretty much remains intact, and I continue to view warily all the exuberant hype around the putative panacea of "big data."
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More to come...