After a decade dominated by ObamaCare- its enactment in 2010, the fraught implementation, its near repeal in 2017, and the welter of inconclusive experiments with Medicare payment reform – healthcare in the 2020s is likely to be reshaped by technological and scientific advances, as well as continued political struggles over societal and family cost. We can expect major change in seven areas:
1. Rising Patient Safety Risks.
Two emerging patient safety risks will spike in seriousness during the 20s. One risk, that of drug resistant bacterial infections, boiled under the surface for more than two decades, with the rise of MRSA, Candida aureas, Clostridiodes difficele and more than a dozen other agents.
Nearly three million people were infected with these agents in 2017, and more than 48 thousand died. While hospital infection control has improved, and deaths from hospital infections fell during the 2010’s, antibiotic drug development has lagged, and the potential for one or more breakout infection risks is highly likely in the 2020s. The Economist published a chilling and entirely possible scenario in July, 2019.
The second major risk has resulted from the confluence of two information technology (IT) trends- the migration of health system clinical and financial operations to the Cloud and the 5G-enabled connectedness of medical devices and hospital infrastructure to the Internet, the so-called Internet of Things (IOT). These two linked migrations opened a gaping digital “back door” in hospitals and systems to “black hat” hackers.
The fall of 2019 saw two major health systems-Tuscaloosa-based DCH Health System (AL) and Hackensack Meridian (NJ) – succumb to ransomware attacks that paralyzed clinical operations for days before the system paid cyber-extortionists to stand down. However, there is a more threatening risk of mass patient casualty episodes in hospitals if hackers gain control over critical life support functions like respirators, infusion pumps, oxygen systems, HVAC and electrical systems.
The virtually unmanaged spread of connected devices and systems in hospitals is a significant threat to patient safety. Health systems and regulators will be playing catch up in both these patient safety domains during the 20s as the degree of patient risk becomes more clearly understood.
“What diagnosis do you want to use for those ear drops you sent on Mr. Johnson,” Jenn texted me. “ICD-L21.8 for seborrheic dermatitis?”
Sigh. Welcome to prior-auth hell.
These are generic ear drops I ordered for presumed fungal infection of the external ear. The cash price for the drops is $15 for a 10 milliliter bottle (I checked before prescribing them). “No,” I responded, “it would be ICD-B36.9 for otomycosis.” (translation: ear fungus)
Jenn tried submitting this new diagnosis without success. She then noted that this medication was supposed to be authorized without need for authorization, so she called the pharmacist, who ran the 30 milliliter bottle through the computer system and the medication was authorized. That size bottle goes for $27 cash.
Rob bangs head on wall.
But Jenn didn’t yell. She didn’t say any profanity (that I could hear). Jenn’s a saint. She lost 30 minutes of her life to this nonsense, as did the pharmacist. As for me, I just got a little extra blood pressure points, a little acid corrosion of my stomach, and a stronger desire for beer when I get home this evening.
While my practice doesn’t accept money from insurance companies, we do serve our patients for the sake of their health. This means that we advocate on their behalf in a system that seems hell-bent on making care less accessible. Prior-auth hell is one example of this wall that has been built up between people and reasonable care. Electronic medical record hell, pharmacy trickery hell, specialist non-communication hell, bloated hospital gouging hell, media non-story hype hell, and opportunist alternative medicine hell are all contributors to the hell-fire heat we are all feeling.
Leading lights of the health insurance industry are crying that Medicare For All or any kind of universal health reform would “crash the system” and “destroy healthcare as we know it.”
They say that like it’s a bad thing.
They say we should trust them and their cost-cutting efforts to bring all Americans more affordable health care.
We should not trust them, because the system as it is currently structured economically is incapable of reducing costs.
Why? Let’s do a quick structural analysis. This is how health care actually works.
Health care, in the neatly packaged phrase of Nick Soman, CEO of Decent.com, is a “system designed to create reimbursable events.” For all that we talk of being “patient-centered” and “accountable,” the fee-for-service, incident-oriented system is simply not designed to march toward those lofty goals.
A machine for creating reimbursable events
The health care system is a machine for creating reimbursable events. This means that its systemic business aim is to maximize reimbursable events and to increase their price, that is, to maximize the energy the system can draw in from its customers.
The news was bad. Mimi, a woman in her early 80s, had been undergoing treatment for lymphoma. Her husband was being treated for bladder cancer. Recently, she developed chest pain, and a biopsy showed that she had developed a secondary tumor of the pleura, the space around one of her lungs. Her oncology team’s mission was to share this bad news.
Mimi’s case was far from unique. Each year in the U.S., over 1.6 million patients receive hospice care, a number that has been increasing rapidly over the past few years. What made Mimi’s case remarkable was not the grimness of her prognosis but her reaction to it.
When the members of the team walked into Mimi’s hospital room, she was lying in bed holding hands with her husband, who was perched beside her on his motorized wheelchair. The attending oncologist gulped, took a deep breath, and began to break the news as gently as he could. Expecting to meet a flood of tears, he finished by expressing how sorry he was.
To the team’s surprise, however, no tears flowed. Instead Mimi looked over at her husband with a broad smile and said, “Do you know what day this is?” Somewhat perplexed, the oncologist had to admit that he did not. “Today is very is special,” said Mimi, “because it was 60 years ago this very day that my Jim and I were married.”
The team members reacted to Mimi with astonishment. How could an elderly woman with an ailing husband who had just been told that she had a second, lethal cancer respond with a smile? Compounding the team’s amazement, she then went on to share how grateful she felt for the life she and her husband had shared.
Cigna conducted a survey on 20,000 of their members.
54% said they always or sometimes feel that no one knows them well.
56% reported they sometimes or always felt like the people around them “are not necessarily with them.”
40% felt like “they lack companionship,” that their “relationships aren’t meaningful” and that they “are isolated from others.”
It’s probably no surprise to most people that it’s actually pretty hard to make friends, especially after college. It’s felt so universally that it’s become an extremely popular genre of meme.
As a thought experiment, what would you do if you moved to another city where you didn’t have an existing network? It’s a pretty daunting proposition without a ton of options (Work friends? Sports league? Meetups?).
We have online tools to connect and organize better, but it feels like they’re creating relationships that are more hollow and circles that are more insular.
Can we use them to make it easier to make friends?
For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.
But today, nine years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine: burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.
People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.
Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.
Remember when physicians were heroes?
For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.
The unofficial mantra of silicon valley entrepreneurs may well be fake it ‘til you make it, an approach of resilient bravado that’s led to a slew of ultimately successful tech giants – and also to frank deceptions like Theranos.
Recently, I heard from VC Marc Andreessen (on the a16z podcast, here) what must be the most forthright explanation of this approach, a sales technique Andreessen calls “evangelistic selling.”
Andreessen was responding to a question about how do you sell into businesses that aren’t intrinsically receptive to change (i.e. essentially every large established business, including those dominating healthcare).
The Evangelistic Sale
First, you can see why some view Silicon Valley denizens as merchants of hype – this is, if not explicitly what Andreessen is championing, perhaps an inevitable outcome of his approach: entrepreneurs and (other) salespeople talking up an often-fantastic vision of a yet-to-be realized future.
Andreessen also points to the example of Elon Musk and Tesla; Musk is often criticized for overselling, says Andreessen, but argues Musk had to paint a vision not only of a car you could plug in, but also a whole system of superchargers along freeways, and his vision had to be compelling enough so he could actually sell enough cars “into that vision” to afford to start installing the chargers he described, and enable the vision to become a reality (which, initially, it wasn’t). Andreessen likens it to selling the first fax, which obviously wasn’t especially useful until and unless it was adopted by others.
Steve Jobs: “Taking LSD was a profound experience, one of the most important things in my life. LSD shows you that there’s another side to the coin, and you can’t remember it when it wears off, but you know it. It reinforced my sense of what was important – creating things instead of making money, putting things back into the stream of history and of human consciousness as much as I could.” (ref 1)
Woodstock (Chip Monck): “To get back to the warning that I received. You may take it with however many grains of salt that you wish. That the brown acid that is circulating around us isn’t too good. It is suggested that you stay away from that. Of course it’s your own trip. So be my guest, but please be advised that there is a warning on that one, OK?” (ref 2)
Warning: The final few paragraphs of this post contain language that some may find offensive. I included it for a reason. In 30 years of practice and in my real life – I have found that many people talk this way. If profanity offends you don’t read the end of this post.
Everywhere I turn these days – whether it is a blog or more traditional media I am struck by the same stories on hallucinogens. If you believe what you read out there, hallucinogens are magical drugs in that they are almost totally benign, consciousness expanding, and they can treat your anxiety or or depression. They have been actively discriminated against like other illegal drugs and that is the only reason we have not done the research to prove that they can treat many problems. Back in the 1970’s we would have said that “The Man” is restricting access to valuable consciousness expanding drugs and if “The Man” was overthrown – the world would be a much better place. I have briefly reviewed the same lines of rhetoric that occur with cannabis. I have not heard similar arguments with ketamine, probably because fewer people have experience with it and it is a more difficult drug to use, even in a medical setting where the drug has a known concentration and purity.
Backache is an intermittent predicament of life. No one is spared for long. Furthermore, no approach to avoiding the next episode has proven effective when submitted to scientific testing. To be well is not to avoid backache; it’s to have the wherewithal to cope effectively and repeatedly.
Almost all of the people we will be talking about in this book were afflicted with regionalbackache, and that is the only type of backache we will consider here. I coined that term for an editorial in The New England Journal of Medicine over twenty years ago.1 Regional backache is the back pain experienced by people who are otherwise well. It comes on inexplicably, usually suddenly, in the course of activities that are familiar, and customarily comfortable. This is the common, everyday backache. We will spend some time considering some of the more frequent complications of a regional backache, particularly the “pinched nerve,” which can cause pain to radiate down the leg. We are not going to consider the unusual causes of backache such as metastatic cancer, infections, or inflammatory diseases of the spine. Nor will we consider the back pain that can result from accidents and other traumatic events.
While I am talking about what this book is not, let me say that it is not a self-help manual. Nor is it a medical textbook. Backbone is an exposé of a contrived “disease” and the enormous enterprises it has spawned that conspire to its “cure” and provide fall back when a “cure” is elusive. That industry has developed a life of its own despite a robust and compelling body of scientific investigation that points toward backache as a socially constructed ailment. The American notion of health, the American’s wherewithal to cope and persevere, and the American pocketbook are paying a heavy price.
Medical historian Stanley Reiser wasn’t kidding when he entitled his best-known book, “Medicine and the Reign of Technology.” To a large degree, technology has taken over medicine. I am not talking primarily about our increased reliance on such technologies as advanced imaging equipment or assistive procedural devices. In such cases, the technology remains largely a tool, and the wielder remains basically in charge. I am talking about a far more pervasive and insidious form of technology whose very name tells a good part of the tale – health information technology.
Many physicians and other health professionals find health information systems clunky, perverse, and intrusive, but their problems go far deeper. Underneath unwieldiness lies the temptation that we begin relying on such indicators to such an extent that we stop attending to our internal resources. Consider the case of the patient said in his admission note to be “status post BKA” – below the knee amputation – but who turns out on rounds to have ten toes. What happened? DKA – diabetic ketoacidosis was mis-transcribed into the medical record as BKA, and the error simply propagated like a virus.
At stake is what we mean by knowledge. Is what we know defined by our own experience – what we have seen, heard, felt, and perhaps even intuited in the presence of the patient? Or do we instead rely on what is represented on a computer screen? Which is a more likely occasion for us to exclaim, “That can’t be right!” – when what the computer screen indicates does not comport with what we have observed of the patient, or when what we have observed in the presence of the patient does not jibe with what the computer is telling us?
For over a decade Washington DC has been busy with fixing health care. For over a decade, the same government bureaucracy, the same advocacy (read lobbying) organizations, the same expert think tanks, the same academic centers, the same business associations, with the same people hopping around from one entity to the next, have been generating and applying the same “innovative solutions” differentiated solely by their aggrandizing names. The result? Health care is more expensive than ever. More people than ever can’t afford to seek medical care. More doctors are disheartened, to the point of committing suicide. All this while the illustrious transformers of health care are accumulating fame and riches, probably exceeding their own expectations, with no end in sight.
It is no secret that back in 2016 many of us voted for Donald Trump hoping that he will “drain the swamp” or at the very least blow it all up into a spectacular artesian fountain of filth. He didn’t and he won’t. The swamp won. Our special health care swamp is deeper and wider than most, and the Trump administration is making it deeper and wider than ever before. The single payer lobby is simply proposing to move the existing health care swamp to a bigger and more noxious location, so it has plenty of room to expand in the future. The swampy strategy for fixing health care has always been, and by the looks of it will always be, a game of hot potato. The potatoes are us.
At the core of the guileful verbosity of health care transformation there is nothing more than an elaborate effort to shield corporations, and the governments that serve them, from financial risk. It’s really that simple. We pay our premiums and our payroll taxes, month after month, year after year, and when the time comes, if it comes, they’d much rather not pay the medical bills they are contractually or statutorily obligated to pay. Blame sick people for being sick. Blame the sick for not shopping the clearance aisle. Blame doctors for treating the sick. Blame hospitals for admitting too many sick people, too often and for too long. Punish them for the errors of their ways. Teach them a lesson or two. And most importantly, make them pay until it hurts.
Three weeks ago I posted a comment here about a decision by the Minnesota Supreme Court in the case of Warren v. Dinter. In that case, the court held, by a 5-2 margin, that hospitalists (and, therefore, the hospitals they work for) can be sued for malpractice even if they were not in a treatment relationship with the patient. I took the position that that decision was the right one. (If you haven’t read my first article, I urge you to do so to understand the facts of the case.)
The ensuing discussion about my article focused primarily on which, if any, of the three health care professionals involved in the decision not to hospitalize Susan Warren were culpable. The question of whether other parties – the hospital, the chain that owned the hospital, Accountable Care Organizations (ACOs) established by the chain, and insurance companies – should be subject to liability received relatively little attention. Two who did comment explicitly on that issue made it clear they thought even asking about third-party culpability was verboten.
In this sequel to “Why did Susan Warren die?” I want to focus on the question, Shouldn’t third parties who make, veto or influence medical decisions be exposed to malpractice lawsuits? My answer is yes. If the answer is yes, then we must support the Warren v. Dinter decision. Imagine if the Minnesota Supreme Court had taken the opposite position. Imagine that the court decided that injured patients cannot sue third parties unless the employee of the third party (the doctor or nurse) who made the decision in question was in a treatment relationship with the patient. Is it not obvious that such a decision would slam the courthouse doors on all patients injured by employees working for insurance companies, hospitals, hospital-clinic chains, and ACOs who were not treating the patients?
This post is my chance to share some relevant data, add my perspective, and ask for your input.
First, the data from a 2018 Hopelab/Well Being Trust study I helped write:
71% of female teens and young adults say they have tried mobile apps related to health, compared to 57% of males. Three in ten (30%) females say they currently use a health app, compared to two in ten (20%) males.
Fully 48% of females ages 18- to 22-years-old and 25% of teen girls say they have used a period tracking app, compared with 2% of males.
Sixteen percent of females use a meditation app, compared with 5% of males.
Two bills that are called “Medicare for all” bills by their supporters have just been introduced in Congress. On February 27, Representative Pramila Jayapal introduced the Medicare For All Act of 2019, HR 1384 , in the House of Representatives. On April 10, Senator Bernie Sanders introduced a bill bearing the same name in the Senate, S 1129. The cost-containment section in Representative Jayapal’s bill will cut health care costs substantially without slashing the incomes of doctors and hospitals. Senator Sanders’ bill cannot do that.
In this article, I explain the differences in the cost containment sections of the two bills and call upon Senator Sanders to correct two defects in his bill that minimize its ability to reduce costs. Defect number one: S 1129 authorizes a new form of insurance company called the “accountable care organization” (ACO). Defect number two: S 1129 fails to authorize budgets for hospitals. Representative Jayapal’s bill, on the other hand, explicitly repeals the federal law authorizing ACOs, and it authorizes budgets for individual hospitals.
I write this essay as both a long-time organizer, writer and speaker for a single-payer (the older name for “Medicare for all” system) and a strong supporter of Senator Sanders. Bernie’s enthusiastic support for a “single payer” solution to the American health care crisis has added millions of new supporters to the single-payer movement. But precisely because he is now the most recognizable face of the single-payer movement, it is extremely important that all of us, whether we’re already in the single-payer movement or we just long for a sane and humane health care system, encourage Bernie to fix the defects in his bill.
To explain the two defects in S 1129, I must first explain why a single-payer bill like Representative Jayapal’s will be effective at cutting the high cost of American health care. I begin by explaining the origin and meaning of the “single payer” label. I will then describe the two defects in S 1129 in more detail.