Seven for the Twenties: A Futurist Looks at the Next Decade


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 MRSACandida 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.  

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My Life In Hell


“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.

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An Unfortunate System of Reimbursable Events


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, 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.

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