What Healthcare Can Learn From United Airlines

What Healthcare Can Learn From United Airlines

Obamacare repeal and replace is going nowhere, despite seven years of promises by Republican members of Congress. For the foreseeable future, it will remain the law of the land, along with rising insurance premiums and deductibles and fewer plans to choose from. It’s worth remembering the next time someone asks you for money to support Republican incumbents.

What if the airline industry could light the runway toward fixing one of the more onerous aspects of Obamacare? United Airlines has done just that. I don’t mean dragging patients out of hospitals and doctors’ offices as United did earlier this year on an airplane—a physician no less. Instead, United now offers a lower cost option for air travel. Let’s apply it to healthcare.

United recently began offering “basic economy” fares, a lower cost option, compared to its “standard economy” fare. Suppose healthcare insurance companies did the same.

Obamacare requires that all insurance plans cover 10 “essential benefits.” Some of these are common sense, including outpatient, hospital and emergency care. Others are beneficial to only some people—pregnancy, maternity and newborn care, mental health and substance-abuse treatment, and pediatric services.

A 60-year-old man doesn’t need or want pregnancy coverage. A middle-aged couple with adult children can pass on pediatric coverage. A teetotaler won’t want alcohol-rehab insurance. But all are forced to purchase this insurance they neither want nor need. That’s like making Coloradans purchase hurricane insurance.   

United recognized that not all its passengers want the benefits that go along with the higher-standard economy fare. Instead, they offer travelers the option of a lower cost fare with fewer perks. For example, standard fares earn miles toward premier status on United, whereas basic fares do not. For frequent flyers looking to achieve higher premier status, this may be important. Not so for infrequent travelers or those who typically fly another airline. Why make them pay for it?

Another difference is that the basic fare doesn’t allow passengers to choose their seats or sit with their travel companions, unlike the standard fare. For a short flight, if you don’t care where you sit and are OK with your travel companion sitting in a different row, why not save your money?

The idea is that United is giving passengers a choice, offering an alternative to their more expensive fares, the airline equivalent of “essential benefits.” If passengers don’t want or need expensive perks, why not let them opt out and pay less?

An amendment along these lines was proposed by Sen. Ted Cruz during the recent Senate debate on Obamacare repeal and replace. His idea was that insurance companies could sell pared-down, less expensive plans, as long as they also sold at least one plan that provided all the benefits.

For United, that would mean they could sell basic economy fares if they still sold standard economy, economy-plus and first-class tickets. Common sense.

How absurd that the government should tell a business what it can and cannot sell, forcing consumers to purchase what the government commands. United, instead, is offering a discounted fare with fewer benefits that is better able to meet the needs and pocketbooks of many of its travelers.

This could be a stand-alone piece of legislation. Perhaps along with a law requiring Congress and their staffs to purchase Obamacare plans. A simple way to ameliorate one of the more bothersome aspects of Obamacare. Not the repeal and replace we were promised, but at least some relief for Americans struggling to afford ever more costly Obamacare insurance.

How Can I Tell If Medical News Is Fake or Not?

How Can I Tell If Medical News Is Fake or Not?

Is coffee good for you?

A recent headline suggested that people who drink coffee live longer. Sounds great to me. I drink a lot of coffee, so maybe I will be immortal. But, wait, another report links coffee to cancer. Dang.

Estrogens were once touted as a life saving elixir for women of elegant ages, until these hormone supplements were linked to increased cancer risk. Wine will either add to your life expectancy or increase chances of breast cancer. If you are married and have cancer, your outcome is better; you live longer (and can drink more wine). Eggs either kill you (dropping the value of egg futures) or do not hurt you at all, (prompting a financial rebound in chicken-by-product).

Each study and report alluded to above is erroneous.

Indeed, these claims are what I call “fake” medical news. My definition: if a medical report is either wrong or not provable, it is fake.

When Is Medical News Fake?

Fake news is a hotly debated topic regarding national political reporting. There is a reason I am extending this concept to reports of wrong or not provable medical information: it is imperative that you begin to look askance at most of the medical information presented to you in news reports.

If you Google “how to tell fake news” you will find enough reading material for the rest of your life and will also find, likely, that some of those articles are fake. Some say fake news is defined by intent to deceive; but this is not sufficient in my view. Some industry folks will tout a study on coffee or wine, for example, to boost sales of each; their intent is no less reprehensible than bald, bare, bold-face lying. Time to call a spade a spade.

But, how do we know what medical news is fake? That is a crucial question. Those worried about fake political news have offered suggestions for identifying “fakeness.” Most of this advice focuses on validating sources, verifying claims, determining if the information actually comes from expert sources, discerning if quotes are legitimate or lifted out of context, and researching origins of any visual images to see if they’ve been doctored.

These “rules” from the political news world are not helpful, however, if you are reading medical news. Some of the most faulty and not provable information comes from legitimate medical journal sources or academic centers, include quotes from those excited about their wrong and not provable “research” findings, and provide distinctive, original pictures of their data.

Three Rules For Uncovering Fake Medical News

To uncover fake medical news, we need better rules. Here are three:

  1. Is the item being reported measurable? (Measurable means that the item is quantifiable and will be measured the same by all, and that the finding is reproducible).
  2. What additional human traits or actions may cloud or confound the relationship between the item being studied and the outcome being touted?
  3. How was the study done?

Let’s try out these rules on the issue of whether coffee is good for us or not:

1. Is the item and outcome measurable?

What is “coffee drinking”? Is it drinking coffee black, or with cream and sugar? How is coffee imbibed; at one sitting, over the entire day, gulped or sipped? Is it Folgers in a Can or Starbucks? How much is a lot of drinking? Was the amount of coffee consumed observed by researchers or self-reported?

Science is about measurement, and if you can’t define a measure, you don’t have science.

2. What additional human traits or actions may cloud or confound the relationship between coffee consumption and life expectancy?

Who is rich enough to drink coffee these days? Is coffee part of a better diet? Was the entire diet/drinking history of each person known, besides their coffee consumption, and recorded? Did the imbibers ride their bikes to the coffee shop, or drink it at home? Are they new to drinking coffee, or have they been drinking all their life?

People vary in many ways; a report isolating one thing from many things about an individual is sure-fire fake medical news.

3.  How was the study done?

Coffee consumption was not randomized to users. The study was an observational comparison (people who drank or did not drink were observed and not assigned to being a coffee drinker or not).

Observational comparison studies, rather than randomized studies, are nearly always fake, as observational studies cannot prove an independent contribution of the item being studied to the outcome of interest. In other words, if they happen to be true, we can’t prove it. Hence, they are fake.

You can repeat these three steps every time you hear a medical report. Estrogens appeared helpful, for example, because the women who took them were healthier than average (confounded; second rule). The same is true about being married and cancer survival; married people are healthier and in better social-economic conditions. There is no proof that wine or eggs do anything to improve or harm our health, as all information on wine and egg consumption and their health benefits comes from observational comparison studies, not randomized scientific experiments (third rule).

Bottom line: if any of the three rules identifies a problem, you are reading fake medical news. I find that the first rule—is it measurable—busts many medical news reports.

I am being tough on medical news. I don’t apologize. Your care is too important to be left to the chance of un-measurable, confounded and poorly studied information (Rules 1, 2 and 3).

If I were forced to offer a recommendation for your medical reading, it would be that you should not read or watch any medical news. Instead, you should partner with your physician when you are ill and focus on knowing the best information for your specific medical choices. That is how you will learn and how you will more likely get the best medical advice.

A Mystery Mission in LA: Aetna, Apple, and a Vision of Digital Health’s Future, Part 1

A Mystery Mission in LA: Aetna, Apple, and a Vision of Digital Health’s Future, Part 1

It was an invitation too intriguing to refuse: fly to LA to participate in a “top-secret mission” related to digital health. Instructions? Bring workout clothes. Don’t disclose your location. “We can’t say much. Just enough for you to quickly pack your bags, fly to California and participate in an exclusive Apple Watch from Aetna event – all expenses paid.” Generally, I’d file this type of message in the junk mail folder, but knowing that Apple takes secrecy seriously, I did some background sleuthing and decided it looked legit.

The mystery unfolded last week as I stepped into a black car at LAX with a secretive driver who joked that I and his other two passengers (who had received similar invites) would have to cover our faces as we drove through town. (Yikes!) When we arrived at a hip “concept” hotel I felt more at ease, and relaxed into enjoying the so-called mission with a glass of wine and some discussion of trends in the digital health industry. Over the course of a couple of days I was fortunate to join a group of new (and some old) friends to exchange ideas, take a challenging hike to the peak of Runyon Canyon Park, interact with Apple and Aetna execs, try out some new technologies, and get a glimpse of what both Aetna and Apple are envisioning for the future of digital health. I was assigned to one of several teams named after famous movies (in keeping with the Tinseltown theme) a personalized agenda, and some critical tools for the modern adventurer, including a bandana, water bottles, a phone charger, and, naturally, a selfie stick.

For about a year Aetna has used the Apple watch as part of an integrated wellness program available to its 50 thousand employees and those of several partner organizations it insures, such as Hartford HealthCare, which was represented among the participants in the mystery mission. Both companies are poised to expand the program.

Why all the secrecy? For Apple, it’s par for the course (and mission participants still can’t disclose all the details of what Apple shared), but this event was primarily arranged by Aetna for its own employees and a few key partners. Most of the 25 or so participants were staff from divisions throughout Aetna who had contributed to its partnership with Apple to date—some by inspiring others. For example, an Aetna employee named Nora lost more than 100 pounds in a year with support from the program. A handful of Aetna outsiders/digital health insiders were also included in the mission order to provide diverse perspectives and help generate new ideas.

In my opinion (though truthfully it remains a bit of a mystery) the top-secret approach was intended to enhance the fun factor for participants—and it worked. The experience was exciting, playful, and edgy, with a generous sprinkle of Hollywood glitter. If Aetna and Apple can harness that kind of energy to motivate people toward better health, more power to them. While I don’t imagine Aetna and its partners will be rewarding large numbers of people with glitzy Californian adventures comparable to this one, the tone and content of the so-called mission shows that they are thinking outside of the proverbial box. Just as the Apple watch takes health and healthcare outside of the hospital and onto your wrist, Aetna is taking traditional workplace wellness programs well beyond the walls of the office.

Stay tuned for further thoughts on the Aetna Apple partnership and its implications for digital health.

Lygeia Ricciardi is President of Clear Voice Consulting, LLC. www.lygeia.com @Lygeia

Author’s statement of conflict of interest:  I am not employed by Aetna or Apple. While my participation in the event described was paid for by Aetna, I was not required or asked to write about her experience.

The Best Part Of The Health 2.0 Fall Conference Agenda

The Best Part Of The Health 2.0 Fall Conference Agenda
There’s still time to secure your ticket before prices increase to this year’s Health 2.0 11th Annual Fall Conference. Whether you’re a Health Provider, Entrepreneur or Investor; the Fall Conference is the place to see the latest health technology, to hear from some of the influential innovators impacting the landscape, and to network with hundreds of health care decision makers. Click here for the full agenda.

Health Providers Agenda Highlights 
  • Provider Symposium: Exchange of ideas between the best minds from leading health care systems in an effort to change the face of health care as we know it.
  • The Evolution of Care Delivery Session: Top innovators from care delivery platforms address how they’re innovating for diabetes, oncology and more.
  • The New Consumer World of Tools and Health Models Session: From the fast-evolving world of consumer genomics to the latest in wearables, we’ll feature exciting new technologies.
Entrepreneurs Agenda Highlights 
  • MarketConnect: A live matchmaking event designed to accelerate the health tech buying and selling process by curating meetings between pre-qualified healthcare executives and innovators.
  • Exhibit Hall: Gain access to 90+ exhibitors, including Startup Alley, is the premier gathering of innovative companies and individuals. The exhibit floor is also home to MarketConnect Live.
  • Developer Day: Expect your day to be filled with strong technical sessions in relation to interoperability and user testing as well as opportunities to network from others in the industry.
  • 2 CEOs and a President Session: Three top health tech executives sit down for separate intimate interviews with a journalist. They will be dishing on both their personal and company journeys.
Investors Agenda Highlights 
  • Investor Breakfast: Bringing together leaders in the Health 2.0 investment community and our innovative startup network for an exclusive breakfast meeting.
  • Investing in Health 2.0 Technologies: Panel experts will address what’s in store for the rest of the year and predict the next big bets in Silicon Valley and beyond.
  • Launch!: Ten brand new companies unveil their products for the very first time and the audience votes on the winner!
  • Traction!: Annual startup pitch competition that recruits companies ready for Series A in the $2-12M range. Teams will compete in two tracks, consumer-facing, and professional facing technologies.

Click here to register for the Annual Fall Conference! Prices increase after September 4th!

A New Pothole on the Health Interoperability Superhighway

A New Pothole on the Health Interoperability Superhighway

On July 24, the new administration kicked off their version of interoperability work with a public meeting of the incumbent trust brokers. They invited the usual suspects Carequality, CARIN Alliance, CommonWell, Digital Bridge, DirectTrust, eHealth Exchange, NATE, and SHIEC with the goal of driving for an understanding of how these groups will work with each other to solve information blocking and longitudinal health records as mandated by the 21st Century Cures Act.

Of the 8 would-be trust brokers, some go back to 2008 but only one is contemporary to the 21stCC act: The CARIN Alliance. The growing list of trust brokers over our decade of digital health tracks with the growing frustration of physicians, patients, and Congress over information blocking, but is there causation beyond just correlation?

A recent talk by ONC’s Don Rucker reports:

One way to get data to move is open APIs, which the 21st Century Cures Act mandates by tasking EHR vendors to open up patient data “without special effort, through the use of application programming interfaces.”

Rucker emphasized the distinction—without quite naming what it is—between open APIs for vendors and open APIs for providers. “We’re hard at work at defining those,” he said. One difference is how the APIs are implemented: Vendors must allow for the APIs technologically, in their products, and providers must actually take advantage of the APIs.

Trust brokers on the health information highway are like the checkpoints of militias in a war zone. What gets through is limited in scope to the lowest common denominator and limited in distance to the path that crosses the fewest boundaries.

The 8 trust brokers did not arise by popular demand of the physicians and patients. Before the era of big EHR vendors for big hospitals, information flowed among physicians and patients over mail, fax, and phone using open and public interfaces and without the “added value” of trust brokers. Faxes are free, universal, and there’s no blocking on the basis of “trust”. When faxes fail, it’s typically obvious, and coupled with a phone call, reliability is high. The current situation is worse for patients as the new digital alternatives add confusion because they vary greatly from provider to provider and add frustration by being unpredictable and unreliable.

It’s hard to put a toll booth in a forest. But as the health information highway became paved (with massive taxpayer subsidy), a growing list of rent-seeking intermediaries have seized the opportunity to put a checkpoint and associated toll booth where none existed before. Hindsight is always 20/20 but the massively bipartisan 21stCC (the Act passed with 392 votes in the House and 95 votes in the Senate) gives the new administration’s ONC the opportunity to begin to take down the checkpoints.

One way to take down the trust broker’s checkpoints is called patient-directed exchange. (The word patient is preferable to consumer because patients have significant legal rights beyond mere consumers and because clinicians have a relationship with us as patients, not as consumers.) Under HIPAA, Meaningful Use Stage 3, and ONC’s API Task Force recommendations, patients get a free pass down the paved health information highway. The pass is literally free in that patients, unlike providers, cannot be charged for sending information down the new digital highway to anyone they specify. It’s as if the toll booths apply only to trucks and private cars are free. Could patient-directed exchange spell doom for trust brokers by giving patients a pass on the highway we already paid-for with taxes?

Here’s where CARIN comes in. An unaccountable and unpublished list of members gets together as an “alliance” to develop yet another set of trust rules as new potholes in the information highway. These rules don’t directly create a checkpoint but they damage the road enough to add costly maintenance to patient-directed exchange. Part of this maintenance cost is to have alliance process closed to non-members. This practice distinguishes CARIN from standards groups and other private industry collaborations that are allowed to coordinate without running afoul of antitrust law.

As the API Task Force concluded, the law is clear that “trust” and “trust framework” do not apply to patient-directed exchange. Epic, holder of medical records for 54% of the US population, provides a leading example of this under their Open.Epic API initiative. More than 30 hospitals using their most recent software are already listed on the Open.Epic website. One of them happens to have records for my 91 y/o mom and, as her proxy, I had a password to that major hospital’s patient portal for many years. After a 30-second online verification of my own name, I was able to use that portal password to access the hospital’s FHIR API and send live EHR information to a new app without any trust framework or other information blocking interference. This is not a fluke. I checked with the hospital’s CIO after the fact.

CARIN’s claim to “Consumer-Directed Exchange” is just the latest attempt to slow-walk and confuse interoperability. Trust frameworks do not apply to patient-directed exchange. Elimination of the trust framework by Open.Epic is only the critical first step in implementing the “without special effort” clause in 21stCC. The HEART workgroup, co-chaired by ONC, recently issued the first specifications for how to improve the patient experience of interoperability, including standards for automated app registration and a refresh capability to allow the patient to determine how long it is before they are asked for their portal password again. ONC should hail the Open.Epic demonstration as an example of making patients first-class citizens in control of our own data and a first step toward a new approach to interoperability based on patient rights.

The public comment period for the Trusted Exchange Framework and Common Agreement will end on ­­­­­­­­­August 25, 2017. A version of this post will introduce the specific comments of Patient Privacy Rights. If you care about the promise of digital health and would like make longitudinal health records a reality, please consider submitting your comments as well.

Sifting Through the Masses to Find Relevant Tech

Sifting Through the Masses to Find Relevant Tech

Much of the time, finding the right partner to test your technology can be difficult and time consuming. From an enterprise healthcare organization’s perspective, identifying innovative technology that fits the strategic needs of the organization can be difficult due to the overwhelming number of startups entering the market. From a startup’s perspective, there are a few major roadblocks including:

  • Finding organizations ready to pilot new health technology
  • Completing a first pilot/proof of concept (or second, or third…) to gather the much needed data to grow commercial partnerships
  • Identifying the right individual in an enterprise organization who will champion new technology
  • Gaining an insider’s perspective about the potential clients’ strategic needs

Enter MarketConnect Enterprise: expediting the matching and vetting process for both the startup and enterprise healthcare organization.

One of the largest health insurers in the United States is looking for innovative technologies to integrate into their organization. From technology to support member communication to solutions that support providers when processing claims, they are looking to find relevant, innovative solutions that are ready to be piloted within a large organization, with no request for equity or IP. Think your technology may fit their needs? Check out the priority areas below, then complete an application here for the opportunity to be introduced.

  1. Consumer/member communication tools to improve engagement experience
  2. Provider tools to improve their experience for processing claims/obtaining prior authorization
  3. Solutions to assist consumers/members navigate & understand insurance billing
  4. Tools to help individuals find the right health insurance plan for them & their families
  5. Tools for consumers to improve, maintain and monitor their own health and wellness especially those that support specific groups of consumers (special needs, hearing impaired, dementia, caregivers, etc.)
  6. Solutions to improve claims processing

With MarketConnect Enterprise, we want to make sure both the health technology company and potential client find the right partners without the hassle. Complete an application to let us know how your technology fits the above priority areas and we will be in touch if there is a strong potential for partnership.

Alyx Sternlicht is a Senior Program Manager at Catalyst @ Health 2.0.

As Bipartisan Plans for ACA Fixes Emerge, Will Congress Act? Probably Not.

As Bipartisan Plans for ACA Fixes Emerge, Will Congress Act? Probably Not.


A bipartisan group of health policy experts has issued a call to action and well-thought-out consensus plan for insurance market stabilization and incremental reform.

The effort adds to the gathering momentum in Washington for urgent fixes to Obamacare, plus additional reforms that might bring conservatives into the fold and appeal across the partisan divide.   What’s still unclear, however, is whether the Trump administration and Republican leadership in Congress will go along.  Outward signs suggest they won’t, but this game is still changing by the day.

Trump continues to tweet-shame McConnell and the Senate Republicans for failing to repeal and replace the ACA, and conservatives in the House and Senate continue to insist they’ll oppose any “bailout” of the insurance industry. (In no way is stabilizing the insurance marketplaces an insurer bailout, any more than tax support of Medicare Advantage plans are a bailout.)

Most recently, on August 11, the House Freedom Caucus called on House Speaker Paul Ryan to bring a “clean” Obamacare repeal bill to the floor this fall.

While this tense and chaotic game of chicken persists, insurers, state insurance commissioners, exchange administrators, most of the health care industry, and millions of consumers fret, wait for clarity, explore options, ready contingencies, and prepare for the worst for open enrollment 2018.

Hope rests largely on two efforts underway in Congress:

(1) Pledges by a growing number of Democrats and moderate Republican Senators to step in and act, led by Sen. Lamar Alexander (R-Tenn.), chairman of the Health, Education, Labor and Pensions (HELP) Committee.   He’s planning hearings in Sept. aimed at quickly crafting bipartisan legislation to shore up the exchanges.

(2) A proposal by a bipartisan coalition of 43 House members dubbed the “Problem Solvers Caucus.”   The proposal shares a central thrust and actions and ideas with the policy experts’ plan, as listed and discussed below.

The problem is time. When Congress returns from summer recess the week of Sept. 4, it has only a few weeks to approve legislation before the Sept. 27 deadline for insurers’ to submit final proposals to states and the federal government to sell marketplace plans in 2018. The Trump administration can extend that deadline but that’s viewed as unlikely. Open enrollment for 2018 starts Nov. 1 and ends Dec. 15.

Some observers think it’s already too late to affect premiums for 2018. Insurers in almost every state have added supplemental premium increases (above those already planned) due to the uncertainty.   Some states, like California, plan to telegraph loud and clear to consumers which plans are being hiked the most.

Courtesy of The Washington Post’s Paige Cunningham and the Kaiser Family Foundation (KFF), out of 20 states (plus DC) that have released enough information to analyze, insurers in 15 have proposed rate hikes in the double digits. Insurer participation in the marketplaces is also down but not as much as anticipated a few months ago. An average of 4.6 carriers intend to sell plans in 2018 compared to 5.1 carriers this year and 6.2 in 2016 in those same 20 states and DC.

HHS predicted this month, however, that as many as one third of U.S. counties—and especially those in the rural western states—might have just one insurer in the exchange in 2018.

The policy think-tankers—from organizations as diverse as the Hoover Institute, Families USA, The American Enterprise Institute and Brookings—recommend the following:

* Fund the cost sharing reduction (CSR) payments. These payments to insurers help reduce deductibles and co-payments for low-income exchange enrollees—critical to affordability.   The cost: $8 to $10 billion a year in 2018 and 2019.   The Trump administration has been paying the CSR bill month-by-month amid litigation over the legality of the payments dating back to the Obama Administration. Trump has personally threatened to cut the CSR payments off unless Congress repeals the ACA. It’s mainly these payments that some Republicans call a “bailout.”

* Reassess the “3 Rs”—risk adjustment, risk corridors and reinsurance—as tried-and-true ways to stabilize the exchange markets. All were in the ACA and played a key role in holding premium increases down from 2014 to 2016. But the reinsurance and risk-corridor programs terminated at the end of 2016. Risk adjustment is permanent but has been administered poorly. HHS should “give states wider latitude to tailor risk adjustment methodologies for their particular markets,” the group advises. HHS secretary Tom Price supports reinsurance, having invited all 50 governors in March to consider it as they sought to restrain premium increases.

* Continue enrollment assistance programs that inform consumers about the ACA benefits, and aid their enrollment.

* Address the needs of consumers in counties with no participating insurers in 2018 by permitting people to enroll in a plan sponsored by the Federal Employee Health Benefits Program (FEHBP).   FEHBP has a presence in every state because there are federal employees in every state.   Insurers could be required, for example, to offer such plans in “bare counties” as a condition of FEHBP participation.

* Permit states to explore alternatives to the individual mandate. A compromise could involve “combining incentives to purchase health insurance with effective sanctions for not enrolling or not maintaining coverage, including financial penalties and waiting periods,” the group said. The ACA’s Section 1332 currently allows states to propose waivers to explore alternatives to the mandate.   The group also recommends that Congress modify Section 1332 to allow states to “integrate federal funds used to cover low income children, adults, and families under Medicaid and CHIP and private insurance to improve coverage and care delivery.”

* Permit states, more generally, to experiment with their health insurance markets. “We support enhanced financing flexibility for states that seek to increase access to affordable coverage for their low and moderate-income populations. Though we differ in our views regarding the scope of the guardrails that should be established, we encourage Congress to consult with states and others on how to refine the guardrails to provide enhanced flexibility.”

* Extend federal funding through 2019 for the Children’s Health Insurance Program (CHIP) and community health centers.

* Expand, judiciously, health savings accounts (HSAs) and health reimbursement accounts (HRAs), including using HSA funds for premium payments and reforms that make pre-funded HSAs available to lower income people who choose to enroll in high-deductible health plans.

Fax This to Washington: Hospital Consolidation Threatens Our Healthcare System

Fax This to Washington: Hospital Consolidation Threatens Our Healthcare System

As hospital consolidations sweep the nation, the monopolies being created are having a profound impact on life in small town America.  Lee County, in Southern Georgia, is a little place with big dreams; they are resolutely determined to build a 60-bed community hospital and provide local residents with real choices. For years, two competing hospitals served the population of 200,000 spread over six counties: Phoebe-Putney and Palmyra Park. Phoebe-Putney Memorial Hospital put an end to that by securing a 939-bed hospital monopoly and an ample market share.

Their efforts began in 2003, when Phoebe-Putney Memorial Hospital in Albany, Georgia successfully opposed a bid for a Certificate of Need (CON) to open an outpatient surgery center. Frustrated from a free-market perspective, accountant Charles Rehberg and a local surgeon, John Bagnato, began sending anonymous faxes to local business and political leaders, criticizing the financial activities of the local hospital.  These faxes quickly gained notoriety, becoming known as “Phoebe Factoids.” Concerned about negative publicity, Phoebe Putney executives hired former FBI agents to intimidate these men.

Undeterred, these two renegades discovered Phoebe-Putney Hospital was charging uninsured patients far more for services than insured patients.   This brought widespread attention to the plight facing millions of uninsured Americans. Many began to question what obligation a nonprofit hospital has to provide charity care for those in need. Phoebe-Putney was caught using aggressive collection tactics, such as wage garnishment and the placing of liens on homes of patients unable to keep up with payments. Their experience inspired a documentary called “Do No Harm.”

In-depth research uncovered millions hidden in offshore bank accounts disguised under the auspices of a non-profit— not only at Phoebe, but also at other non-profit hospitals across the country. As whistleblowers, Rehberg and Bagnato were subsequently targeted by Phoebe and indicted on fraudulent charges of telephone harassment, aggravated assault and burglary; charges without merit which were dismissed in 2006.

After successfully blocking the surgery center CON, Phoebe-Putney set its sights elsewhere looking to acquire the only other hospital facility in the surrounding six-county area: Palmyra Park. In 2011, the Federal Trade Commission (FTC) attempted to block this proposal on the grounds that the combined entity would control in excess of 85% of the market share. Phoebes’ CEO insisted hospital consolidation was necessary to deliver cost-effective, high-quality medical care, calling the merger “the right thing for citizens.’’   The FTC argued the deal was anti-competitive (which it was) and health costs would increase significantly (which they did.) The FTC secured a preliminary injunction but Phoebe prevailed, arguing Georgia CON laws prohibited the sale of Palmyra Park to an independent entity.

Ultimately, the FTC was obligated to settle with Phoebe, making the dream of a hospital monopoly a reality. However, the settlement had three stipulations: 1) Public acknowledgement the acquisition would substantially lessen competition within the six-county market; 2) Phoebe was required to provide the FTC with prior notice of transactions acquiring any part of a general acute-care hospital, or controlling interest in other facilities; and 3) Phoebe was precluded from opposing CON applications from other entities for five years.

Barring Phoebe from challenging CON applications was an innovative solution to a monopolized region; however, Phoebe already handily dominated the market. The Certificate of Need process is expensive and time-consuming; therefore, legal experts anticipated this limitation alone would be ineffective in enticing new competitors to enter the region. Yet, predictions can sometimes be incorrect.

Enter the little county that could, a.k.a Lee County, Georgia, with its population of 29,000 and land mass of 362 square miles. The community and their steely resolve have yielded unexpectedly positive results. Lee County officials filed a Certificate of Need application for a 60-bed hospital earlier this year. The Lee County Development Authority will own the hospital structure and a separate entity will lease the facility. Services offered will include acute and emergency care, including an ICU, medical/surgical unit, inpatient and outpatient beds, and full radiology capabilities, such as CT and MRI. The hospital will create more than 350 “good-paying jobs” and provide access to health care for all, regardless of their ability to pay.

While Phoebe Putney agreed not to challenge a CON application until 2020, the settlement does not preclude engaging in “sneaky” public relations tactics. Phoebe commissioned a study to calculate the effect the Lee County Medical Center would have on the financial outlook for Phoebe-Putney. DHG Healthcare projected Phoebe will lose more than $250 million in revenue over five years.  The firm found by the third year of operation, annual losses will be $30.1 million for inpatient care, $23.7 million in outpatient care, and $6.4 million for emergency care at Phoebe.

Lee County is on their way to achieving something extraordinary; challenging the dominance of a hospital monopoly. On July 21, 2017, the CON application for Lee County was deemed complete by the Georgia Department of Community Health. A decision is anticipated by Nov. 15. If granted, the county plans to break ground on the new structure in early 2018. The CEO of Lee County Medical Center, Mr. G. Edward Alexander, stated “Our goal is to ensure that decisions for the hospital are made locally by people who live and work in Lee County.”

Lee County, I salute you. Medically underserved communities everywhere are supporting your efforts to transform the healthcare landscape for the better. May your success inspire a revolution, proving that healthcare can be repaired by patients, physicians, and communities – working together.


Dear Humans, Diverse Social Networks are the Answer

Dear Humans, Diverse Social Networks are the Answer

In biology, it is clear that access to more genes leads to greater overall health. This is true because it allows for a greater likelihood that a genetic defect can be compensated by a gene from a different pool. This is the reason that inbreeding leads to more genetic diseases. This same phenomenon exists in social science. Complex social networks are healthier than more narrow (constrained) ones. Dr. Amar Dhand of the Brigham and Women’s Hospital’s Department of Neurology has, for example, shown that people are more likely to get to the emergency room in time to receive a clot busting therapy for stroke if they are part of a more complex, rather than constrained, social network.

The probable reason for this effect is the diversity of ideas that are available in the complex social networks is greater than in the narrow ones. Despite these advantages, human beings tend to resist diversity, depending instead on a competing drive to create cliques and clubs.   In Arlie Russell Hochschild’s book, Strangers in Their Own Land, she attempts to understand what she sees as a paradox.   Why do people vote in manners that seem to be contrary to their own self interest? In fact this is not a paradox, but rather simply a competition between two deeply ingrained human traits; one biological and the other sociological.

The phenomenon of professional burnout is a case in point. It is generally defined as a sense of cynicism, depersonalization and ineffectiveness. Some believe that we are in the midst of an epidemic of burnout, affecting as many as half of medical doctors, for example. The causes of burnout are protean, but at the core of the problem is the perception of unfairness; that one is the subject of a form of bias or prejudice whereby certain resources are unfairly distributed by a powerful force, such as the employer or the government. Any individual or group may be subject to this perception. Much of the conflict that is being expressed around the world can be understood as an analogue to professional burnout, in other words, caused at its root by a perception of unfairness. So what is perception and from where does it arise?

It is useful to employ a theory of mind. By theory of mind, I mean the capacity to put oneself on another’s position. It is different than sympathy or even empathy in that it allows one to understand other viewpoints without actually experiences them oneself. There is neuroscientific evidence that there are some nerve cells in the brain (mirror neurons), which are specialized to respond to actions performed by another individual. These cells may or may not exist in humans, but it is definite that certain neurological conditions damage the theory of mind, making it difficult or impossible to perceive the perspectives and feelings of others. In related conditions, one may even become disconnected from one’s own body or thoughts, such that even major deficits, such as paralysis, cannot be perceived, a condition called anosognosia (denial of deficit). In other words, we live in virtual reality. What the brain experiences is, in fact, reality.

Diversity is the solution to the apparent paradox. If one cannot perceive an aspect of the world, it can be helpful for another person to provide that insight. The more an individual, a group or society can provide diversity, the stronger it will become. This principle is not limited to one or another group. It is a basic biological and sociological trait of humans. Rather than a “republican” or “democrat” pollster, as they are always identified, what is needed is a diverse representation of the largest possible numbers of opinions, views and perspectives. Such an approach is the most effective immunization against burnout and its core cause, the perception of unfairness. The counterpoint to the narrow (constrained) network is the complex, diverse one. Wouldn’t it be nice if our media and our leaders could embrace this simple solution?

In the words or Robert Burns:

And would some power the gift would give us
To see ourselves as others see us
It would from many a blunder free us,
And foolish notion
What airs in dress and gait would leave us
And even devotion

Martin Samuels is a professor of neurology at Brigham and Women’s Hospital.

Why Smart Pill Bottles and Financial Rewards Don’t Improve Medication Adherence

Why Smart Pill Bottles and Financial Rewards Don’t Improve Medication Adherence

A study published recently in JAMA Internal Medicine showed financial rewards and connected pill bottles don’t work. One explanation suggests that “other patient concerns about potential adverse effects of these medications, such as impotence or fatigue, were not targeted by this engagement strategy.”


How can a patient engagement strategy not target the patient’s concerns? Isn’t that the very definition of patient engagement? Impotence and fatigue are a big deal to most people. Would an extra $15 a week compel you to take a medication that made you impotent? $150 a week? Would a pulsating pill bottle in your cabinet get you to swallow a pill that made you feel foggy and tired all day?

We can’t incent or remind someone to do something they never agreed to or intended to do. It would be like Amazon pinging you to buy something you would never consider adding to your cart. Amazon nudges you to buy things that you would put in your cart or things you saved to your cart, but never purchased. Why aren’t we as laser-focused on what matters to patients?

When 1/2 of all people prescribed a medication do not adhere to their plan, we have to consider that they never agreed to it or recognized its importance in the first place. They didn’t forget. (Psychologists, myself included, don’t believe in “forgetting.”) Even the most “forgetful” people do not forget to eat or have sex.

You forget what you don’t want to do. Forgetting is a way of saying “no.” Patients don’t say no to their physician’s face, but they say “NO!” en masse when they don’t fill their prescription or fill it but don’t take it. When I wrote a post recently about the importance of welcoming the patient’s resistance to their care plan, some responded that I wasn’t recognizing the dangers of non-compliance. This couldn’t be further from the truth. I am simply not deluded that we can control, coerce, enforce or even educate our patients into compliance. In light of the recent JAMA Internal Medicine article, we need a different approach.

The Paradox

If we let patients say “no” to their treatment plans, they are more likely to say “yes.”

When they say “yes,” they are more committed.

The conclusion: Let them say “no,” if we want better results.

The physician is the expert at prescribing medication; patients are the experts on why they won’t take it.

I have spent my career working with patients who are making decisions that will determine whether they live or die, whether they lose limbs to disease, contract diseases that can kill them or destroy their lives and bodies through addiction. It’s a harrowing drive on a road with hairpin turns.

We clinicians are in the passenger seat no matter what we do. And the driver has never been down this road before.

When I teach residents in psychiatry, I tell them that learning to let patients drive is like training yourself to accelerate into a skid on an icy road. At first, every muscle in your body wants to resist, pull away, brake, as you feel the loss of control when the car slips on the ice. Then, you remember the facts: you are supposed to accelerate into the skid, so you let go off your tight grip on the wheel, you accelerate, you hang in the balance horribly for an instant and then the car rights itself almost effortlessly. And then, you realize you never held the wheel at all, you were in the passenger seat the whole time working with an imaginary set of controls! It takes years of experience and profound discipline to accelerate into these skids with our patients.

How does a patient-driven approach work in practice?

In 15 minute visits, providers need to get right to the point, by saying things like:

Dr. S: Look, I am prescribing this medication because I believe it can help you, but 1/2 of patients don’t end up taking it. So, before I give you this prescription, tell me all the reasons you might not take this medication and how this plan we just made is going to fail.

Patients will be surprised by this. Good! The surprise gets them thinking and engaged. They are being called on as the expert in their own care.

Mr. X: No, I am going to take it. I know I need to.
Dr. S: Some people who take this medication say it affects their sex drive and it makes them feel foggy. What will you do if that happens to you?

Mr. X: Seriously? Well, first, I am going to be very mad at you, Dr. Smith (laughs). No, but I get it, it’s important. I guess I could come back you? I’m not saying I would like it if that happens, I might have to come back to you though if that happens.

Dr. S: Of course you can come back to me. But I can’t promise that I can solve it.

Mr. X: Are there any other options? I’ve heard some people change ____ and they don’t have to take any medication at all.

Dr. S: Yes, we can talk about that and they might reduce the amount of medication you have to take and some of the side effects, but you likely still have to take medicine.

What just happened? The doctor acknowledged the patient was the one behind the wheel, the patient was surprised but intuitively started driving and making decisions and commitments. By letting the patient say no, the doctor let the patient say yes. And the patient’s yes is a critical step to improving adherence. The patient starts making suggestions, problem-solving, and asking for alternatives. This is one interaction that needs to be repeated again and again.

Patients don’t need reminders, extrinsic motivators, or incentives. They need help identifying intrinsic motivations and personal barriers, and they need their internal problem-solving abilities mobilized. All of our well-meaning education, instructions and attempts at coercion are noise from the passenger seat – distracting the driver.

What does this mean for digital health?

Digital health technologies are not doomed, in fact, this study marks a major turning point. We see what doesn’t work and we can move on. Fail fast and learn.

Digital technologies are well-suited to a patient-driven approach. At Vital Score, we have turned a disciplined patient-driven methodology into a codified method of delivering thousands of digital conversations with patients. We call our method Motivational Indexing™ because we capture and categorize what motivates people, we let them navigate a pathway to health, and we learn from the paths they create. Motivational Indexing™ works because it learns from the experts on non-adherence: patients.

We should welcome the news that reminders and incentives don’t work. It turns out the experts in medication adherence are not behavioral economists, physicians (or psychologists!). The experts are patients and we will learn if we listen to them.

Hilary Hatch is Founder and CEO of Vitalscore.