Regarded

By MARGALIT GUR-ARIE

As is customary for every administration in recent history, the Trump administration chose to impale itself on the national spear known as health care in America. The consequences so far are precisely as I expected, but one intriguing phenomenon is surprisingly beginning to emerge. People are starting to talk about single-payer. People who are not avowed socialists, people who benefit handsomely from the health care status quo seem to feel a need to address this four hundred pound gorilla, sitting patiently in a corner of our health care situation room. Why?

The all too public spectacle of a Republican party at war with itself over repealing and replacing Obamacare is teaching us one certain thing. There are no good solutions to health care within the acceptable realm of incremental, compromise driven, modern American solutions to everything, solutions that have been crippling the country and its people since the mid-seventies, which is when America lost its mojo. To fix health care, we have to go back to times when America was truly great, times when the wealthy Roosevelts of New York lived in the White House, times when graduating from Harvard or Yale were not cookie cutter prerequisites to becoming President, times when the President of the United States conducted meetings while sitting on the toilet with the door open and nobody cared. Rings a bell?

Single-payer health care is one such bold solution. Listening to the back and forth banter on social media, one may be tempted to disagree. We don’t have enough money for single-payer. Both Vermont and California tried and quit because of astronomic costs. Hundreds of thousands of people working for insurance companies will become unemployed. Hospitals will close. Entire towns will be wiped out. Doctors will become lazy inefficient government employees and you’ll have to wait months before seeing a doctor. And of course, there will be formal and informal death panels. Did I miss anything? I’m pretty sure I did, so let’s enumerate.

Single-payer is going to bankrupt the nation

We have $3 Trillion in our health care pot right now. We have 325 million Americans, men women and children of all ages. First grade arithmetic says we have almost $10,000 per year to spend on each American, the vast majority of whom is either young or healthy or both. For comparison, Medicare spends on average around $12,000 per year for the oldest and sickest population. Last year a platinum plan for a 21 year old cost less than $5,000 per year and this includes the built in waste of private health insurance. So please, tell me again how we can’t afford to pay for everybody’s health care needs at a Medicare actuarial level, which is slightly less than commercial platinum.

And no, we need not increase taxes either. You keep paying what you’re paying. Your employer keeps paying what it is paying. The government keeps paying what it’s paying. But instead of dispersing all that cash to all sorts of corporate entities standing in line with their golden little soup bowls ready to catch the last drop, we put it all together in one big beautiful barrel, and pay for care directly to those who provide care – one pool, one budget, and one accounting system for all. This is a national endeavor. It is irrelevant that Vermont failed and California bungled the whole thing. Do you think California and Vermont could afford to provide for their own armies, air force and navies? I didn’t think so.

Single-payer will cause millions to lose their jobs

Hundreds of thousands of people work for commercial insurers. Claims need to be processed, money needs to be collected and paid out, books need to be kept, customers and service providers need to be supported, computers have to be maintained, audits need to be performed, contracts need t be managed, lots and lots of labor and lots and lots of decently paying jobs. Do you have any idea how Medicare administration works? Or are you under the impression that Medicare runs itself with no human labor? Have you ever heard of Noridian or Cahaba? No? Then I respectfully suggest that you should refrain from opining about the horrors of single-payer.

Medicare is run by private administrative contractors called MACs, each assigned to specific geographical regions and specific portions of Medicare services. In addition to the MACs there are slews of functional contractors that specialize in one or more types of supporting services to the MACs. These are private entities no different from Boeing, Lockheed Martin, Hewlett-Packard, Booz Allen Hamilton, GE and many more. They employ thousands of people and if Medicare becomes our single-payer, there will be more MACs, more functional contractors, and hundreds of thousands more private employees.

That said, it stands to reason that consolidation from many payers to one, will introduce some efficiencies and the total number of available jobs will be reduced, so here is a solution to this potential problem. Currently all insurers including Medicare and Medicaid are offshoring claim processing and in the case of private insurers other functions, including clinical, as well. Change the regulations and bring those jobs back home where they belong in the first place, and offer them to those who will lose their commercial insurance jobs. This administration is especially well positioned to effect such changes to CMS regulations.

Single-payer will take away our freedom

What if Sam’s Club only carried General Mills cereal and Costco only carried Kellogg’s?  What if you had a Costco membership but stopped by another store to pick up some Cheerios and were charged ten times as much as Sam’s Cub sells it for? No it’s not exactly the same, but you get the idea. Would you consider this to be freedom of choice? Or would you rather have one big huge market where all brands sell their products directly to you competing against each other? The latter is how single-payer could work. Freedom to shop for an insurance plan is freedom to shop for your preferred rationing scheme and ultimately your own flavor of death panel.

Traditional Medicare allows you to choose your doctor and your hospital and it pays for all medically necessary services. No commercial plan can say the same unless it’s one of those platinum things nobody can afford. Traditional Medicare can do that because it sets the prices for all health care providers, instead of negotiating with a few preferred vendors. Medicare can take these liberties because it’s big enough and because it’s a Federal program. But Medicare doesn’t pay for everything. That’s why most seniors purchase supplemental plans if they can afford them, and if they are poor enough, Medicaid kicks in as the secondary payer. Being the safety net for the fixed price single-payer should be the sole function of a new and federally administered Medicaid.

Single-payer will destroy our health care

I think American medicine is the best in the whole world. Not because it’s expensive and not due to the corrupt ways in which it’s being financed, but in spite of these things. Finding a better way to pay our medical bills has nothing to do with the quality of American medicine. The concern here is that once Medicare becomes the only game in town, it will unilaterally cut its fee schedules and all hospitals will go bankrupt, all doctors will be driven into homelessness, no new drugs will be developed and we’re all going to die. On the other hand, the Federal government is the sole purchaser of aircraft carriers, stealth bombers, and weaponry of all types. How cheap are those items?  How powerless and decrepit is that industry?

Precisely because of the lessons learned from the mighty military industrial complex, single-payer reform will have to change three things in the structure of our current so-called health care system. First, all hospital consolidation and acquisition of physician practices will need to be rolled back. Second, petty regulations, vindictive carrots and sticks strategies and crude attempts at social engineering by clueless bureaucrats, will have to be dismantled brick by brick. Third, physicians will need to form a union of independent small contractors to negotiate fees and terms alongside the already powerful hospital associations. I have been a longtime proponent of a physicians’ union, even in our current system, to serve as check and balance to corporate greed and government arrogance. A single-payer system cannot and will not succeed without unionized independent physicians.

Single-payer is not the American way

We have been conditioned by large corporations to think that what they do to us is the nature of free-markets, and thus the only way to achieve prosperity for all. I would submit (for the millionth time) that what Apple is doing to the world has nothing to do with Adam Smith’s free markets. The actors in classic free markets must be approximately equal. When sellers are so big that they need artificially intelligent tools to even notice the existence of buyers, there is no free market. When the price of products sold exceeds the lifetime incomes of most buyers, there is no free market. When no one can muster enough moral turpitude to publicly say that if you’re poor, your babies should die, there is no free market. There is no free market and there can be no free market in health care.

There can however be competition. Perhaps not in sparsely populated areas, and perhaps not for highly complex procedures, but there can be competition for most health care services in most places. The uniform single-payer price should be set so that innovative hospitals and entrepreneurial physicians can thrive by charging less and those holding themselves in higher than usual esteem, or those who choose to provide luxury, are free to charge more. If all sellers are small enough, and if the standard single-payer price is fairly negotiated, we will have a real market, because people will shop to save money (in a rewards system like credit cards have) and some will shop for status and vanity.

Will there be a role for private insurance?  There could be, but private insurance should not be allowed to cover any services covered by the single-payer because that would take us back to where we are today. Let private insurance cover stuff nobody needs, but wealthy people like to flaunt, like fresh baked brioche for breakfast after having a baby, or executive physicals in palatial settings, and let those things become frightfully expensive, as these types of things usually are in a free market.

Single-payer will create a new set of losers. Health care executives making tens of millions of dollars every year for no particular reason will be losers. Perhaps they can find new careers at Boeing or Lockheed Martin seeing how their expertise is easily transferable. Health insurance stocks will tank and improperly managed pension funds will also lose bigly. People running for elections will see a major cash cow go dry after the initial struggle is over and done with. There will be powerful losers and it won’t be easy.

But Obamacare has its losers too. Hard working, taxpaying middle class citizens were the designated losers of Obamacare. Some by commission and most by omission, because Obamacare made no attempt to solve the health care problems facing the vast majority of workers with employer sponsored health insurance. That bomb keeps ticking away at a steady pace. The newly empowered Republican Party has nothing to offer either, and I can’t blame them. There is nothing more we can do here. We tried everything else, and now it’s time to do the right thing. It’s the American way.

By SAURABH JHA, MD

For American conservatives, Britain’s NHS is an antiquated Orwellian dystopia. For Brits, even those who don’t love the NHS, American conservatives are better suited to spaghetti westerns, such as Fistful of Dollars, than reality.

The twain is unlikely to meet after the recent press surrounding Charlie Gard the infant, now deceased, with a rare, fatal mitochondrial disorder in which mitochondrial DNA is depleted – mitochondrial depletion disorder (MDD). In this condition, the cells lose their power supply and tissues, notably in the brain, die progressively and rapidly.

The courts forbade Charlie’s parents from taking him for a last dash of hope to the United States. This confirmed for many conservatives the perils of a government-run healthcare system, where the state decides who lives and who dies through Death Panels.

Ted and Mike, whose healthcare reform might affect many curable little Charlies, were moved by the plight of an incurable Charlie. No European will understand the science behind their sentiment – if you care so much about a sick incurable baby, why don’t you care about sick, cure.

Brits will never get the importance conservatives place on individual choice, even if that choice is forlorn, and of the lure of medical heroism. Conservatives seldom acknowledge that modern medicine reaches its limitations too quickly for Death Panels to be effective. Charlie was given a grim prognosis by doctors at the Great Ormond Street Hospital (GOSH), arguably the finest hospital for sick children in the world.able babies, they’d ask.

GOSH might not have the endowments of its American counterparts. It is an orthodox British hospital with creaking staircases, the sort where I trained, where doctors have incredible clinical acumen, paranormal common sense, and dabble freely in paternalism. Doctors know best and are not ashamed to say so. When doctors at GOSH say death is imminent, Death Panelists are rendered unemployed, unless there’s a miracle to slay. For Charlie, that miracle was a New York neurologist offering an untested therapy.

The reaction to Charlie’s plight is as instructive as the reaction to the reaction to his plight. It’s as if everyone took the Rorschach test simultaneously.

Charlie’s plight was felt by the Pope. The Pontiff is a busy chap and can’t possibly Tweet in support of every dying child in GOSH. But once the media portrayed his suffering, everyone jumped on the bandwagon. The Pope was joined by Ted Cruz, Donald Trump, Theresa May, Nigel Farage and even the notoriously unsentimental Jeremy Corbyn. This is the power of the identifiable victim.

Some have wondered whether our preoccupation with stories such as Charlie’s diverts our moral and financial resources from tackling deaths from malaria in Africa – i.e. we don’t care about deaths from malaria because we care too much about one dying infant. In this classic utilitarian fallacy, the utilitarian treats moral sentiments as a zero-sum game with opportunity costs. The truth, as Adam Smith pointed out in Theory of Moral Sentiments, is that we’ll always be more perturbed by events proximate to us, the identifiable victim, than random people who don’t appear on our Twitter timeline. If Charlie hadn’t surfaced in our news channels, we still wouldn’t be fretting about deaths from malaria in far off countries we’ve never heard about.

Charlie’s case showed the limitations of not just modern medicine but modern medical ethics.

When all hopes seemed lost, Charlie’s parents did what many do today – they consulted Dr. Google, who didn’t disappoint. Their search revealed a New York neurologist – Dr. Michio Hirano, a researcher and an expert in mitochondrial disorders.

When hope resurfaced so did the controversy. The first point of controversy was that the nucleoside therapy Dr. Hirano was offering was not scientific – i.e. there was no proven benefit of the nucleoside in the specific variant (RRM2B) of Charlie’s MDD – it hadn’t even been tested on animals with that variant. GOSH, the High Court and the terribly unoriginal European Court, used the absence of proven efficacy in their justification for stopping the parents from taking the child to the US.

“Not scientific”, a compelling statement as no one can argue with science, needs parsing. It is possible for a treatment for a rare disease to have promising results in a small trial in the US, but still not be available in the NHS either because the National Institute of Clinical Excellence (NICE) hasn’t gotten around to approving it or is waiting for more evidence. This wasn’t the case with Charlie’s disorder, but my point is what may be unscientific today may truly be unscientific or may simply be waiting for NICE to schedule a conference call.

Charlie would have been the first patient with the RRM2B variant to have received the nucleoside therapy. Though we don’t know for certain, it is highly unlikely Charlie would have responded favorably. Had he responded favorably, the treatment’s efficacy would be certain. This is because Charlie’s condition had a 100 % fatality and anything that’d have saved him, gotten him off the ventilator and breathing spontaneously, and restored his motor function, would either be a parachute or a prophet – you don’t need a double blind, placebo-controlled, randomized controlled trial to test the efficacy of a drug for a condition which is imminently and uniformly fatal.

The neurologist was accused of having financially conflict of interest in nucleoside therapy, which he has strongly denied.

This familiar moral dilemma, which brings science closer to morality than necessary, begs legitimate questions. Was the doctor genuinely motivated by a desire to help or by making more money? Was there truly therapeutic equipoise or was he selling snake oil?

Science being morally neutral means that the neurologist’s motivation for helping was moot. The therapy either worked or didn’t. And if it worked no one would care if the doctor is Satan. If it didn’t work it scant mattered if he were the Pontiff. His financial conflict of interest is relevant only because it indicates whether equipoise – i.e. that the therapy may work –  is justified.

To emphasize, we must believe that science, i.e. proven treatment benefits, is morally neutral –  because it would be silly not to – I mean it’d be like saying a treatment would work better if the prescribing doctor were more pious.

But, seemingly, equipoise is not morally neutral. What we’re saying is that the uncertainty, and I repeat the uncertainty, that a treatment may work depends, to some extent, on the motivations of who is calling the experiment. This is understandable because medicine is replete with stories of sellers of snake oil. But there’s a large coastline of plausibility far removed from snake oil.

Dr. Hirano wasn’t selling snake oil. He was selling a plausible but untested treatment to desperate parents. The nucleoside therapy had modest efficacy in a variant of Charlie’s disorder (TK 2). But had never been tested in the RR2MB mutation, which Charlie had. It was unscientific because it was unproven – it wasn’t implausible – it certainly wasn’t snake oil.

Ironically, precision medicine exposed the unscientific nature of the nucleoside therapy. Imagine if you couldn’t sequence. You wouldn’t know that MDD had variants – that is you wouldn’t know whether Charlie’s MDD was the TK2 or the RR2MB variant, it’d all be the same. Would the nucleoside therapy, which had worked in a handful of patients with the TK2 variant, still have been unscientific? This is not a dig against precision medicine. I’m merely asking for less dogmatism in what we call unscientific, given that the line is so thin between groups in which therapies work and don’t work.

This takes me to the desperation of Charlie’s parents. I can’t even begin to imagine what they were going through. I recall how I reacted at the very slight possibility that my older son, when he was three weeks old, had pyloric stenosis. My frontal lobe stopped working. Were I Charlie’s parents, I’d have fought tooth and nail and eked every possibility. I’d have done exactly what they did.

Parents of children who have terminal illnesses have nothing to lose, so they pursue any hope, no matter how hopeless the hope is. Some ethicists find this sentiment repugnant. You can see why the ethicist’s ire is drawn. Picture this – desperate parents willing to do anything, offered false hope by a doctor who knows that their condition is hopeless, who knows the treatment is unproven, and who is merely taking advantage of their predicament, like a parasite. Won’t you be disgusted by that doctor?

Let’s reframe this. A doctor offers hope to desperate parents who have nothing to lose except hope itself. The doctor believes that denying hope, no matter how hopeless, will be crueler than giving hope. Incidentally, Lord Krishna, one of the many Gods of Hindus, said that a lie which makes someone feel better is better than a thousand truths which make a person feel worse.

Are you still disgusted with the doctor prescribing hope? I’d say “repugnance” is a rather strong sentiment in this ethical gray zone, where the answer depends on how the situation is framed. To believe medical ethics is as absolute as Newton’s Third Law of Motion betrays an alarming level of judgment.

Charlie would have been the first to receive the nucleoside therapy for his condition. In any trial of medical treatment, there is always an index patient – the first to receive the unproven therapy. This is an inviolable fact, whether the unproven therapy later proves itself or not.

Would we be offended if Charlie was the first to receive the unproven treatment as part of a research trial with a hypothesis where the researcher purposefully set out to collect data and specified the outcomes in advance?

It was unethical to experiment unproven therapy with Charlie. Paradoxically, it was also unethical to give Charlie unproven treatment because it wasn’t an experiment.

What then in modern era is the difference between a neurologist responding to desperate parents by giving unproven therapy and a neurologist responding to desperate parents by giving unproven therapy as part of a trial? It’s easy seeing that both scenarios are experimental. But there is a difference. The latter comes with regulatory oversight, the former doesn’t. So, a major gripe here is the absence of regulatory oversight.

This wouldn’t have been the first-time unproven therapy has been offered to sick children with fatal conditions short circuiting a trial. Take the case of surgery for complex congenital heart diseases such as Hypoplastic Left Heart Syndrome. The first time a surgeon operated on a neonate with this condition, the treatment was unproven and, therefore, unscientific. The treatment was offered to desperate parents who believed they had nothing to lose. Indeed, the operative morbidity and mortality for early cardiac surgery for congenital heart disease was so high that whatever short life span these babies had was curtailed by the surgery – i.e. surgery made matters worse. Then the heart surgeons learnt from their errors, improved their technique and patients lived longer. Today, patients with complex congenital heart disease are old enough to worry about cancer and dementia.

Again, the ethics of offering an unproven treatment to a sick child of desperate parents is trickier than first appears. While it may make us balk, the first few recipients of unproven therapy can be made worse, even if the therapy later does net good. I’m not terribly fond of utilitarian reasoning – greatest good to the greatest number – but utilitarianism makes its way through multiple avenues. One argument, which I’m partial to, is that if you relax the access to therapies which haven’t been adequately scientifically vetted for rare diseases with no cures, drug developers will have little incentive to produce genuine cures. This is a compelling and highly plausible conjecture, but it is utilitarian at its core – i.e. we believe that easy access for a few could lead to net harms for many.

Some have defended the action of GOSH by saying it is not about costs, only effectiveness. This is understandable – no one wants to muddy the issue by talking about costs – but disingenuous. Of course, costs are important when the taxpayer is footing the bill. Charlie was ventilated. He’d have to be shifted by air ambulance and accompanied by trained personnel. Medical resources aren’t free even in the NHS. And given that the effectiveness of the nucleoside therapy is nearly zero, the cost-effectiveness would be nearly infinite.

Charlie’s parents had raised funds to help with the costs. This evokes a familiar sentiment in the NHS – should they be allowed to pursue treatment simply because they can afford it? The NHS prides itself, rightly so, on equity – no one is denied proven treatment because of inability to pay. But it’s hard seeing how equity is disrupted if someone decides to pay for futile treatment. Furthermore, Britain has a parallel private system in which proven treatment is accelerated for those who can pay. The Brits, when they want, seem perfectly capable of tolerating inequity.

The crux of the matter was the tension between the welfare of the child and the wishes of the parents. When I was a junior doctor working in an emergency department in London, we were counselled not to bow to the demands of parents and prescribe antibiotics for febrile children. Doctors, even junior doctors, knew best.

The trickier situation is when parents refuse treatment for their sick child. Doctors have the law on their side here and you can understand why. If parents of a child with meningococcal septicemia are conscientious objectors of synthetic therapy and decide that antibiotics for meningitis aren’t indicated, their wishes can’t supersede medical necessity. That is if parents clash with doctors, the doctors will prevail, and the child will receive life-saving antibiotics against the wishes of the parents, and rightly so. Let me state this in no uncertain terms – the courts agree that doctors know best.

Neither medical paternalism, nor the fight against it, is absolute. Doctors do know best, but “best” is a spectrum. For example, the courts can’t force a child to be vaccinated against the wishes of the parents. Few would dispute that vaccinations are beneficial to both the individual and society. But the courts distinguish between a proximate harm and a probabilistic harm to the child.

Would subjecting Charlie to unproven therapy worsen his welfare? Arguably, yes – there’s a fate worse than death, and being on a ventilator prolonging death senselessly is a form of suffering, no less because it can’t be articulated. Does this come under the antibiotics – meningitis domain (proximate harm) or the vaccination domain (probabilistic harm)? I’d be inclined to put it towards the former, unless I was Charlie’s parents. But you can see that this, too, is in the ethical gray zone.

There’s no doubt that the doctors in GOSH made a good clinical call. But every now and then the medical profession encounters an outlier and responding to an outlier needs more than clinical acumen.

The matter reached the European Court – an institution which excels itself at irrelevance by saying nothing new. It’s hard not concluding that a drama was made of a crisis in a tricky realm where each actor wanted to stamp their absolutism. Would it really have been the world’s greatest travesty if Charlie had been taken to the US to receive an unproven therapy? Could GOSH have handled the matter more prudently? Was a legal injunction really necessary? Could the NHS have avoided been morally scolded by Ted Cruz?

Of note, when Dr. Hirano examined Charlie at GOSH he concluded that the brain damage could not be reversed. Perhaps if the doctors at GOSH had incorporated Dr. Hirano as part of their multidisciplinary team at the outset, thus respecting the parent’s preferences, the legal drama could have been avoided. NHS hospitals have something to learn from their American counterparts.

For conservatives, the Charlie Gard story affirms that the NHS is a tyrannical apparatus which conspires to rob people of their fundamental human rights and that Brits submit meekly to medical paternalism. In this tragic story, no one has been more naively absolutist than the conservatives. Calling the NHS “tyrannical” when it saves many poor kids without bankrupting their parents is absurd. This noble institution could, however, do with better PR, because it has come across as inflexible and dogmatic instead of compassionate and scientific. For both the National Health Service and the Great Ormond Street Hospital, this is a huge travesty.

Saurabh Jha is a contributing editor to THCB.

 

 

 

 

 

 

 

 

 

 

 

 

By DANIEL STONE, MD

Tom Price, President Trump’s new Secretary of Health and Human Services (HHS) strode to the podium to the sound of applause.  The two thousand medical administrators and physicians at the annual meeting of CAPG, a trade organization representing physician groups, heard him described as the most influential person affecting the 300+ participating groups that provide care for millions.   Only the third physician to lead HHS, many hoped that the orthopedist and six term GOP congressman would bring new sophistication to the federal government’s healthcare programs.   

The perfectly coiffed Secretary looked every bit the new man in charge of healthcare.  Sadly, his resonant voice soon dashed any hope for substance.  He might have commented on the essential U.S. healthcare quandary:  A country with average household income of $56,000 can’t afford the $15,000 annual cost of health insurance for a family of four.   Neither Republicans nor Democrats can conjure up inexpensive insurance that covers unaffordable healthcare services.   What does the Secretary think?  He sidestepped the issue, twice patting his audience on the back by touting the American health system as “the finest in the world.”  Seriously?  If Price had attended the morning session he would have heard that the U.S. spends about 6% more of its GDP on healthcare than average developed country.  That extra $1.2 trillion amounts to more than twice the defense budget.  Yet U.S. health outcomes for crucial measures like infant mortality and lifespan rank average or even worse.  Yes, U.S. medical technology leads the world and foreign dignitaries still travel here for world class, high tech care.  But shouldn’t the secretary of HHS understand that the measure of a healthcare system is the quality and accessibility of care provided to average citizens?  

Perhaps more surprisingly, Price failed even to comment on the GOP-sized elephant in the room: The proposed House and Senate healthcare measures, supported by the administration, then awaiting action.  The non-partisan Congressional Budget Office estimated that the measures would cause millions to lose coverage.  Price’s Hippocratic Oath had no sunset provision.  If allowing millions to face loss of their coverage under the Affordable Care Act (ACA) would somehow “do no harm” why not explain the thinking to those on the front line?

Despite Price’s silence, the now fading proposals reveal a strategy of shifting national healthcare priorities toward an individualist rather than a collective approach.  This shift can be seen most readily in the GOP opposition to the standard benefit package, an ACA provision that requires insurance to cover  specific services.   Advocates for repeal note that eliminating standard benefit would reduce the cost of plans.  Although true, the savings occur only because enrollees play “benefit roulette,” hoping that that the omitted services don’t turn out to be needed in the future.  And if they do?  Dr. Price and the GOP would just leave that problem to the individual selecting the plan. 

Similarly, the proposed rollback of the mandate to purchase insurance allows individuals to opt out of the system entirely.  GOP proponents promote the change as enhancing individual liberty.  They ignore the fact that when uninsured individuals get sick and arrive at emergency rooms, they no longer opt out.  The costs of their care get covered by those paying into the system.   Those opting out become “free riders,” enjoying catastrophic coverage paid for by others.  Price and other advocates of repeal seem unconcerned about balancing individual liberty versus personal responsibility and social consciousness.   They also fail to appreciate that insurance—the pooling of community resources to cover risk—is inherently collective and rewards individuals with financial and healthcare security in return for the their support of others.  Secretary Price should stop promoting the illusory benefits of healthcare libertarianism and advocate instead for the health security of all the American people.       

The Secretary’s CAPG photo-op resembled a prince’s foray to a rebellious provincial outpost.  He did not brook questions from the assembled nor deign to meet the organization’s board.  He granted permission for four questions that were submitted and approved in advance.  The attendees might have been reminded of the Bourbon monarchs, who on their restoration to the throne of France to were said to “have forgotten nothing and learned nothing.”  The Republicans in Washington have certainly not forgotten their years of opposition to the ACA.  Their willingness and capacity to adapt and to learn more about U.S. healthcare needs in the post-ACA era remains uncertain.  Secretary Price’s recent visit to CAPG provided little cause for optimism.      

By JIM PURCELL

This Spring, California SB (Senate Bill) 562 proposed a single-payer healthcare financing system for California.  Governor Jerry Brown was immediately skeptical, stating, “This is called ignotum per ignotius….In other words, you take a problem and say, ‘I’m going to solve it by something that’s even a bigger problem,’ which makes no sense.”  And in early July, California Assembly Speaker Anthony Rendon tabled the bill calling it “woefully incomplete.”  While true, that incurred the predictable wrath of single payor advocates.

Understandably, it’s difficult for supporters not to be enthusiastic about SB 562 given the conclusions reached by the Political Economy Research Institute (PERI) based out of the University of Massachusetts, Amherst. PERI has released a Study commissioned by the California Nurses Association (which has always favored single payor universal coverage) that projects reductions in healthcare spending by $37.5 billion a year!  No small change there.

The Study reports that the proposed single payor system could provide “decent health care for all California Residents…” and while providing full universal coverage would increase overall system costs by about 10%, it “could” produce savings of about 18%.  The savings supposedly will be realized through reduced administrative costs, reducing pharmaceutical reimbursement charges, and “a more rational fee structure for providers.”  “More rational” usually means “reduced,” and that usually means primary care and mental health are the first in line to take it in the neck, given their limited negotiating leverage.

And it gets even better.  There would be no premiums, copays, or deductibles.  According to the Study, people could get treated whenever and wherever they want.  And money will be saved.  This is like heaven. 

There was much missing from SB 562.  For example, it did not include a funding mechanism in the Bill, leaving that to California’s Assembly.  It was strong on what but light on how.  That obviously troubled Speaker Rendon.  The PERI Study suggested a 2.3 percentage point increase in the State sales tax which would raise California sales taxes to 9.55% not including local add-ons, and a 2.3% business gross receipts tax on revenue exceeding $2 million. 

I admit to a modicum of skepticism as much as I welcome new and aggressive ideas.  But the theory of single payor universal coverage has been around for decades, and the last state that went down this path (Vermont) got a very rude financial awakening when the real numbers were toted up.    As the Boston Globe reported,

“The numbers were stunning. To implement single-payer, the analysis showed, it would cost $4.3 billion in 2017, with Vermont taxpayers picking up $2.6 billion and the federal government covering the rest. To put the figures into perspective, Vermont’s entire fiscal 2015 budget, including both state and federal funds, is about $4.9 billion.”

The Globe went on to report that the Vermont Governor’s office estimated needed tax increases on income and payroll that more than doubled existing taxes. The Governor, who ran on this issue, pulled the plug. 

California Governor Jerry Brown may well do the same in California if a final bill reaches his desk next year, but the Wall Street Journal, in an editorial that ran on June 12, urged him to consider just the opposite.  The WSJ editorial, most probably tongue-in-cheek, noted Governor Brown’s comment with the Latin phrase, and yet suggested that this concept be taken for a “test drive” by California, saying:

“ But if Mr. Brown believes this, maybe he should sign it and force progressives to live with the consequences before they foist another health-care experiment on the entire country.”

Not a bad point.  For years, politicians advised by liberal-leaning economists have been on a rant for just this.  Given the paucity of other more workable initiatives and the inability of Republicans in Congress to agree on much of anything, it may well be time to call the question once and for all.  And where better than California?

Of course, a universal coverage single payor system would save money right off the bat in some areas.  System-wide administrative costs indeed would be reduced.  Commercial insurers as we know them would be eliminated with their varied operating expenses, procedures, and the ever-present bureaucratic red tape. 

Employers would be relieved entirely of providing health insurance as a benefit.  [Might that incent more employers to move to California?]  Providers would have but one set of procedures and rules to comply with.  And given that there will be no copays, copayments, or deductibles, significant administrative burdens on providers (as well as some collections problems) will be eliminated.  While the savings would not constitute as big a portion of the overall coverage cost as some suggest, it represents real money in a one-time savings.  However, it does nothing for the other 85% or so of the cost of coverage, namely, the claims expense. 

Of course, the State of California, which would be the single payor, would incur some administrative costs in running the system, processing claims, managing networks, etc.  And if history is any guide, States usually are not uber efficient.  But if this were to be similar to Medicare, there is almost no management of care and very little other cost-control type activity or overview.  Good for reducing administrative expenses; bad for reducing claims expenses.  And to the extent California engages in cost-control activities, its administrative costs would increase, but at least there would be substantial economies of scale.  And those evil private insurers would (at last) be gotten rid of.

However, let it be repeated:  Once implemented, the administrative cost reduction would be a one-time reduction; thereafter, premium increases would resume unabated, and in fact, without cost-controls, they presumably would increase more rapidly than they have to date, unless the citizens of California undergo a huge transformation in lifestyles and how they use services. 

As difficult as it is to digest, the only way to truly reduce healthcare costs substantially and in increasing amounts over time is to reduce claims expense.  To do that, either fees must be reduced or reductions must be had in the per person rates of usage of services.  And as I have written repeatedly, the focus eventually must be on the rates of use of services by focusing on the chronically ill, and improving overall health.  THAT is the way, over time, to put increasingly large bites into the cost of healthcare. 

SB 562 does apparently proceed down the path of reducing fees (pharma and “a more rational fee structure” whatever that might mean), but reducing pharma charges is easier said than done.  Kudos, if California can do it; but it seems a far bigger problem than one that even a state as large as California can tackle alone.  SB 562 (of course) does not even dip its toes into the reduction of the use of services.  In fact, just the opposite given its aim of no copays or deductibles, and the ability to get care wherever Californians want without restriction.  Just sayin’.

Should California actually proceed down this path, I would encourage the State to keep close track of certain data so that we all can learn from the experience, such as:

• Administrative expense saved solely on the payor side (one payor of enormous scale, elimination of commercial insurers, etc.)
• Administrative expense saved on the provider side (only one set of rules, one set of claims forms, no copays, etc.)
• The extent and cost of management of claims by the payor, if any
• Changes up or down in fees paid to providers, and which providers experience the greatest increases or decreases
• Changes in per capita rates of use of services by category
• Changes in rates of emergency room and inpatient care use
• Wait time particularly for primary care and mental health care
• Polls of impacts on providers and particularly primary care
• Financial impacts on hospital systems
• Pharma costs
• Member satisfaction

If California eventually proceeds on this course, I strongly urge them to engage in massive patient education on appropriate system access and self-care.  It must somehow reduce the rate of use of care to survive.

What is unstated in all of this would be the future role of employers, if any, in the financing of healthcare coverage.  Section 1c of the Bill states: “This act does not create any employment benefit, nor does it require, prohibit, or limit the providing of any employment benefit.”  Otherwise, the Bill is silent on employer-based coverage.  As I read it, employer-based coverage would disappear, and why not from the employers’ standpoint.  Presumably employers would be free to offer an added level of insurance as a perk, but why would they given the open-ended access of SB 562?

Indeed, some of today’s perversities in our healthcare financing system derive from the employer-based coverage anomalies.  No other country is like the US in that regard.  And it must be admitted that single payor universal coverage is much simpler.  Like education up to certain levels, it now becomes a right funded wholly by tax dollars.  Does burying its costs in our already choking level of taxes make it more palatable?  We did that with Medicare and Medicaid for years.

More and more commentators are edging toward varied forms of single payor or increased federal involvement.  For example, Dr. Dan Stone in his July 5 post to this website proposes what appears to be a more sensible approach, albeit one that takes us further down the path of single payor. 

However, David Johnson, while also discussing the current Congressional morass, warns:

“Constructive health reform does not require more money.  It does require redistributing healthcare resources away from acute and specialty care and into preventive health, chronic disease management and behavioral health services.  It also demands greater transparency, lower administrative costs and balanced regulatory oversite.

“The challenge is not what to do.  It’s how to do it.  Beyond the BCRA (Senate bill), Congress must find ways to stabilize health insurance markets, encourage innovation, incentivize health over care, increase coverage, improve access and reduce inequality?

Whew!  A mouthful.  But as an older lawyer once commented to me while we were considering litigation strategies, “It has the additional advantage of being the truth.”

Joe Flower keeps reminding us that we are having the wrong discussion.  Rather than obsessing on who pays, we must obsess on reducing how much we pay by making the systemic changes needed to reduce the need for payment.  In that regard, Republican attempts to make huge cuts to Medicaid without concomitant systemic changes seems short sighted.

So only partly tongue in cheek, I join in with the Wall Street Journal in inviting the great State of California, the home of so many other societal innovations, to take the plunge, adopt single payer universal coverage, and show the rest of the country how to do it.  One way or the other, we will learn something, I’d hope.  And isn’t that the Federalist way?

Who know?  Stranger things have happened, and we sure could use something like PERI forecasts.

NIRAN AL-AGBA, MD

I told you so.  I also told the POTUS in my open letter, but he did not read it. 

Who could honestly believe the nation would support dumping coverage for 22 million people?  As David Leonhard wrote recently op-ed in the New York Times: “They [Republicans and President Trump] had only one big weakness, in fact: They weren’t dealing in reality.”  When faced with reality, it is interesting what a few good Senators with a conscience will refuse to do. 

Success is never attained by taking shortcuts.  We do not need reform of health care; we need to reboot the entire system.  Special interests do not belong in the picture.  They are incompatible with developing innovative solutions that place profits on the back burner.   Congress is making this too difficult.  They need to roll up their sleeves, go back to the drawing board, and start again.  My suggestions:

Step 1:  Every member of Congress should participate in a mock hospital admission as a patient, starting with presentation to the ER, being poked and prodded, having surgery if necessary, and staying overnight to recuperate.  After your experience, you should be provided a “bill” on your way out the door and pay the balance by cash or check. 

Step 2:  Go see your own primary care physician for two reasons.  The first is to have an annual exam and to connect with your constituents in the waiting room, solicit their comments, thoughts, or suggestions, and converse with office staff to understand their perspective.  The second reason is to elicit feedback directly from your primary care physician.  Listen for groundbreaking solutions to the perplexing boondoggle of caring for greater numbers at a lower cost.

Extra credit:  Follow a primary care physician in a Health Professional Shortage Area (HPSA) for three days.  Listen, engage, clarify, empathize, and most importantly absorb how monumental this undertaking of reforming health care will be. 

Step 3: Return to Washington D.C. inspired and reboot, resolving to do it right this time. 

The nation has been having entirely the wrong conversation; that dialogue must change.  The biggest obstacle faced by lawmakers is maintaining access while reducing cost.  Providing coverage without coupling it to budgetary constraints is sheer lunacy.  However, reducing government involvement in coverage without ensuring the needy can afford health care will never garner widespread support.  Affordability has become an impossible dream and is currently our largest stumbling block. 

The U.S. spent $10,345 per person annually in 2016.  The average OECD country spends $3997 per person annually in comparison.  During the 1980’s Spain created a network of community health clinics within a 15 minute radius of every citizen, a system which was funded by the taxpayers.  In 1975, the average life expectancy from birth was equivalent in both nations, at 69 years of age.  Today, life expectancy in Spain is 83 years compared to 78.8 in the United States.  We are spending twice as much as Spain and our life expectancy is significantly lower. 

An appropriate policy goal would be to focus on developing a sustainable solution, implemented only after great deliberation.  Scaffolding already exists, in community clinics and Public Health departments; these facilities are cost-effective, yet grossly underfunded, underutilized, and unappreciated.  Every single man, woman, and child needs primary care services, a fact which in incompatible to the insurance model.  We must sever the connection between insurance and primary care.  Providing basic care universally is something we must accept as reality. As I have written before, investing in primary care as a solution is a no-brainer; increasing by one PCP/10,000 persons decreases mortality by 5.3%. 

Basic care will bring us all out from the shadows and into the light.  Provide immunizations, screenings, and annual exams to everyone in this country.  Those working in the community clinics will be employed by the government and salaried.  These clinics could have evening or weekend walk-in hours and handle urgent matters.  The electronic medical records system should be universal and patient-centric.  People will no longer live in fear of our government eliminating access for chronic conditions or emergencies.  Struggling families will not be one catastrophic illness away from losing their hopes and dreams. 

As we continue filling in the grid, specialty care should be added at the public health facilities or community clinics.  A specialist would cover a greater number of patients when overseeing or consulting on difficult cases with the primary care physicians.  These specialists would be employed by the government and salaried as well.  If an individual becomes severely ill or injured and requires very specialized treatment, hospitalization, or surgical management, either they have Medicaid, Medicare, or their catastrophic insurance plan kicks in to cover these needs. 

No discussion would be complete without including third party payers, who distance patients and physicians from being cognizant of cost.  For what we do in our offices, services could be far cheaper.  For example, a self-employed middle-aged patient with a $25,000 deductible sustained a 4cm laceration to the head and went to buy glue to repair it himself.  On this particular holiday weekend, the stores were already closed.  He inquired as to the cash price for repair after texting a picture. 

I had no answer, but primary care physicians love repairing lacerations and I am no exception to the rule.  He came to my office; I cleaned the wound and sutured it.  He handed me his credit card, similar to the cashier at a grocery or hardware store.  Supplies cost roughly $50; the laceration repair took 15 minutes.  I figured $150 seemed reasonable.  He paid $200 and was thrilled. 

While the lack of transparency hindered my research, I compared the cost to repair a 4 cm laceration in the emergency room.  The estimated charges were:  $1000 emergency room facility charge, physician cost $500, and the procedure bill was $200.  My hardworking patient would have coughed up $1700 at a minimum (some estimate as high as $1000 per stitch) and waited well over 15 minutes for the privilege. 

Allow the free market forces to remain a part of the infrastructure.  A great deal of the population fears a universal basic system because they are afraid of losing choice.  Direct Primary Care practices would flourish in a system with a basic care safety net for those in need.  Those who can afford choice would have options to patronize the private market, which absolutely should not be eliminated.   

Reviewing the events this week reminds me Rome was not built in a day. Repairing the tangled web of health care will take unconventional thinking and the tincture of time. Costs have spiraled out of control past the point of affordability.  The nation will only support reform once Congress overhauls our broken system prior to embarking on repealing anything.  Finally, everyone is profiting except the two most critical components: the physicians and their patients.  Repair, reboot, and rebuild from the ground up and when you do, start by putting patients ahead of profits. 

MICHAEL CHEN, MD

Dr. Matthew Hahn blogs about the current state of today’s EHR’s and rightly points out many of the same reasons that I have identified in my previous posts:

1. The negative impact of Meaningful Use (MU) since 2009
2. Poor usability of EHR’s

There are several other important concerns that have been left unanswered by our current Health IT offerings.

1. Patient privacy and control of their health records
2. Interoperability

Government Pipedream?

The solution Dr. Hahn proposed is one that hinges on the hope that government will abandon MU (unlikely given this political climate), and create a whole new EHR development program based on a national competition and then for the government to subsidize the cost of that winner EHR for physicians to use.

Subsequently, this national competition will engage physicians so that they have control over their destinies in designing the EHR of their dreams.  But is it realistic to hope that government will support such an endeavor?  Although I’m a believer that government should and ought to play a role in setting fair rules and be accountable to the public (for the many and not the few) and not to be overrun by lobbyists and those with the most money and influence who can rig the system, I doubt this solution will see the light of day with our currently polarized politics and the continued, large influence of big money interests in government today.

Movements as Inspiration

Here is my proposal that leverages existing platforms and technologies (but that most physicians may not be aware of) without hoping for the government to intervene today (or yesterday).  Only until a community of patients, physicians, and developers that have a common goal of creating an EHR that works for both physicians and patients, that we ultimately compel the government to support (financially) the further development and adoption of this type of system.  Those who have studied previous movements (such as the LGBT social movement, thee Civil Rights movement, and the women’s suffrage movement) took a group of like-minded individuals from different walks of life who struggle together, make their voices heard, participate, and ultimately control the cultural narrative to the point that government had no choice but to abide to the sea change that has already taken place.  This is where physicians and patients have to start.  And we have the tools to start the change as we see fit.

 

Open Source to Start the Movement

So rather than a national competition, let’s take an existing software development framework that’s called open source.  Open source is analogous to peer review in the medical world.  The software code is public for all to see, to poke at, to test drive, to criticize, and to improve upon.  It’s not proprietary (like almost all other EHR’s are) and one can take a base code and improve it and customize it as they please and donate back to the base code all the good features and code in the custom project that everyone else can share.  No need for reinventing the wheel.  Open source code and the ideas behind it already exists!

Another benefit of open source is that physicians can learn to be okay with learning something new, even coding.  Software code does not have to be a “black box” and hoping that some “magician” can save our souls.  It’s a directive, like a physician’s order – nothing more and nothing less.  Open source just pulls the curtain behind so one can learn how to code and learn how it all works.  Open source makes all of us (patients and physicians) more informed about the tools that we use.  Personally, I owe a lot to the open source movement, which is where I learned to code despite being a busy family physician.   I didn’t have to go to a class.  I just go on GitHub where most open source code projects are stored and published and away I went.  It can be done!

Lastly, open source is not expensive.  There is no license fee.  There is no entrance fee.  Physicians and patients do not have to belong to a secret membership or society to play…anyone can join.  This is how this community of physicians, patients, and developers is born.  This community is where we begin to discuss the common interests that we all have to improve our health care technology sphere beyond the current framework of rent-seeking middlemen, trust entities, and monopolistic EHR companies. The open source ethos is inclusive, not exclusive.

But, gosh, you might say, “it’s daunting to create an open source EHR from scratch”.  But I’ve got you covered…there are already several different fully developed EHRs for different scenarios and countries but the one of interest here is NOSH ChartingSystem project coupled with HIE of One.

What makes HIE of One coupled with NOSH ChartingSystem unique?  It addresses the issue of patient privacy and gives control back to the patient over the sharing of his or her protected health information to others.  How does this work?  To start with, let’s point out the current state of EHR’s today.

The Current State of EHR’s

EHR’s are typically owned and operated by an entity (large or small) where they store more than 1 patient chart at a time.  This could be a small solo practice, a hospital, a HIE (Health Information Exchange) and even the EHR vendor.  What’s the problem with this framework?  Aside from physician’s eternal gripes of poor design, two key issues: Patchwork privacy and security concerns.

Patchwork privacy is a situation where a patient belongs to an entity and has health information stored in one EHR and that information may or may not be shared to a patient-designated provider or person.  This is where interoperablity will likely be unachievable in our current EHR framework.  It’s also possible that there are instances where the patient may not know that their health information is being shared to someone else (and this is not OK!)  The patient literally has no control over their health information!  Furthermore, a signed HIPAA agreement or release of records does not guarantee that the patient has control of his or her health information and where it’s directed to.  It’s perfectly reasonable for patients to be suspicious for having their records stored in a central database just for this design reason.

Security concerns with current EHR’s are based on the idea that a system containing more than 1 patient will create a “honey pot” of data.  Imagine that you are a malicious hacker who wants to get data (social security numbers, demographics, medical diagnoses, etc.).  The chance that the hacker can break into a system without having to do it multiple times and on multiple systems is much less when they are trying to hack a central server with multiple patient records.  They only have to crack the code once to get maybe a million records.  It’s like robbing a bank versus robbing a home.  Which is more efficient for the hacker?  What you are seeing in the news these days of data being held at ransom due to malware is not new and will continue to be an ongoing threat.   We must move away from honey pot or centralized data systems if we are going to seriously address the issue of health information security.

The Fix

A national competition for an EHR system for doctors will never seriously address these key design issues because the traditional or current EHR system itself is a flawed framework to begin with.  The best solution is actually a complete inverse of the current EHR framework.  Imagine each patient having their own electronic data container that contains data for only one person (hence HIE of One) that belongs to him or her and not by anyone else unless they designate an individual to control it.  Let’s also imagine that these data containers can talk to each other (this is called a distributed network – such as peer-to-peer) and to other entities (hospitals, government, corporations, FitBit, health device company, you name it) but only at the behest of the patient.  Imagine that approved physicians can access, add, and update their patient data container (which is a single patient EHR, NOSH ChartingSystem) at any time irregardless if the patient is physically there (so it’s not a physical device carried around by the patient, like a USB key, because, you know, sometimes people don’t carry things with them all the time, especially if they are seriously hurt, unconscious, etc).  Imagine this data container being similar to a health journal that a patient would carry around with them and make the physician jot and update their medication list, allergies, problem lists, immunizations, medical history and it’s a running list that is up-to-date, not of dispute, and that the patient can verify.  Of course, I know only a handful of patients who diligently keeps their own medical records, but can you imagine solving the patient data reconciliation process if every person had their own legal health journal?

And that is what HIE of One coupled with NOSH ChartingSystem hopes to be.  HIE of One and NOSH ChartingSystem can be deployed on a small, secure web server (like a cloud virtual machine, or a physical appliance such as a router) that is on 24/7.  Using the latest encryption technologies, one can access this data on a web browser, smart phone, or tablet.  Using self-sovereign technology (which in our project case, performs as an independent electronic notary service for the person signing a prescription, encounter,  or document), any entity can go back and verify that indeed such an activity took place and was notated legally by the patient-allowed physician or user.

Is This A Dream?

No, we are actually closer to reality with what I proposed than the dream of a government sponsored national EHR competition.  The code already exists.  There is a working demonstration of this technology from start to finish.  But the catch here is that the word must get out and that a community supports this endeavor because without it, the project will only  be a small demonstration of what it could be.  Without buy in from almost everyone, we could all lose.

Who wins?

Physicians because they now have control over the design of their EHR for good because it is now in alignment with the patient and physician’s best interest, not administrators, insurance companies, or even government entities.

Patients, because they now have control over their health information and who gets to see or use it and who doesn’t.  Patients win because they can communicate with their physicians in a secure way without compromising their privacy and security.

Hospitals (yes, hospitals) and insurance companies (yes, insurance companies) because they no longer have to be liable for security breaches each time a nefarious hacker or Big Brother goes after their data.

Government (not to be confused with Big Brother) because there is now true alignment between patient and physicians which can potentially reduce health care costs for the entire population due to reduction of unnecessary or duplicate testing, better communication between a team of physicians working on one record for one patient…you get the picture.

Who loses?

Hackers with malicious intent, because it’s magnitudes harder to crack a server one by one just to get one patient record.

Rent-seeking middlemen, because their technology proposals to go between the patient and provider will no longer be relevant.

Big Brother, because patients now have control over who uses or sees their health record and not stored in some centralized database system without patient knowledge or control.

In a nutshell

So the current state of EHR’s clearly put physicians and patients on the sidelines – sowing seeds of discontent.  The fix involves the use of open source code, community support, with a novel distributed network model using one patient, one record, self-sovereign identity, and single-sign-on technologies.  The fix puts physicians and patients firmly back in the driver’s seat, kicking hackers, middlemen, and Big Brother to the curb and without needing to hope that government will open their eyes today and see the wisdom of aligning the interests of patients and physicians who care for them.

By ALYX STERNLICHT

$200,000 in Awards to Health Tech Companies and Pilot Partners for the 4th Class of Digital Health Marketplace

Six winners were awarded of a total of $200,000 in grant funding through Digital Health Marketplace.

Digital Health Marketplace, a New York City Economic Development Corporation (NYCEDC) program, powered by Health 2.0, connects health technology buyers with market-ready sellers through biannual matchmaking and by providing grants to offset the cost of piloting their technologies in healthcare institutions. The program has provided over $2,500,000 in grant funding over the course of 3 classes. This year, the fourth class of Digital Health Marketplace winning pilots are anticipated to impact over 6,000 patients in New York City throughout the next year. The technologies span from care coordination platforms to patient engagement systems to devices.

The Digital Health Marketplace is part of Mayor de Blasio’s New York Works plan, which is made up of twenty-five initiatives to spur 100,000 jobs with good wages over the coming decade.

Digital Health Marketplace builds on a previous NYCEDC program launched in 2013 called Pilot Health Tech NYC. Over the life of the two programs, they have facilitated seven hundred matches between buyers and sellers and granted over $2.5 million in awards to health tech startups and their pilot partners. Building on this success, the City will invest $750,000 to support three years of expanded operations for the Marketplace. With these resources, the Marketplace can expand the number of matchmaking events to up to four per year, which will increase companies’ access to customers.

Below is a snapshot of the 2017 winners:

Canopy Innovations/Maimonides Medical Center
Canopy Connect is a mobile and web-based interpreter delivery and analytics platform. It improves the coordination, tracking, and funding of interpreter services at healthcare organizations, to elevate the quality of care for the Limited-English Proficient (LEP) patients. In the pilot, the Canopy Connect platform will be rolled out to Maimonides Medical Center providers in departments with a need for “on-the-fly” translation services.

CareGeneral/Northwell Health
CareGeneral offers a care coordination platform and web/mobile app that provides personalized care plans for patient adherence and education in up to five languages. In this pilot, CareGeneral and Northwell-Lenox Hill will target the Hispanic population (with a focus on diabetes management) to track patient engagement, patient adherence, utilization of hospital services and improved clinical outcomes/self-care behavior.

Klara/Betances
Klara is a cloud-based secure messaging tool for healthcare professionals used to assist with workflow, care coordination, and patient-centered care. The pilot with Betances focuses on patient communication via text messaging to triage care and increase patient satisfaction. The goal is to reduce the time per patient request and avoid unnecessary call-backs and voicemails.

PurpleSun/Northwell Health
PurpleSun offers a patented device that illuminates targeted spaces with UV light to disinfect hospital/healthcare equipment in ninety seconds. In piloting with Northwell, they aim to evaluate the implementation of the PurpleSun System between surgery cases, evaluate the quality of disinfection and assess the process/impact on operational turnover time between surgery cases.

Vital Score/AdvantageCare Physicians (ACPNY)
Vital Score supports innovative health systems and health plans in a patient-driven approach to Population Health and Quality. In three-minute digital conversations during wait time in provider visits, their point of care platform increases up to twenty times the rates of participation in services such as pediatric vaccines, diabetes prevention, smoking cessation and palliative care. The pilot with AdvantageCare Physicians (ACPNY) will build out a new model of patient-driven HEDIS to improve patient care and increase rates of immunization and medication adherence.

Wellth/Mount Sinai Health System
Wellth is a mobile based platform that helps patients change their behaviors to achieve better adherence, engagement, and overall health. In the pilot, the Wellth solution will be implemented with Acute Myocardial Infarction (AMI) and heart failure patients to increase medication adherence, decrease readmissions and reduce costs per patient at Mount Sinai.

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

ANISH KOKA, MD

Who knew healthcare could be so complex? The GOP proposal for health care reform rests on health savings accounts and high deductible health plans.   The basic premise is that price opacity, and deep pocketed third party payers drive up the cost of health care.   Giving patients dollars in health savings accounts they control should make them price sensitive, and thus help reduce the cost of healthcare.  A recent analysis by Drs. Chandra and others provides an interesting perspective on the matter.

The researchers took a large self insured firm that required all of its employees to switch from an insurance plan that provided free healthcare to a nonlinear, high deductible plan.  The switch worked.  Health care spending was significantly reduced, but the concern was the mechanism by which spending was reduced.  One would like to believe spending reductions related to price shopping, so patients were getting the same services just for cheaper.  Unfortunately, it appeared that consumers reduced all spending regardless of whether it was worthwhile or not.  Deciding what is worthwhile in healthcare is a complicated business that I will leave for another day but I agree with the general contention of the paper – giving a patient control over health care dollars does not make for a smart price shopper.

I learned this the hard way when I chose a high deductible health care plan.  I needed an outpatient CT scan as well as some basic labs.  The local hospital was incredibly accommodating with its service as well as its bill 2 weeks later.  Almost $2,000!  No one told me the cost of any of this upfront, and I stupidly didn’t think to ask.  I have learned much since – basic labs can be availed of for $30 in the right place, and imaging in hospital owned facilities is significantly more expensive.  So when a patient (I’ll call him John) recently came to me with some concerning symptoms, and I ordered a CAT scan of the abdomen and pelvis, I was expecting the inevitable question:  “Do I really need this doc?  I have one of those high deductible health plans..”

To give you context – John is a 6 figure earning white collar individual who has an insurance plan on the individual market through the ACA.   I explained my rationale, he found it reasonable, and I reassured him that I would attempt to find the cheapest place in the city to get a CT scan and get back to him.  Thus began my little odyssey.   Philadelphia is a town of hospitals – there are four academic medical centers in the city within a 10 mild radius of each other.  So I first called up one of the academic medical center’s imaging center.

Me. I have a patient with a high deductible health care plan and was hoping you could tell me how much it would cost him to have a CAT scan of the abdomen and pelvis with and without contrast?

A.  The cash price is $1100.  That’s a 60% discount!

Me.  A discount from what? Medicare?

A.  Hesitating.  Yes, Medicare..

Me. Are there outpatient facilities you own that the rate is cheaper?

A.  Yes I think so.  It has to do with proximity from the main campus.  Location A and B have lower rates

Me.  Is the price you quoted me the lowest rate?  Could you tell me how much you charge for a CT Abd/Pelveis?

A. Yes.  And no we can’t divulge that.

I next called two radiologists I know to ask if they knew any non-hospital owned imaging centers.  There was one remaining center with a location just outside the city proper.  A friendly receptionist picked up on the first ring.

Me. Hello, I have a patient with a high deductible plan… who needs  a CAT scan of the abdomen and pelvis..

A.  Our cash price is $440, but remember, this won’t apply to his deductible.

Me. Wonderful.  He does have insurance, so do you have any idea what he would pay if he went through his insurance

A.  I have no idea – we have different contracted rates for different insurances.

Me. Could you tell me what your fee schedule is? How much do you charge for a CT, just so I have an idea what he can expect to pay.  I plan to send more patients to you, but would like to give them a sense of what they would pay going through insurance

A.  I can’t tell you what our fee schedule is – but I can tell you that your patient won’t pay more than $2,000.

It should be clear to anyone paying attention that opacity forms the bedrock of American healthcare today.  My attempts at transparency were only partially successful.  What remained opaque was the imaging providers fee schedule, or their contracted rate with the insurance company.   But I did find out enough.

The Medicare reimbursement can be looked up.  Contrary to what I heard from the first imaging center – $1100 was not 60% of the Medicare rate.  Medicare reimburses approximately $400 for this particular CAT scan.  Commercial/private insurance reimburses approximately $1100.  Medicaid reimburses ~$200.  The cash up front rate at the academic medical center I called was $1100, and at a private non-hospital owned imaging center was $400.

 

	Medicare	Medicaid	Commercial Insurance	Uninsured (Nonprofit hospital)	Uninsured (For-profit private imaging center)
CT Abd/Pelvis With and without contrast	$401	$214	$1,100	$440	$1,100

He elected to pay cash. He didn’t think he had other medical expenses that would put him over his deductible, and the contracted rate was probably 3 times what it was to pay cash.  So just to repeat this to drive home the apparent idiocy here – the ‘negotiated’ cash rate for John is two to three times less than if he were to use his insurance plan.
So I called John with the news. I explained that the cheapest option was a private diagnostic imaging center just a mile outside of the city. I explained that if he used his high deductible health care plan insurance, I was not exactly sure what he would pay. He could call his insurance company to find out the contracted rate.  My best guess was that the fee schedule for at least the private imaging facility was ~$2000, and that the contracted rate would be around half of that.  Choosing to pay cash upfront would be cheapest, but that would not apply to his deductible.  

I understand the rationale for the seemingly inflated rates at non-profit academic medical centers.  On any given day they take care of complex patients with no insurance in their ERs or in the hospital, have to staff 24/7 teams of cardiologists to open occluded coronary arteries at 2 am, and have to staff hospitals to fulfill a dizzying number of meaningless regulations.  Whether all of this should translate into a multiple of 3 for a CAT scan is also a topic for another day, but there are certain points that shouldn’t be in doubt when we think about about what to do with the 45 million patients who did not have insurance prior to the ACA.

Clearly, patients need a marketplace that allows them to price shop intelligently.  It is hard to see how patients can do this without the help of a professional adviser.  For the purposes of this post we can call this professional adviser a doctor, though I am certain some whipper snapper doing a pHd in something I can’t begin to understand will  come up with a title that includes the phrase ‘care manager’.  Of course, having a doctor on your side doesn’t much matter if prices are opaque.  In the current system, having insurance automatically shrouds the cost of health care widgets in an impenetrable fog. Clearly more transparency would be helpful, but even price transparency and a doctor on your side isn’t enough!

Strangely, the problem is having insurance.  Yes, you read that right.  In this case, having insurance means being subject to some unknown negotiated rate that will then come out of your HSA.  Perhaps transparency would force prices to be lower, though this is far from certain.

If this is about John and his ~45 million brethren that could potentially be on an individual market, it is more than a little unclear to this particular economic illiterate how insurance is helping here for the health care version of an oil change.  You can perhaps understand why ‘MD twitter’ – as derogatorily referred to by health policy wonks – would be happy with any health care plan that gave patients the freedom to spend dollars from an HSA to pay cash for a CAT scan.  You’ll also understand why the dim physicians trying to do the best thing for their patients may not quite understand the current handwringing about subsidies based on actuarial values.

The actuarial value refers to the total average costs for covered benefits a plan will cover.  The ACA specified that beginning in 2014, insurance sold to individuals must be at one of four actuarial values: 60% (a bronze plan), 70% (a silver plan), 80% (a gold plan), 90% (a platinum plan).  The ACA failed at cost containment because it gave patients and their physicians no good mechanism to exert any downward pressure on costs.  If you got an ACA plan – and showed up at whatever random place (with hospital consolidation, you are much more likely to end up at a hospital owned facility) your doctor told you to get your CAT scan, you were likely to pay through the nose.  If you had a subsidy you paid less, but the difference was picked up by the taxpayer.  Hospitals, especially, loved this!  It should come as no surprise, then, that actuarial values rose, and the costs in the form of higher premiums were passed on to the ever narrower band of unsubsidized patients who were buying plans on the individual market.

The effect of the new health care bill with its additional amendments is a mystery to me, and apparently the only folks with certainty about what is to come are economists and wonks.  I am neither.  Broadly speaking I have been supportive of patients having more flexibility and control of  their health dollars.  I say this not out of ideological zeal – I just want folks like John to be able to pay for his damn CAT scan out of the HSA account he funds!  It is unfortunate that any move towards lowering subsidies, or increasing flexibility is met by a religious fervor from the left that would make Pentecostal Christians proud.  It may be well intentioned, but it isn’t helping.  Health care is complex and we need to to do a lot more than find a solution for John.  Clearly the think-tanks have their work cut out for them – but would it really be a bad thing if policy econowonks started thinking like practicing doctors who see patients?

Anish Koka is a cardiologist, and wanna-be econowonk.  He can be followed on twitter @anish_koka

PS.  I also have to point out that after talking to two radiologists in the city, they could only think of one private, non hospital owned imaging center in the Philadelphia vicinity.  It makes sense – why stay private, when you could make make much more money by selling to a hospital, and get paid a salary for doing less that was better than what you could do on your own?

 

STEVEN FINDLAY

At long last, the Senate is poised to begin voting today on a measure to repeal and/or alter portions of the Affordable Care Act.

Much remains in flux regarding process and the substance of what will be voted on.   According to multiple media sources today, Senate leaders latest strategy is to hold a vote on a narrower piece of legislation than those circulated in recent weeks.

The substance of such a measure—if indeed, it exists and is submitted for a vote—is unclear as of this posting.  But it reportedly could contain just a repeal of the ACA’s individual and employer mandates and a few of the law’s taxes, such as the one on medical device companies.

This narrow, or “skinny,” bill would not have any provisions pertaining to Medicaid.

The idea, apparently, is to pass this initial piece of the puzzle—to get things going—and then to take up the larger and more controversial issues that have so deeply divided the Republican caucus.

According to the Huffington Post, House and Senate leaders would then try to negotiate a version of the more comprehensive legislation in both chambers that Republicans could rally around.

That would seem still to be a tall order, especially if they are still trying to get it all done before the August recess, which begins August 11.  Of course, that’s subject to change as well.

And there’s not yet any certainty that initial votes would allow this “skinny” bill process to proceed.  Some Republican lawmakers might balk out of concern that no replacement for the mandates and larger bill, for example, would ever be forthcoming.  That would then compel a vote to repeal the initial repeal bill since that bill would likely lead to a rush to the exits by insurers now serving the exchange markets.

CBO has estimated that repealing the individual mandate while leaving the rest of the ACA’s regulations in place would result in 14 to 15 million more uninsured and premium hikes of 20 percent within a few years.

There’s broad consensus that John McCain’s return to the Senate today adds significant impetus to Republican efforts—in terms of sentiment and possibly some outright political opportunism leveraging his dire diagnosis to spur action.

As Axios’ David Nather opined this morning: “How insane could all this get? Completely, wildly, utterly, spectacularly insane.”

Further spinning our heads in the last few days, Democratic leadership has begun to talk openly about submitting and pushing a “Medicare for All” bill this year and in 2018 if the Senate effort fails.

THCB’s editor asked me to write this quick synopsis of where things apparently stand today (July 25), and to get the ball rolling on comments and updates over the coming days.   All thoughts welcome as this historic process begins.

 

By ANDY ORAM

Health care providers love to vaunt the unique and subtle needs of patients. How many ads have you heard from cancer centers or health clinics touting their flexibility and showing grateful, tear-flecked patients?

But key aspects of our health care systems turn out to be rigid and heartless in practice. Despite the compassion of individual staff, our organizations tell patients in dozens of ways that they are widgets on an assembly line:

• We force patients to come early for every appointment and fill out the same paperwork each time with information they have given before.
• Patients traverse long, crowded corridors from one station to another, asking at each station for information they don’t get and never knowing how long each stop will take or how many more stations remain on their Kafkaesque journey.
• Patients rush to undergo batteries of mysterious tests, sometimes repeatedly, only to wait long periods to hear the results.
• We refer them to specialists who, it turns out, can’t see them, or who issue contradictory opinions without coordination.
• After frustrating and unsuccessful attempts to learn the costs of procedures in advance, they receive cascades of arcane bills and watch their funds bleed out to charges that bear little relation to their experience in the clinic or hospital.

More fundamentally, our field has stuck to a cycle of diagnosis and treatment that leads to people suffering through death in a welter of tubes and IVs, while 28% of all Medicare costs are incurred in the last six months of life. Pharmacologist Jay Gupta claims that nearly 50% of all seniors in the US take a medication that is not clinically necessary. This is expensive, debases their health, and leads to greater risks of adverse reactions.

These are the sorts of conditions that the unique conference on health IT and design, HxRefactored, confronts each year. The focus is on getting organizations to change their operations, with health IT in a supporting role. Over time, the conference has de-emphasized technology–although sessions on such topics as blockchains, wearables, and interoperability are still popular–and has boosted its approach to health care systems and larger communities. HxRefactored is held jointly by Health 2.0, now operating under the umbrella of HIMSS, and the design firm Mad*Pow.

The overarching question: whither technology?

Attending the sessions of this conference, I pondered the effects on patient/doctor relationships of automation and artificial intelligence, expected to be a 6.6 billion dollar market in health care by 2021 (page 2 of PDF). Will they devolve control to patients and help them practice self-care, or will they reinforce the tendency by health care institutions to manipulate patients as widgets? There is a real risk that the large, well-funded institutions investing in automation will fit it into their familiar philosophies of control. The technologies may simply reduce the costs of doing things the current way, without involving the patient further or pushing health care past current horizons.

Feeding my concern over the purpose of technology was the presence of several companies who have found a viable business model by occupying niches in a bad system: for instance, optimizing one aspect of finding a doctor in the maze of providers, or optimizing one aspect of a broken and wasteful billing system. I appreciate the critical importance of finding a place for yourself in the system, but the cleverness of these entrepreneurs worries me in two ways: first, that they profit from health care anarchy instead of fixing it, and second, that their business models may evaporate if saner health care systems come into play.

I hope that Mad*Pow’s recently launched Center for Health Experience Design follows through on conference goals and consistently champions the rights, responsibilities, and needs of patients, doctors, and communities. The opening keynote by Mad*Pow founder Amy Cueva touched on all the right themes, with such statements as “collaboration is the new innovation” and “worldwide, people are struggling to be heard in health care systems.” I will raise questions of control by patients, doctors, and communities throughout this article.

Conference themes

The expanding scope for design was laid out by Cueva. Classic design used to restrict itself to a single object (such as a Wiener Werkstätte teapot or the classic Eames chair), but the newer human-centered design invites in the users of a system to inform the design.

(Of course, many designers historically have raised their eyes beyond the object–just visit a home architected by control freak Frank Lloyd Wright–but for a long time they were outliers. As an unfortunate representative of the norm, consider the notorious Tilted Arc by Richard Serra, a striking artistic statement designed in 1981 with a total disregard for its effects on people and the environment in which it was set.)

Going further, purpose-centered design considers the object’s environment and how people interact with it, potentially rerouting an organization to meet its goals. If classic design focused on making a single web page beautiful and easy to read, human-centered and purpose-centered design would define the service offered by the site and how visitors can navigate through its pages to achieve their goals. Health care design can employ psychologists, teachers, technologists, and others.

Empowering patients

Although hospitals (and the Centers for Medicare & Medicaid Services) conduct patient surveys, I can’t find data on whether they use these surveys to good benefit. If hospitals do listen, can surveys improve anything more significant than the selection of TV channels?

A more intense, and perhaps more productive, effort is the Human Theater Project started by two medical residents, Omar Ishaq and Saad Mir, who described it in an HxRefactored keynote. These doctors lead patients to describe their stresses and experiences, capturing results on video. They claim that patients who participated have better outcomes and survival rates, while the professionals who viewed the videos showed increased empathy.

Payaal Patel, in the panel on the “Patient experience of the future,” said that researchers need to talk to patients to find out what really concerns them. For instance, a person who has trouble using her hands will be worried about how she can brush her teeth–a question that probably wouldn’t come up in a normal clinical setting. Too often, Patel said, we collect data only on deficits and disabilities, leading patients to feel depressed about their conditions and to overlook the strengths they possess that can improve their lives.

Researchers in health care, including pharmaceutical companies, are learning the benefits of listening to patients. If they design trials around topics that patients care about, more will sign up for the trials and persist to the end.

Ultimately, to fix the health care system, it must engage patients on a daily basis in caring for themselves better than they are doing now, and technology will play a key role. Particularly intriguing, to me, are opportunities for new data sources to break the stranglehold that health care institutions have maintained on patient data. These new data sources may well democratize the health care system simply because they run ahead of EHR vendors’ abilities to trap the data, and of hospitals abilities to monetize it. If a Fitbit can produce key insights into your health, maybe you can build a personal health care system around them. HIE of One is an example of an open source personal health record that allows the patient to share data flexibly with many caretakers.

New data sources came up during the session “Breaking down the silos,” ostensibly a technical session about interoperable software, but with intriguing forays into how to help health care systems evolve. Sumit Nagpal, co-founder and CEO of LumiraDx, started his argument with the observation that we need to reduce health care costs by moving treatment into lower-cost settings, notably the home. We need large care teams including the patient, the family, and various professionals, all sharing a care plan. And we need to focus on prevention and wellness. Nagpal was not afraid to say, “individuals have to be accountable.” But a holistic treatment plan based on prevention requires a lot of data that current EHRs don’t hold.

Holistic treatment also brings diagnosis and treatment closer to the patient. Modern equipment allows much testing to be done in the home, a drug store, or even an ambulance, rather than the lab or doctor’s office. Environmental sensors and social media monitoring can contribute to a 360-degree view of the patient. Predictive analytics can remind the patient to take her medications, keep her appointments, and so forth.

Another element of Nagpal’s proposal is a broadened consent policy, so that patients can share data with numerous caregivers without extra paperwork. He did not explore how this system might interact with segmented records, which would let patients restrict the kinds of information their providers can see.

Keynoter Robin Farmanfarmaian said that 70% of routine doctor visits could be done remotely. (The hedge-word “routine” here is ambiguous and probably significant.) She mentioned, as an example of bringing health care into the home, that patients with neurological problems could take tests as often as once a week, and that the tests could be gamified to make them appealing.

Research on telehealth is encouraging, but sometimes ambiguous. Although patients seem to like virtual visits, other data suggests that they might not reduce health care costs because virtual visits sometimes encourage patients to overuse their doctors.

Even insurers–favored targets for public invective–are evolving toward holistic, prevention-based care. These efforts were laid out in the session “Navigating the health system.” As Robin Gasco, from Blue Cross/Blue Shield of Massachusetts said, “We won’t fix health care with an app or a portal–we must straighten out the system.” This Blue Cross/Blue Shield pioneered bundled payments when most payers were just talking the talk.

Insurers in general are becoming alert to the financial distress caused by rising premiums and deductibles. Understanding the financial as well as clinical effects of treatment may actually be good for patients. However, innovation here may require patients to trust insurers with more personal data than they have in the past. Insurers are also large, slow-moving institutions that can take years to move an idea from a concept into the mainstream.

Empowering doctors

We now know that more and more doctors hate their work. Alarming numbers are quitting the profession–you can tell that by reading the KevinMD blog for a couple weeks–or at least opting out of the government’s safety net programs. Can technology lift the burdens of regulation and insurance from doctors instead of worsening them? Can the clinical experience be redesigned to favor doctors?

Danny van Leeuwen of Health Hats, whom I met through the Society for Participatory Medicine, told me of a company called Herald Health that gives doctors control over system alerts. The innovation that makes this different from standard EHRs is the control given to the individual physician. When the vendor, the clinic, or the hospital determine what alerts are delivered, they tend not to be appropriate for the doctor’s workflow. Whether or not the imposed alerts are important, they tend to get ignored. Better to let doctors define alerts themselves and share the ones they like with other doctors, who can then choose whether to adopt them.

Empowering communities

Ever since running water was introduced into cities–and perhaps even earlier–the biggest gains in public health have come through, well, public health. Simple interventions could make a huge difference, such as housing the homeless or providing deliveries of fruits and vegetables to neighborhoods known to be food deserts.

Some modern efforts in public health were highlighted by Olga Elizarova and Samantha Dempsey in a keynote and panel. They pointed out that you can miss racial and economic disparities if you look at the city or state level. Data must be more fine-grained, highlighting differences between neighborhoods.

Education provides a crucial example of community-based intervention. There have always been expensive private schools that offer intensive one-on-one coaching and individualized learning plans. But some organizations, such as the Harlem Children’s Zone and the Northside Achievement Zone of Minneapolis (described by director Andre Dukes) apply these principles to at-risk children in deeply underprivileged areas. Such organizations bring in professionals to counsel parents and children alike. They partner with organizations that can provide evidence of successful interventions. The motto of the Northside Achievement Zone is “Every child can and will attend college.”

Like Gasco, whom I quoted earlier, Elizarova and Dempsey said their solutions don’t use apps. Our health problems are complex and embedded in communities, so the solutions must take communities into account. Furthermore, changes in housing, education, etc. take a long time and don’t offer fast, Silicon-Valley style returns on investment. Finally, designers who want to help communities need to recognize their own biases, coming as they usually do from privileged backgrounds relative to whom they’re collaborating with.

Like home-based treatment plans, public health plans require a lot of data. Traditional healthcare data is not enough.
HxRefactored squeezed a lot into two days. Some major catches, such as Aneesh Chopra and Bakul Patel (Associate Director of Digital Health for the FDA), offered keynotes. Attendees can take many lessons away from the conference–this article has focused on those that touch on empowerment throughout the system.