Screen Shot 2016-01-08 at 11.31.53 AMThomas Hobbes described life as pitifully “nasty, brutish, and short.” Thanks to the free market and the state, life is no longer a Hobbesian nightmare. But death has become nasty, brutish, and long.

Surgeon and writer, Atul Gawande, explores the medicalization of ageing and death in Being Mortal. Gawande points to a glaring deficiency in medical education. Taught to save lives and fight death, doctors don’t bow out gracefully and say enough is enough. We’re not taught about dying. We’re taught about not dying.

In our lexicon, life is a constant war against the Grim Reaper. We say inactivity kills; screening saves lives; an intervention reduces mortality by 5 %—an arithmetic impossibility as mortality for our species, barring select prophets, remains 100%. Words have precise meanings. Words also hide precise desires. It’s not that we can’t distinguish between a murderer and colorectal cancer; but by giving cancer moral agency—we wage war on cancer—we imply that death is an anomaly that must be fought.

And we fight. We fight death in the hospices. We fight death in the hospitals. In many parts of the world, more people die in hospitals than in their homes. Some die, attached to a noradrenaline infusion, in the CAT scan—the last pit stop of hope between the intensive care unit (ICU) and the morgue.



“See? Obamacare is failing!” according to industry expert C. Little, citing Wolf Report 712A just filed by Boy W. Cried.

What is the hue and cry about this time? United Healthcare is saying it has lost large bales and wads of money on Obamacare exchange plans, and just may give up on them entirely. Anthem and Aetna allow that they are not making very much either. Some new not-for-profit market entrants have gone belly up, and the others are having a hard time.

Before we perform the Last Rites over Obamacare, perhsp we should think for a moment about the hit ratio of the first 711 Wolf Reports from Boy W. Cried and ask a few questions.

First: Do we trust implicitly the numbers that the health plans are giving out in press releases, citing unacceptably high medical loss ratios? Medical loss ratios (MLRs) are self-reported. Yes, there is a certain amount of accountability. The numbers have to square with expenses given on their corporate tax forms and so on, but there is wiggle room in just what is reported and how. If is a reasonable supposition that if you wanted to look for the professionals with the greatest skill in juggling numbers, you would find them working for insurance companies, especially health plans, because the stakes are so high. These numbers people at the top of their game have huge incentives to report a high MLR, so if there is wiggle room, I am sure they will find it.

Beyond that, MLR is reported by state, by market segment (large group, small group, individual), against what portion of a premium is “earned” within that reporting period, and by calendar year rather than any company’s financial year. To say, “Our MLR is X” is to claim that X the correct aggregate number across their entire multi-state system, from all their subsidiaries, appropriately weighted for the size of each region. We don’t have access to those numbers, just to what they are telling us. There are plenty of reasons for them to want to report the highest MLR they can get away with, plenty of reasons to be skeptical of the numbers they are giving out, and plenty of reasons not to base drastic policy changes on such pronouncements.


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When John Milton (Al Pacino) chuckled in the Devil’s Advocate “vanity, definitely my favorite sin,” he may have been referring to academics, not attorneys.

In academia skins are thin, hairs are split, emails are long, humor is self-congratulatory, and everyone cites themselves thinking that they’re Shakespeare. In the land of geniuses pettiness lies next to godliness. Wallace Sayre, a political scientist, once said that academic politics is vicious because the stakes are so low.

The iconoclast, Nassim Taleb, reserves special derision for academics. He took Steven Pinker to task for claiming that violence has progressively declined because of a decline in religion. According to Taleb, Pinker was ignoring fat tails – or the long lull before the storm. Pinker responded by saying that Taleb was being fooled by belligerence.


flying cadeuciiFor the past few months I have been traveling around the globe. In my travels I have been talking to “leaders” from Ministries’ of Health, Insurance Companies, Hospitals, Physicians, and Professional Societies.

In many of the conversations I continue to hear more of the same story:

In order for change to happen, the incentives need to be in place.

Things such as, “…in order for physicians to adopt, the incentives need to support the actions.”

“…until incentives align it is difficult for hospitals to adopt changes in care models.”

“…in order for me to spend more time with patients the payment models need to align accordingly.”

Repeatedly I hear that in order for people to make changes inside of healthcare,that the money trail needs to lead the charge.

Yes, that worked so well with the adoption of EHR/EMR.

Leaders followed the dollars only to adopt and implement data archives that do not talk, interact, or share knowledge across the care continuum for patients.

Since when do “leaders” follow?


Screen Shot 2015-09-28 at 9.42.44 AMOctober first is nearly upon us.  For many of us, this date has little significance beyond the promise of cooler weather, lovely autumn colors, and the invasion of neighborhoods with giant inflatable Halloween decorations.  While these decorations are fascinating to me, they do cause me to ponder the enormous gulf  between my taste and that of my neighbors.  I am not certain if this is meant to scare off potential alien invaders or simply to make them think we are not worth bothering with.

October 1, however, is a huge day to the medical community.  It is a day that will live in infamy.  It is the object of dread, of diaphoresis, of doom.  October 1 is ICD-10 day.  This view was further bolstered when I went to the CMS (Government Medicare) website, there was actually a doomsday countdown timer at the top of the page. Just looking at this makes me anxious.

For those still unaware, ICD-10 is the 10th iteration of the coding taxonomy used for diagnosis in our lovely health care system.  This system replaces ICD-9, which one would expect from a numerological standpoint (although the folks at Microsoft jumped from Windows 8 to Windows 10, so anything is possible).  This change should be cause for great celebration, as  ICD-9 was miserably inconsistent and idiosyncratic, having no codes describing weakness of the arms, while having several for being in a horse-drawn vehicle that was struck by a streetcar.  Really.


Screen Shot 2015-09-24 at 9.23.55 AMToxoplasma gondii is a parasite that causes opportunistic infection in helpless people. It may have met its match. The cost of treating Toxoplasmosis, a rare but extant infection, just shot up exponentially. Drug-resistant strain, you ask? Have physicians in Infectious Disease gone mercenary, you wonder? No. A change in ownership.

Daraprim (pyrimethamine) is a nifty drug which kills parasites. It’s been around for eons. I still recall its name from my medical school pharmacology exam. The price of Daraprim, whose production barely costs a dollar, may rise from $13.50 a pill to $750 a pill, after the rights to distribute the drug were acquired by Turing Pharmaceuticals.

Why? The answer is best told by Michael Shkreli, the CEO of Turing, and former hedge fund manager. The reason why Shkreli has acquired a generic drug lying in a forgotten backwater, and raised the price of a magnitude more suited to the hyperinflation of the Weimar Republic, is to make profits. Lots of profit. If this answer seems inane, ask yourself why a former hedge fund manager would be interested in a rare disease of devastating consequences. Penitence is the wrong answer.


flying cadeuciiHave a prediction for 2016?

Send them in. There’s still time.

Want to know what the crystal ball holds in store? Register for athenahealth’s “The Future of Healthcare: Predictions for 2016.”

Saurabh Jha writes:

My predictions for 2016:

1. ICD-10 will not have caused a third world war centered in the middle east. However, it might have persuaded some physicians to consider a third career, may be as coders. Meanwhile, ISIS changes their torture tactics from decapitation to ICD-11.

2. We will still be discussing what is quality and what is value. Meanwhile, Propublica’s surgeon scorecard will have the same fate as Leo Tolstoy’s War and Peace – one is too ashamed to admit one didn’t read it.

3. Interoperability will finally be achieved by redefining interoperability. “Interoperability is when disparate electronic health records in disparate healthcare systems do not wage physical war against each other.”

John Irvine of THCB writes:

“In 2016 Donald Trump will propose a wild health reform plan combining free-market principles, the ritualistic destruction of most of Obamacare (except for the parts that quote “work okay”) with elements of the Swedish, French and Japanese systems and the deployment of “lots of attractive doctors.”

Pundits will spend most of year debating the insanity and surprising merits of the plan.”

Matthew Holt of THCB writes:

“In 2016 Health 2.0 technologies will add diagnostic tools to now mainstream virtual visits

ballsy prediction — Several big hospitals default on bonds as inpatient volume craters and they still have to pay for their EMR implementations

amusing prediction  — Epic tries to buy athenahealth, eClinicalWorks & Practice Fusion but is stopped by the DOJ”

B.S. writes:

1. ICD-10 will cause an explosion in fraudulent and abusive medical bills during a messy implementation

2. Health Catalyst will file for an IPO and IBM will preemptively buy them

3. Revenue Cycle Management companies, in the face of reimbursement changes, will attempt to morph into analytics companies.

4. One or both of the mega health plan mergers will not be approved due to market concentration concern.

5. Centene/Health Net merger will get done and Centene’s stock will hit a post split $100 by year end 2016.

6. United Healthcare will lose to Humana and Health Net for the new TriCare contract as three regions are reduced to two- UHC will lose its appeal”

Andy Oram of O’Reilly writes: 

“The 1980s have returned, and the HMO battles with them. In the 1908s, capitation was used by insurers to deny necessary care. Now, instead, patients are forced to accept high deductibles and are told to control costs — while the institutions in health care withhold the necessary information. See http://bit.ly/1Mxb5zj

Unable to wait for standards to evolve in structured patient data, health care providers and payers will turn on a massive scale to natural language processing to extract structured data from free-text patient notes.

We’ll admit that genetic research, the great hope held forth by the Precision Medicine initiative and other futurists, will not solve most health problems. The interactions among genetic markers and between the markers and the environment are too complex to predict or alter.

Institutions will hold back on sharing patient data for research purposes because anonymization removes too much useful detail and interoperability remains almost insurmountable. Instead of the promised future of big data crunching on enormous data sets, we’ll see more focused research based on medium-sized, local data sets.”

Rob Lamberts writes:

“1.  ICD-10 will create increased physician distress and ennui – This not only increases the overall workload of medical offices, but it does so while putting their cash-flow at risk.  At a time where physician dissatisfaction and frustration is high, adding more work and potentially less income is a disaster waiting to happen.  EMR products, of course will pose as the guy in the white hat ready to rescue doctors, but this will only serve to associate these record system with one more distasteful thing.

2.  With this increase in angst, doctors and patients will increasingly seek alternatives.  Patients will continue demanding access to their records and an increase in their role in their own care.  Doctors will move in increasing numbers toward alternative models of care, be they retail, concierge, or direct care.  The number of inquiries I’ve had over the past few months from physicians wanting to change over has increased sharply, and their level of interest is much higher.”

Dick Quinn of QuinnsCommentary writes:

“We will continue on the road to destruction of employer-based health benefits no matter who controls Washington, and on the road to a single-payer system. Obamacare won’t work to manage costs, the Republican alternatives to date are just silly.  Individual state solutions make no sense. So what’s left?”

Ron Hammerle of Health Resources Ltd.

“Implementation of elective, medical aid in dying in Canada (and maybe California) will begin to have an impact on end of life care, “informed consent,” medical costs, patient-empowerment and the reduction of unwanted medical care in the U.S.”

IndustryYoda writes

“Uncertainty about the outcome of the 2016 election will lead to increasing fear and gridlock as large healthcare organizations elect to play a wait and see game. GOP attacks on the Affordable Care Act will spook many. Doc morale will continue to spiral as a consequence. If the Republicans win the White House, the shit is going to seriously hit the fan …

ICD-10 will (flip a coin) either be delayed yet again in a last minute reversal by red-faced administration officials or be pushed through incompetently, causing stress and economic chaos among providers. Those who prepared will survive. Those who did not will feel extreme pain. The real winner? The consultants.

At least one ineptly-run electronic health record vendor will flame out spectacularly (note: this is not the company mentioned above), with dire consequences for customers. Citing obscure contractual language, the vendor will attempt to monetize customer data in various sleazy ways. Outrage and vows of official action will follow in Washington but no substantive action will be taken.”

Salesforce.com will Eat the World writes:

“You want predictions? Okay. Fine. Here’s my totally-insane world-changing-prediction-that-could-change everything. Salesforce will win over at least one huge healthcare name, causing a major freakout among vendors. Several will see the writing on the wall and announce plans to launch compatible services. Will it actually happen? Who knows. Not a fan of Salesforce, but I almost hope it does. ”

The University of South Carolina’s Joan Creed writes: 

“We now have retail health care.  I’ve thought for years we’ll one day have drive-thru health care: stop at the first window with your symptoms, then stop at the second window to pick up prescriptions, whether for medications, tests, whatever.”

Terry Bennett of Clinic on the Commmons writes:

“I am strongly tempted to say ” More of SOS”

There do not appear to be any trending stories about the return to the classic model, wherein an individual physician is responsible for an individual patients’ care.

Ditto any nationwide look at the impact of nonprofit hospitals becoming for profit gigantic Taj Majals, dominating both the jobs market and the real estate market in their communities, and the redundant duplicating/reduplicating of the servicers and technologies offered at the just-down-the -road former community”not for profit hospital”

Add to that the “90 day contract”that most young docs are forced to sign upon landing a job at one of these centers, wherein the doctor may be fired without recourse and without any stated cause. This widespread ” hear no, see no, speak no evil policy does very little for constructive criticism/two way discourse as to the best way forward.


Art Caplan 2The New York Times editorial page is the latest in a lengthening series of commentaries worrying about the impact of two proposed corporate mergers in the health insurance market.   Anthem has agreed to acquire Cigna and Aetna is taking over Humana. That means the number of big health insurers will drop from five to three.

The Times and every other commentator who has weighed in including the AMA has warned that diminished competition is not good for taxpayers or consumers. They want the Justice Department to take a long hard look at these latest mergers to insure that consumers are not stuck with higher premium costs as many parts of the country turn into markets with only one insurance provider.

The critics are wrong. Blocking these deals is a terrible idea. The mergers should be allowed to continue. In fact they should proceed until there is only one private insurer left. Only, at that point should the government step in, declare the last company standing to be required to merge with Medicare thereby letting the free market produce what many reformers have only been able to dream of—a single payer system.


Dale SandersThe number of mergers, acquisitions, and collaborative partnerships in healthcare continues to skyrocket. That’s not going to change for the next few years unless the FTC decides to be more restrictive. In all of these activities, older generation executives (I can say that because I’m older) have underestimated the importance and difficulties—technically and culturally—of integrating data and data governance in these new organizations, and the difficulties are exponentially more complicated in partnerships and collaboratives that have no formal overarching governance body. In 2014, 100 percent of Pioneer ACOs reported that they had underestimated the challenges of data integration and how the lack of data integration has had a major and negative impact on the performance of the ACOs.

Seamless Data Governance

After 33 years of professional observations and being buried up to my neck in this topic, especially the last two years as the topic finally matures in healthcare, I’m convinced that the role model organizations in data governance practice it seamlessly. That is, it’s difficult to point a finger directly at a thing called “Data Governance” in these organizations, because it’s completely engrained, everywhere. As I’ll state below, it reminds me of the U.S. transition in the early 1980s when organizations finally realized that product quality was not something that you could put in an oversight-driven Quality Department, operating as a separate function. Quality must be culturally embedded in every teammates’ DNA. Data governance is the same, especially data quality.


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No one knows how Donald Trump’s meteoric rise to the top of the GOP primary race ends, its impact on Campaign 2016 or its domestic and foreign policy implications for the U.S. will play out. What we know is the man knows how to get a crowd, spark discussion, and steal media attention from his 16 GOP primary rivals. He has built his brand as a straight shooter on tough issues and unapologetic foil of political correctness.

Friday night, the Donald show flew into Mobile, AL, and lit up a crowd estimated at 20,000 at the University of South Alabama football stadium. He left town on Trump Air dominating the weekend’s media coverage, perplexing the pundits who were betting the Donald show would flame out.

Political theatre is prone to big stories like “the Donald”. He’s brash, cocky and unfiltered as he talks about dicey issues. He has simple solutions to immigration reform and the threat of ISIS. He promises to be a tough commander in chief in war zones and fierce negotiator in trade pacts. Healthcare is on his list as well.