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Category: Health Policy

More Laughing, More Thinking

By KIM BELLARD

There was a lot going on this week, as there always is, including the 20th anniversary of 9/11 and the beginning of the NFL season, so you may have missed a big event: the announcement of the 31st First Annual Ig Nobel Awards (no, those are not typos).  

What’s that you say — you don’t know the Ig Nobel Awards?  These annual awards, organized by the magazine Annals of Improbable Research, seek to:

…honor achievements that make people LAUGH, then THINK. The prizes are intended to celebrate the unusual, honor the imaginative — and spur people’s interest in science, medicine, and technology.  

Some scientists seek the glory of the actual Nobel prizes, some want to change the world by coming up with an XPRIZE winning idea, but I’m pretty sure that if I was a scientist I’d be shooting to win an Ig Nobel Prize.  I mean, the point of the awards is “to help people discover things that are surprising— so surprising that those things make people LAUGH, then THINK.”   What’s better than that?

Healthcare could use more Ig.

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Policies, Techies, VCS: Musings From a Futurist

By IAN MORRISON

I should’ve been in Paris last week on vacation with my wife, instead I listened in to the Policies Techies VCS:  What’s Next For Healthcare conference (I’ll explain why later).  Matthew Holt and Jessica DaMassa did a magnificent job of assembling the Who’s Who of digital health tech to wax lyrical about what the new kids on the block were up to, where it is all headed, and what it will mean for the system. (Full disclosure Matthew and Jess are friends of mine, I hired Matthew from Stanford almost 30 years ago to join the Institute For The Future (IFTF) and have watched proudly as he has become a Health 2.0 impresario.  Jess simply deserves a gold medal for wrangling Holt and all the other tech Bros with wit, charm and intelligence).

This is a tumultuous time for digital health technology because of the pandemic and the related rise of digital solutions not to mention the very frothy investment market and massive deal flow over the last 24 months.   There are a lot of exciting new faces.  But, many of the companies on display have been at this for some.   And for many of the old guard, like Livongo and now Transcarent Founder Glen Tullman, Athena Health and now Zus Founder Jonathan Bush, and Amwell CEO Roy Schoenberg and others this has been a much longer journey.

(Parenthetically, as a young management engineer in Canada, a position, I was not qualified for, I wrote the justification for an all-computerized hospital at the University of British Columbia in 1979!  I still find it just incredibly pathetic that it has taken us 40 years to suddenly “discover” digital health. I wrote The Second Curve which forecast (among other things) the rise of digitally enabled health transformation 25 years ago!  So it is hard for me to get really excited that this is either “new” or “next”.)

So, while a lot of us have been in this movie for a long time, there is something very different about the current crop of offerings.  In particular, technology has advanced considerably and there are clearly new cloud and SaaS tech enabled care solutions.  There is a new cadre of talented and committed investors and entrepreneurs who believe they have the capability and capital to scale meaningful enterprises that will disrupt incumbent healthcare players and better serve consumers and providers.  And the timing seems right as the pandemic forced consumers and the health care system to confront new ways of doing business.

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Selfish Much?

By KIM BELLARD

In a week where we’ve seen the bungled Afghan withdrawal, had Texas show us its contempt for all sorts of rights, watched wildfires ravage the west and Ida wreak havoc on a third of the country, and, of course, witnessed COVID-19 continue its resurgence, I managed to find an article that depressed me further.  Thank you, Aaron Carroll.

Dr. Carroll – pediatrician, long-time contributor to The New York Times, and now Chief Health Officer of I.U. Health — wrote a startling piece in The Atlantic: We’ve Never Protected the Vulnerable.  He looks at the resistance to public health measures like masking and wonders: why is anyone surprised? 

Some of his pithier observations:

  • “Much of the public is refusing. That’s not new, though. In America, it’s always been like this.”
  • “COVID-19 has exposed these gaps in our public solidarity, not caused them.”
  • “America has never cared enough. People just didn’t notice before.”

Wow.  What was that about Texas again? 

Some of Dr. Carroll’s examples include our normally lackadaisical approach to influenza, our failure to recognize the dangers we often pose to immunocompromised people, our paltry family and sick leave policies, and our vast unpaid care economy.  He could have just as well pointed to our (purposefully) broken unemployment system or the stubborn resistance to Medicaid expansion in 12 states (Texas again!), but you probably get the point. 

Everyone likes to complain about our healthcare system – and with good reason – but it is not an abyss we somehow stumbled into.  It’s a hole we’ve dug for ourselves, over time.  We may not like our healthcare system but it is the system we’ve created, or, perhaps, allowed. 

Health insurance was once largely community-rated, spreading the risk equally across everyone to protect the burden on the sickest, until some insurers (and some groups) figured out that premiums could be cheaper without it.  Use of preexisting conditions and medical underwriting also served to protect the less vulnerable, until ACA outlawed those practices. 

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Does Our Healthcare System Work for the Most Vulnerable Americans?

By DEBORAH AFEZOLLI, CARL-PHILIPPE ROUSSEAU, HELEN FERNANDEZ, ELIZABETH LINDENBERGER

“Why did you choose this field?” Most physicians are asked this question at some point in their early careers. We are geriatrics and palliative medicine physicians, so when that question is posed to us, it is invariably followed by another: “Isn’t your job depressing?”

No, our job is not depressing. We are trained in the care of older adults and those with serious illness, and we find this work very rewarding.  What truly depresses us is how many vulnerable patients died during the pandemic, and how the scourge of COVID-19 revealed the cracks in our health system. Never before in modern times have so many people been affected by serious illness at the same time, nor have so many suffered from the challenges of our dysfunctional health system. Our nation has now witnessed the medical system’s failure to take comprehensive care of its sickest patients.  This is something those in our own field observed long before the pandemic and have been striving to improve.

All of us practicing geriatrics and palliative care have had a loved one who has been challenged by aging, by serious illness, or indeed by the very healthcare system that is supposed to help them. As medical students and residents, we personally confronted these systemic deficiencies and wondered about alternatives for those patients with the most complex needs. We chose fellowships in geriatrics and palliative medicine because we wanted to try and make a difference in the healthcare that is offered to our most vulnerable patients.

During the New York City surge in the spring of 2020, we were front line workers at a major academic medical center. While the global pandemic took us all by surprise, our clinical training and passion for treating vulnerable populations left us feeling capable and ready to serve. Due to the urgent needs of overwhelming numbers of extremely sick patients, our Department was charged with rapidly expanding access to geriatrics and palliative care across our seven hospitals. We were embedded in Emergency Departments (EDs), hospitalist services, and critical care units.  We roamed the hospitals with electronic tablets and held the hands of dying patients, while urgently contacting families to clarify goals of care.  For those who wanted to receive care in the community, we scrambled to set up telehealth visits and coordinate the necessary support. Way too often we could not meet their needs with adequate services, forcing them to visit overwhelmed Emergency Rooms.

While we helped individual patients and eased some of the strain on our hospitals, our system was overwhelmed and mortality numbers continued to steadily rise. Within our hospitals, staff were redeployed to care for the most critically ill in the emergency departments and intensive care units.  In this frantic time, we were fortunate that our hospitals had sufficient medical resources to care for the sickest patients and for the staff.  However, the sub-acute nursing facilities (SNF) and long-term care facilities strained to protect their residents and their employees. Shortages of PPE, staff, space, testing supplies, and funding all contributed to the high mortality numbers we saw in many NYC facilities and across the nation. There were also limited resources allocated to delivering outpatient care in our patients living in the community.  The rapid shift to telehealth was not feasible for many of our older patients, and even when it was possible, the delivery of diagnostic and therapeutic care was limited and suboptimal.

Data now shows that older adults and those with underlying chronic illnesses were disproportionately affected by the COVID-19 pandemic, experiencing higher hospitalization rates as well as higher death rates. Although adults 65 and older account for only 16% of the US population, they represent 80% of COVID-19 deaths. Residents of nursing homes, the frail homebound, and older people of color were the hit the hardest. Thirty-five percent of the deaths in the US from March-May 2020 occurred among nursing home residents and employees. Nationally, over 600,000 nursing home residents were infected with COVID-19 and over 100,000 died from the disease. These data are underestimates and the death toll is likely higher. We cannot explain why older Black Americans were 1.2 times more likely to die than white Americans nor why the odds of dying from COVID were nearly two times higher for persons living in South Dakota as compared to Wyoming or Nebraska. Often, the paid caregivers for these vulnerable patients were themselves vulnerable underpaid women of color who were at higher risk of contracting COVID.

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Healing at Home: Answering the $30,000 Question

By DAWN CARTER

If you’ve been working remotely for the past year, would a $30,000 raise entice you back into the office? In a recent survey of 3,000 workers at dozens of large US companies, the vast majority of respondents said they would forego the hefty raise if they could keep working in their pajamas.

I’ve spent more than 25 years in healthcare strategy and planning, and that was one of the most remarkable surveys I’ve ever seen – though not in terms of HR, because healthcare is one of the few industries where remote work never took hold during the pandemic.

Instead, I think the urgent lesson for healthcare planners is all about how – and where – services will be delivered in the future. Call it “the Covid effect”: In the same way that employees over the past year discovered the advantages of working at home, we’ve seen a huge number of new patients who discovered the advantages of so-called Hospital at Home programs.

Hospital at Home is not exactly a new model, but it’s been relatively unknown among patients until now. That’s because limited, early experiments suffered from low participation rates – just 7 to 15 patients per month. But those numbers got a huge boost over the past year as hospitals scrambled to preserve in-patient capacity for only the most extreme Covid cases. The Association of American Medical Colleges says interest in Hospital at Home “exploded” during the pandemic, and health systems from Boston to Cleveland to Seattle launched or expanded in-home programs that served thousands and thousands of new families.

It may be hard to put this genie back in the bottle. If workers won’t go back into the office for $30,000 what could possibly entice patients back into the traditional hospital setting once they’ve experienced the benefits of healing at home?

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Health Care, Meet Gall’s Law

By KIM BELLARD

I can’t believe I’ve gone this long without knowing about Gall’s Law (thanks to @niquola for tweeting it!).  For those of you similarly unaware, John Gall was a pediatrician who, seemingly in his spare time, wrote Systemantics: How Systems Work and Especially How They Fail in 1975.  His “law,” contained therein, is:

Have you ever heard of anything that applied so perfectly to our healthcare system? 

As anyone who has been reading my prior articles may know, I’m a big believer in simple.  I’ve advocated that healthcare’s billing and paperwork should be much simpler, that “less is more” when it comes to design,  that healthcare should first do simple better but, above all,  that healthcare should stop doing stupid things.  I’ve equated the ever-increasing intricacies of our healthcare system to the epicycles that kept getting added to the Ptolemaic theory in a desperate attempt to justify it. 

Few would disagree that the U.S. healthcare system is complex.  Healthcare systems in general have evolved towards more complex, but the U.S. system takes complexity to extremes, with its thousands of payors, its powerful pharma/medical device industry, and its highly concentrated hospital markets (including ownership of physician practices), among other things. 

Simple isn’t always better, of course.  Life is complicated and so is our health, but, come on: how many people can explain why PBMs exist, what their heath insurance plan actually covers, how their health care bill was arrived at, or why we spend so much time in the healthcare system just waiting?  Literally no one understands our healthcare system.

It shouldn’t be that way.  It doesn’t have to be that way.  But it is.

Some pundits argue we don’t even have “a system” but, rather, thousand or even millions of smaller health-related markets that co-exist but don’t really work together.  For anyone who doubts that, try to explain the presence of workers compensation healthcare or why dental is at best a separate form of coverage (last I looked, the mouth was part of the body).  Try to explain why child care is most definitely not part of healthcare but home care is – depending, of course, on whether it is “custodial” or not.   Silos abound.

It could be argued that healthcare started with a simple system that “worked.”  Some are nostalgic for the days when people saw their family doctor, paid their doctor, and that was it.  It doesn’t get much simpler than that.  Of course, those doctors couldn’t really do all that much for their patients and didn’t really get paid all that much, so to say that it “worked” for either party is debatable. 

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Sleepless Nights For Evolutionary Biologists: A Greek Tragedy in The Making

By MIKE MAGEE

In my Jesuit high school, we were offered only one science course – chemistry. I took it in my Senior year and did pretty well. In contrast, I took four years of Latin, and three years of Greek, as part of the school’s Greek Honors tract.

Little did I know that Covid would create a pathologic convergence of sorts six decades later. Let’s review the Covid mutants:

Alpha – A variant first detected in Kent, UK with 50% more transmissibility than the original and has spread widely.

Beta – Originating in South Africa and the first to show a mutation that partially provided evasion of the human immune system, but may have also made it less infectious.

Gamma – First detected in Brazil with rapid spread throughout South America.

Delta – First seen in India with 50% more transmissibility than the Alpha variant, and now the dominant variant in America and around the world.

Our ability to track and identify mutating viruses in real time is now extraordinary. Over 2 million Covid genomes have been cataloged and published. But describing the “anatomy” of the virus is miles away from understanding the functional significance of their codes, or the various biochemical instructions they may instruct.

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Matthew’s health care tidbits

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Each week I’ve been adding a brief tidbits section to the THCB Reader, our weekly newsletter that summarizes the best of THCB that week (Sign up here!). Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

For my health care tidbits this week, I am getting very close to home. I live in Marin County, California which is an incredibly wealthy, well-educated, liberal place. My little town voted 90% for Biden and, as you’d expect, county-wide 87% of those eligible (over 12) are fully immunized with most of the rest on the way. But Marin also has a small hard core of anti-vaxxers, and by that I mean those who reject childhood vaccinations. At one Waldorf school nearby only 22% of kids are vaccinated (MMR et al).This week the CDC released a study about how this past May an unvaccinated elementary school teacher who was sneezing but didn’t wear a mask infected 55% of their class.

I know that public schools in Marin have insisted on their teachers and students wearing masks and have highly, highly encouraged vaccinations among teachers and staff. Furthermore that school had only 205 pupils which is well below the average for elementary schools (at least in my school district). So I am prepared to bet that the maskless teacher was at a charter school or other private school. (Post newsletter update: I found out that it was a parochial school in Navato)

Clearly we need vaccines for kids ASAP. But I also am starting to wonder that, as COVID-19 becomes endemic and probably never goes away and as studies like this show how rapidly it spreads, will the majority who believe in masking, vaccines et al start to impose more medical and social mandates and bans on those who do not?

The FDA’s Culture: Should Safety Dominate All Practices?

By STEVEN ZECOLA

An organization’s culture is an internal set of shared values, attitudes and practices. The cohesiveness of the organizational culture will affect whether the entity will meet its vision, purpose, and goals.

One type of organizational culture is hierarchical in nature.   Unlike a risk-taking culture, this structure features policy, process and precision. It is best suited for mature and stable organizations.

The disadvantage of a hierarchal culture is that its stability and control can turn into rigidity. In many cases, the organization develops a negative attitude towards ideas supplied by third parties. It paints itself as having the perfect answer for every issue, no matter how large or small.

My interactions with the FDA suggest that its cultural practices are focused on safety, seemingly to the exclusion of all other issues.  This practice may be appropriate in the regulation of food, but not for drug research where flexibility and creativity are required to cure complex diseases.

Over the past decade, I have witnessed an excessive adherence to its existing practices in the context of BRCA1-related breast cancer, metastatic cancer, precision medicines, “Big Data” and Parkinson’s disease. While the rulings were directed at me, the FDA’s position on these issues has impacted millions of people for the worse.

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Delta Double-Down: A Universal Health Plan Is Long Overdue.

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By MIKE MAGEE

On March 25, 1966, during the Poor People’s March that the Rev. Martin Luther King Jr. said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

This week, my niece in Orlando, Florida, sent her 8-year old son, masked, back to public school. He has a history of severe allergies, including several anaphylactic episodes requiring emergency respiratory intervention. His class included a voluntary mix of masked and unmasked children. He now has a 105 degree fever and has tested positive for the Delta variant of Covid.

His crisis, and those of countless other children in Republican led states now lies clearly on their governor’s shoulders. It also suggests, as with voting rights, that we can no longer allow health planning and delivery to be captured entities of the states rights crowd. Dying children are just not acceptable in a civilized society.

The impassioned and illogical pleas of leaders like Florida Gov. Ron DeSantis are literally as old as this nation. As with many controversies in human endeavor, the easiest way to decipher history and meaning is often “to follow the money.” Such was the case in the battle between state and federal rights. This battle engaged early and often, with Thomas Jefferson and Alexander Hamilton on opposite sides of the spectrum.

Soon after the 1788 ratification of the U. S. Constitution, Washington’s Secretary of the Treasury, Hamilton, suggested a federal bank to manage debt and currency. Jefferson, then Secretary of State, opposed it for fear of a federal power grab. Regardless, in 1791, Congress created the First Bank of the United States with a 20 year charter.

When the charter ran out in 1811, it wasn’t renewed. But then the War of 1812 intervened, and in 1816 the Second Bank of the United States was created with the Federal government holding 20% of the equity. The divide led to the creation of two political parties – the Federalist Party and the Democratic-Republican Party whose members were committed to undermining the bank.

The battle came to a head when, in 1818, the Maryland’s state legislature levied a $15,000 annual tax on all non-state banks. There was only one – the Second Bank of the United States, which refused to pay. The suit rose to the Supreme Court with Maryland claiming the right to tax based on their reading of the 10th Amendment claiming state protection against extension of non-enumerated rights to the Federal government.

The landmark 1819 case – McCulloch v. Maryland, defined the scope of the U.S. Congress’s legislative power and how it relates to the powers of American state legislatures. In ruling against Maryland, Chief Justice Marshall argued that:

“Let the end be legitimate, let it be within the scope of the constitution, and all means which are appropriate, which are plainly adapted to that end, which are not prohibited, but consist with the letter and spirit of the constitution, are constitutional.”

It was the people who ratified the Constitution and thus the people, not the states, who are sovereign.

One hundred and thirty years later, on December 10, 1948, the newly formed United Nations, adopted the Universal Declaration of Human Rights. That day, Eleanor Roosevelt spoke for America, stating: “Where after all do human rights begin? In small places close to home…Unless these rights have meaning there, they have little meaning anywhere.”

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