The super connector and super intelligent Emily Peters, (who has quite her own patient adventure story–tl:dr GO GIVE BLOOD) and has written several books including Artists Remaking Medicine, is working on another one called Money Remaking Medicine. She invited me on a show called the Positive Deviants Detectives which is kind of a book club called the Health Care Reinvention Collaborative all hosted by the very wise Dawn Ellison. We talked and the audience joined in about the history of money, HMOs and more in health care and whether we can re-fangle it to make the money do the right things. Matthew Holt
Have Some Water – While You Can
By KIM BELLARD
We live on a water world (despite its name being “Earth”). We, like all life on earth, are water creatures, basically just sacks of water. We drink it, in its various forms (plain, sparking, carbonated, sweetened, flavored, even transformed by a mammal into milk). We use it to grow our crops, to flush our toilets, to water our lawns, to frack our oil, to name a few uses. Yet 97% of Earth’s water is salt water, which we can’t drink without expensive desalination efforts, and most of the 3% that is freshwater is locked up – in icebergs, glaciers, the ground and the atmosphere, etc. Our civilization survives on that sliver of freshwater that remains available to us.
Unfortunately, we’re rapidly diminishing even that sliver. And that has even worse implications than you probably realize.
A new study, published in Science Advances, utilizes satellite images (NASA GRACE/GRACE-FO) to map what’s been happening to the freshwater in the “terrestrial water storage” or TWS we blithely use. Their critical finding: “the continents have undergone unprecedented TWS loss since 2002.”
Indeed: “Areas experiencing drying increased by twice the size of California annually, creating “mega-drying” regions across the Northern Hemisphere…75% of the population lives in 101 countries that have been losing freshwater water.” The dry parts of the world are getting drier faster than the wet parts are getting wetter.
“It is striking how much nonrenewable water we are losing,” said Hrishikesh A. Chandanpurkar, lead author of the study and a research scientist for Arizona State University. “Glaciers and deep groundwater are sort of ancient trust funds. Instead of using them only in times of need, such as a prolonged drought, we are taking them for granted. Also, we are not trying to replenish the groundwater systems during wet years and thus edging towards an imminent freshwater bankruptcy.”
As much as we worry about shrinking glaciers, the study found that 68% of the loss of TWS came from groundwater, and – this is the part you probably didn’t realize – this loss contributes more to rising sea levels than the melting of glaciers and ice caps.
This is not a blip. This is not a fluke. This is a long-term, accelerating trend. The paper concludes: “Combined, they [the findings] send perhaps the direst message on the impact of climate change to date. The continents are drying, freshwater availability is shrinking, and sea level rise is accelerating.”
Yikes.
“These findings send perhaps the most alarming message yet about the impact of climate change on our water resources,” said Jay Famiglietti, the study’s principal investigator and a professor with the ASU School of Sustainability.
We’ve known for a long time that we were depleting our aquifers, and either ignored the problem or waved off the problem to future generations. The researchers have grim news: “In many places where groundwater is being depleted, it will not be replenished on human timescales.” Once they’re gone, we won’t see them replenished in our lifetimes, our children’s lifetimes, or our grandchildren’s lifetimes.
Professor Famiglietti is frank: “The consequences of continued groundwater overuse could undermine food and water security for billions of people around the world. This is an ‘all-hands-on-deck’ moment — we need immediate action on global water security.”
If all this still seems abstract to you, I’ll point out that much of Iran is facing severe water shortages, and may be forced to relocate its capital. Kabul is in similar straits. Mexico City almost ran out of water a year ago and remains in crisis. Water scarcity is a problem for as much as a third of the EU, such as in Spain and Greece. And the ongoing drought in America’s Southwest isn’t going any anytime soon.
Continue reading…Gen Z Should Give Health Care a Stare
By KIM BELLARD
Last I knew, Gen Z showed its disdain for older generations with a dismissive “OK Boomer.” But that was a few years ago, and now, it appears, Gen Z doesn’t even bother with that; instead, there is what has become known as the “Gen Z stare.” You’ve probably seen it, and may have even experienced it. TikTok influence Janaye defines it thusly: “The Gen Z stare is specifically when somebody does not respond or just doesn’t have any reaction in a situation where a response is either required or just reasonable.”
It’s been blowing up on social media and the media over the last few days, so it apparently has tapped into the social zeitgeist. It’s often been attributed to customer service interactions, either as a worker receiving an inane request or as a customer facing an undue burden.
You can already see why I link it to healthcare.
It’s off-putting because, as Michael Poulin, an associate psychology professor at the University at Buffalo, told Vox: “People interpret it as social rejection. There is nothing that, as social beings, humans hate more. There’s nothing that stings more than rejection.”
Many attribute the Gen Z stare to Gen Z’s lack of social experience caused by isolation during the pandemic, exacerbated by too much screen time generally. Jess Rauchberg, an assistant professor of communication technologies at Seton Hall University, would tend to agree, telling NBC News: “I think we are starting to really see the long-term effects of constant digital media use, right?”
Similarly, Tara Well, a professor at Bernard College, told Vox: “It’s sort of almost as though they’re looking at me as though they’re watching a TV show… We don’t see them as dynamic people who are interacting with us, who are full of thoughts and emotions and living, breathing people. If you see people as just ideas or images, you look at them like you’re paging through an old magazine or scrolling on your phone.”
Millennial Jarrod Benson told The Washington Post: “It’s like they’re always watching a video, and they don’t feel like the need to respond. Small talk is painful. We know this. But we do it because it’s socially acceptable and almost socially required, right? But they won’t do it.” Zoomer (as those of Gen Z are known) Jordan MacIsaac speculated to The New York Times: “It almost feels like a resurgence of stranger danger. Like, people just don’t know how to make small talk or interact with people they don’t know.”
On the other hand, TikTok creator Dametrius “Jet” Latham claims: “I don’t think it’s a lack of social skills. I just think we don’t care,” which might be more to the point.
ABC News cited some customer service examples that deserved a Gen Z stare: “I’ve been asked to make somebody’s iced tea less cold. I’ve been asked to give them a cheeseburger without the cheese, but keep the pepper jack of it all.” As Zoomer Efe Ahworegba put it: “The Gen Z stare is basically us saying the customer is not always right.”
Ms. Ahworegba doesn’t think a Gen Z stare doesn’t reflect Gen Z’s lack of social skills, but rather: “They just didn’t want to communicate with someone who’s not using their own brain cells.” As some Zoomers say, it is “the look they give people who are being stupid while waiting for them to realize they are being stupid.”
Still, as one commenter on TikTok wrote: “I think it’s hilarious that Gen Z thinks they’re the first generation to ever deal with stupidity or difficult customers, and that’s how they justify the fact that they just disassociate and mindlessly stare into space whenever they are confronted with a difficult or confusing situation, instead of immediately engaging in the situation like every other generation has ever done before them lol.”
Or perhaps this is much ado about nothing. Professor Poulin noted: “To some degree, it’s a comforting myth that all of us who are adults — who’ve gotten beyond the teens and 20s — that we tell ourselves that we were surely better than that.” When it comes to displaying socially acceptable behavior, he says: “This isn’t the first generation to fail.”
———
Interestingly, Gen Z is already skeptical of our traditional healthcare system, as well they might be.
Continue reading…Why Multi-morbidity Requires Two Health Systems, not One
By JEREMY SHANE
What’s behind the coming health care reckoning? Most industry leaders have their preferred list of culprits: not us! Left-leaning critics blame large insurers, drug companies, and private equity firms. Take the profit and self-dealing out of health care. Those on the right blame excessive regulation, poorly-designed insurance markets, or limits on individuals’ ability to pick their own coverage. Debates yo-yo between these views in a political stalemate. While the views are diametrically opposed on solutions, they share a belief that financial issues are the root cause of systemic dysfunction. That manipulating how clinicians are paid or insurance is structured can improve health outcomes.
A half century into efforts to fix health care, it is clear that both views are wrong. Americans’ healthspans are shrinking while costs spiral upwards thanks to chronic disease. Progressively worsening illness throughout adulthood eventually explodes in multimorbidity, driving cancer and dementia, and protracted hospitalizations. Clinicians know this, with their well-worn chorus of “if only” laments. If only we could reward prevention instead of treatment. If only we intervened earlier before advanced pathology takes hold. If only clinical care was not fragmented. If only people had a direct stake in their longer-term health. Yet the debate in Washington DC, even shaken up by the MAHA movement’s focus on chronic issues, regresses into an interminable blame game, and conflicting ideas about how Congress or CMS could end the madness.
It is time to break the cycle and say clearly what we know to be scientific fact. It’s impossible to use a system built to solve acute issues to also solve multi-decade, highly variable disease threats. Yet this presumption, that one system can do it all, addressing everything from colds to car crashes to cardiovascular issues to cancer, is so deeply ingrained in our thinking as to escape scrutiny.
It is folly to continue. We need two systems, not one — the first for routine, emergency, and elective treatments and the second to confront long-term, complex challenges. Absent this change it will take far longer than it should, and cost far more, to decipher chronic issues or create economic arrangements that can bring forward the ultimate value of preventing disease.
Resetting Assumptions
It’s illuminating to focus on the scientific drivers of disease rather than the financial after effects. It becomes clear why Medicare Advantage is imploding, and no, it’s not because CMS changed payment rates. Since 2000, the percent of Americans entering Medicare with multimorbidity has jumped by two-thirds, from a quarter of new entrants to over 40%. Software may be eating the world but multimorbidity is eating Medicare, Medicaid, and private insurance, and with it, most Americans’ healthspans.
Most Americans now live a decade more than their grandparents, only to spend all the additional years, and then some, in poorer health.
Continue reading…I’m on the Surgeon’s Record
If you want to hear a little about Commons Clinic from Benjamin Schwartz, MD but rather more from me about who knows what, it’s on The Surgeon’s Record podcast — Matthew Holt
We’re Gonna Need a Bigger Boat
By KIM BELLARD
My friends, we are like explorers of yore standing at the edge of a known continent, looking out at the vast ocean in hopes of finding new, unspoiled, better lands across it. True, we may have despoiled the continent behind us, but certainly things will be better in the new lands.
In the metaphor I’m thinking of, the known continent is our shambles of a healthcare system. For all the protestations about the U.S. having the best health care in the world, that’s manifestly untrue. We don’t live as long, we have more chronic diseases, we kill each other and ourselves at alarming rates, we pay way more, we have too many people that can’t afford care and/or can’t obtain care, we have too much care that is ineffective, inappropriate, or even harmful, and we spend much too much on administration.
We don’t trust the healthcare system, we don’t think its quality of care is good, we have an unfavorable opinion of it, we think it fails us. The vast majority of us think it should be fundamentally changed or completely rebuilt. That’s what we want to flee, and it’s no wonder why.
Across that metaphorical ocean, in the distance, over the horizon, lies the 22nd century healthcare system. It will, we hope, be like magic. It will be more equitable, more effective, more efficient, more proactive, less invasive, more affordable. We don’t know exactly what it will look like or how it will work, but we’ve seen what we have, and we know it can be better – much better. We just need to get there.
This leads me to the next part of the metaphor. I recently read a great quote from the late nature writer Barry Lopez, from his posthumous book of essays Embrace Fearlessly the Burning World. Mr. Lopez laments: “We are searching for the boats we never built.”
The boats aren’t coming to save us, to transport us to that idealized 22nd century healthcare system. Because we never built them. Because we still don’t have the courage to build them.
We’ve never built a system to ensure universal coverage. We rely on a hodgepodge of coverage mechanisms, each of which is struggling with its own problems and still leaving some 25 million people without insurance – and that’s before the 10-20 million who are predicted to lose coverage due to the “Big, Beautiful Bill” – plus the tens of millions who are “underinsured.
We’ve never built a system that was remotely equitable, just as we never did for housing, education, or employment. Money matters, ethnicity matters, geography matters. Discrepancies in availability of care and in outcomes show up clearly for each of those, and more.
We’ve never built a system that prizes patients above all. We deferred to doctors and hospitals, not calling them out when they gave us substandard care or when they charged us too much. Now health care has gone from a “noble calling” to a jobs and wealth creator. A recent New York Times analysis found (among other things):
- Health care is the nation’s largest employer;
- In 1990, health care wasn’t the largest employer in any state; now it is in 38 states;
- We spend more on health care than on groceries or housing.
Pick your favorite target: private equity firms buying up health care entities, for-profit companies extracting profits from our care (or nominal “non-profits” doing the same), the steady corporatization of health care. Throw in favorite boogeymen like health insurers, PBMs, or Big Pharma. One way or another, it’s about the money, not us.
The adage about Big Tech comes to mind: we’re not the customer, we’re the product (or, as I’ve written before, we’re simply the NPCs.).
We’ve never built the systems to make administration easier. So many codes, so many rules, so many types of insurance, so many silos, so many administrators. By now you’ve no doubt seen the chart of the growth of administrators versus clinicians in our health care system, and are aware that around a quarter of our healthcare dollar goes to administration. It doesn’t have to be this way, it shouldn’t be this way, but administrative bloat is getting worse, not better.
We’ve never built the systems to properly track our health or risks to it.
Continue reading…Water, Water, Everywhere . . . but Not a Drop to Drink
By MIKE MAGEE
In the wake of last week’s human tragedy in Texas, it would be easy (and appropriate) to focus on the role played by Trump’s reckless recent dismantling of FEMA and related federal agencies. But to do so would be to accept that the event was an anomaly, or as Trump labeled it on Sunday on his way to a round of golf at Bedminster, “a hundred year catastrophe.”
In reality, tragedies like this are the direct result of global warming, and last week’s suffering and loss are destined to be followed by who knows how many others here and in communities around the world.
In 2009 President Obama joined global leaders in New York City for the Opening Session of the UN. One of the transboundary issues discussed was Global Warming. All agreed that the Kyoto Protocol had failed. It failed because the target to decrease emissions by some 5% was too low. It failed because large transitional nations like India and China were excluded. And it failed because US leadership opted out.
The global community today has a deeper hole out of which it must dig. In doing so we would do well to focus on health and safety as outcome measures, and define strategies to manage the obvious consequences of this ongoing crisis.
Two decades ago, the warnings were clear. Left unattended, we would soon not only need to plan mitigation, but also need to prepare and resource intervention to deal with inevitable human injury and disease fall-out. Of course, back then, we could not have predicted that wise disease interventions in climate ravaged hot spots around the globe, like expansion of USAID funding in the Bush and Obama administrations, would be X’d out under Trump/Musk. Who could have imagined such reckless and ultimately self-destructive moves?
And yet, here we are:
Continue reading…Microplastics Are Here, There, Everywhere
By KIM BELLARD
Vaccine experts are going rogue in response to RFK Jr’s attacks on vaccine safety. Health insurers promise – honest…this time – to make prior authorizations less burdensome (although not, of course, to eliminate them). ChatGPT and other LLMs may be making us worse at learning. So many things to write about, but I find myself wanting to return to a now-familiar topic: microplastics.
I first wrote about microplastics in 2020, and subsequent findings caused me to write again about their dangers at least once a year since. Now there are, yet again, new findings, and, nope, the news is still not good.
A new study, from researchers at the Food Packaging Forum, Swiss Federal Institute of Aquatic Science and Technology (Eawag) and the Norwegian University of Science and Technology, and published in npj Science of Food reviewed 103 previous studies about the impact food packaging and “food contact articles (FCAs)” can have on micro- and nanoplastics (MNPs) in our food. They found that even normal use — such as opening a plastic bottle, steeping a plastic tea bag, or chopping on a plastic cutting board – can contaminate foodstuffs.
“This is the first systematic evidence map to investigate the role of the normal and intended use of food contact articles in the contamination of foodstuffs with MNPs,” explains Dr. Lisa Zimmermann, lead author and Scientific Communication Officer at the Food Packaging Forum. “Food contact articles are a relevant source of MNPs in foodstuffs; however, their contribution to human MNP exposure is underappreciated.”
Their collected data are freely accessible through the FCMiNo dashboard., which allows users to filter included data by the type of FCA, the main food contact material, the medium analyzed, and whether MNPs were detected, and if so, for their size and polymer type.
Removing the plastic from items you purchase at the grocery store may contaminate it with microplastics, as might steeping a tea bag. Simply opening jars or bottles of milk can as well, and repeated opening and closing of either glass or plastic bottles sheds “untold amounts” of micro- and nanoplastics into the beverage, according to Dr. Zimmerman, who further noted: “The research shows the number of microplastics increases with each bottle opening, so therefore we can say it’s the usage of the food contact article which leads to micro- and nanoplastic release,”
Dr. Zimmerman told The Washington Post: “Plastic is present everywhere. We need to know what we can do.” Examples of what she suggests we can try to do include avoiding storing food in plastic whenever possible and avoiding heating plastic containers. She admitted, though: “We have not really understood all the factors that can lead to the release of micro and nanoplastics.”
Continue reading…American Medicine’s Meagerness Paradox
By MARC-DAVID MUNK
In our palliative medicine clinic in the working suburbs of Boston, my colleagues and I tend to some of the sickest patients in the city. Through the window, I can see the afflicted pull up to our squat building in family sedans, wheelchair vans, and subsidized municipal ride cars. Few drive themselves: most bear terrible illnesses that make them too frail or sedated. I watch as patients who are barely able to dress themselves, somehow arrive in their Sunday best for clinic.
Our job, as their doctors, is to manage their pain and provide moral support and practical help with things such as rent and transportation, sometimes spiritual support too. It’s important work, among the highest callings in medicine. Yet, as noble as this work might be, our clinic doesn’t begin to support itself financially. If there was ever a reason to spend graciously on patients and their needs, these visits, with their sick and vulnerable patients, would be exemplars. In fact, we don’t receive enough payment from insurers to cover the costs of the complicated work that’s needed. Practically, this translates to few staff to help with appointments, not enough follow-up calls, nobody to help with insurance headaches or pharmacy shortages, nobody answering the phone. Our facilities are tired. The simplest niceties—coffee in the waiting room, magazines, a comfortable chair—are long gone.
There is a feeling of “meagerness” in the air. It’s the feeling of being rationed. It’s an absence of all but the truly essential; no plenitude, a lack of graciousness. I see meagerness when my friend, an emergency physician at a major trauma center, shares pictures of his decomposing ER: desk chairs held together with medical tape, rooms without functioning equipment. Medical supplies that are so scarce that doctors keep stashes in their desks and coat pockets.
The administrators will say that these barren conditions are a consequence of financial scarcity. There isn’t enough money to pay for more than skeleton support and upkeep. Hospitals are running deficits and downsizing. Keeping the lights on is apparently a question of saving pennies at every opportunity. And, with every cut, meagerness grows. This all sounds, on its surface, understandable till you take a step back and realize it isn’t. We know that American healthcare consumes more money than any other country, per capita. Money is pouring, truly flooding, into our healthcare system. Family health insurance premiums rose 7% from 2023, after another 7% increase the year before. The average family policy now costs around $25,000 per year.
Which leaves me wanting to reconcile how there can be so much money entering the system, with so little left for essential front-line care. I know that this isn’t a complicated answer.
Now is the Time to Modernize Communication in the Medicaid Program
By ABNER MASON
What do television shows 60 Minutes, Roseanne, Designing Women, and Murder, She Wrote all have in common? They were top 10 prime time shows in the 1991 – 92 season according to Nielson Media research. Obviously, what Americans want to watch has changed in 34 years. The decline in market share the major networks – ABC, CBS, and NBC – have experienced, and the dramatic growth of streaming services proves the point. It makes sense to let people watch what they want to watch on the device of their choice, and use new technologies like streaming services to access the shows they want to watch. It would be foolish for us to insist that Americans watch only shows from the legacy networks on traditional TVs. But this is basically what we are doing now when we force Medicaid Managed Care Plans (Plans) to comply with a 1991 Federal Law when they communicate with Medicaid recipients.
Here’s the problem. Federal legislation called the Telephone Consumer Protection Act (TCPA), enacted in 1991, makes it very difficult for States and Plans to use text messaging to communicate with their members, even though texting is the primary, and preferred mode of communication for all Americans including Medicaid recipients. TCPA requires a State or Plan sending a text to have permission from the person receiving the text before the text is sent. Violations of TCPA result in significant financial penalties for each infraction, and penalties are tripled if the sender knowingly sent the text without consent.
Medicaid recipients are typically assigned to Plans, they do not choose their Plan, and as a result, in light of TCPA, and potentially enormous financial penalties being assessed, plans have taken the position that they do not have consent from recipients to text them. And that is the problem.
Texting is the way most Americans communicate today. Other modalities like US mail (called snail mail for a reason), phone calls (who answers calls anymore?), and email (likely to go without a response for days or weeks) are dramatically less effective. Because they are low income, many Medicaid recipients often do not have a landline, or a laptop. They rely on their mobile phone for all their communication, including healthcare related communication. Texting is their preferred, and often only way of communicating.
As Founder and CEO for SameSky Health, I spent over a decade working with Plans to help them engage their members and navigate them into healthcare at the right time and the right place. Again and again, we found when we could maneuver around the outdated restrictions TCPA placed on Plans, we got higher engagement which translated into more well child visits, more breast cancer screenings, more diabetes (a1c) screenings, and so on. Using modern tools of communication is a way of meeting people where they are. It builds trust and leads to better health outcomes. But sadly, because of TCPA, we were not able to text members in most instances.
What has been a significant problem will be made exponentially worse when Federal Work Requirements are implemented as now seems likely. A Federal Medicaid Work requirement will dramatically increase the need to modernize how States and Plans communicate with Medicaid recipients. Compliance with TCPA is standing in the way of this modernization. And if it is not fixed, many, many people will lose their Medicaid benefits for purely procedural reasons.
To improve health outcomes, allow efficient communication to verify work status, and provide twice yearly redetermination information, States and Plans must be exempted from the outdated provisions of TCPA. Senate action on, and final passage of the Reconciliation legislation offers the best opportunity to get an exemption from TCPA passed and signed into law.
The time to act is now.
So lets focus on (1) getting the exemption language in the Senate version of the Reconciliation legislation, (2) working with HHS and CMS to ensure post legislation guidance directs States and Plans to include texting as a best practice when implementing work requirement programs and communicating with recipients more generally, and (3) implementing a media strategy to build support for using modern technology to create easier more efficient ways for Medicaid recipients to comply with the new work requirements.
We have two months – June and July – to get action on an exemption in the Senate, and the remainder of the year to influence Administration guidance on work requirement programs.
Medicaid beneficiaries will be the biggest winners if we succeed because an exemption is a key strategy to reduce unnecessary loss of Medicaid benefits.
What can you do? Call your Senator and ask them to support modernizing how States and Plans communicate with Medicaid recipients. And please share this blog post with your network.
Abner Mason is Chief Strategy and Transformation Officer for GroundGame Health. He serves on the Board for Manifest MedEx, California’s largest health information exchange, is Vice-Chair of the Board for the California Black Health Network, and is a member of the National Commission on Climate and Workforce Health. Here are are just some of articles and interviews he has published over the past 10 years pushing for States and Plans to be able to text Medicaid recipients.
