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Why Sam Altman Cares So Much About Voice

By MIKE MAGEE

When OpenAI decided to respond to clamoring customers demanding voice mediated interaction on Chat GPT, CEO Sam Altman went all in. That’s because he knew this was about more than competitive advantage or convenience. It was about relationships – deep, sturdy, loyal and committed relationships.

He likely was aware, as well, that the share of behavioral health in telemedicine mediated care had risen from 1% in 2019 to 33% by 2022. And that the pandemic had triggered an explosion of virtual mental health services. In a single year, between 2020 and 2021, psychologists offering both in-person and virtual sessions grew from 30% to 50%. Why? The American Psychological Association suggests these oral communications are personal, confidential, efficient and effective. Or in one word – useful.

As Forbes reported in 2021, “Celebrity endorsements, like Olympic swimmer Michael Phelps’ campaign with virtual therapy startup Talkspace, started to chip away at the long standing stigma, while mindfulness apps like Calm offered meditation sessions at the click of a button. But it was the Covid-19 pandemic and collective psychological fallout that finally mainstreamed mental health.” As proof, they noted mental health start-up funding has increased more than fivefold over the prior four years.

Altman was also tracking history. The first “mass medium” technology in the U.S. was voice activated – the radio. He also understood its’ growth trajectory a century ago. From a presence in 1% of households in 1923, it became a fixture in 3/4 of all US homes just 14 years later.

Altman also could see the writing on the wall. The up and coming generations, the ones that gently encouraged Biden to exit stage left, were both lonely and connected.

The most recent Nielson and Edison Research told him that the average adult in the U.S. now  spends four hours a day consuming audio and their associated ads. 67% of that listening was on radios, 20% on podcasts, 10% on music streaming and 3% on satellite radio.

Post-pandemic, younger generations use of online audio had skyrocketed.  In 2005, only 15% of young adults listened online. By 2023, it had reached 75%. And as their listening has risen, loneliness rates in young adults have declined from 38% in 2020 to 24% now.

A decade earlier, screenwriter Spike Jonze ventured into this territory when he wrote Her. Brilliantly cast, the film featured Joaquin Phoenix as lonely, introverted Theodore Twombly, reeling from an impending divorce. In desperation, he developed more than a relationship (a friendship really) with an empathetic reassuring female AI, voiced by actress Scarlett Johansson.

Scarlett’s performance was so convincing that it catapulted Her into contention for 5 academy awards winning Best Original Screenplay. It also apparently impressed Sam Altman, who, a decade later, approached Scarlett to be the “voice” of ChatGPT’s virtual lead. She declined, seeing the potential downside of becoming a virtual creature. He subsequently identified a “Scarlett-like” voice actor and chose “Sky” as one of five voice choices to embody ChatGPT. Under threat of a massive intellectual property challenge, Altman recently “killed off” Sky, but the other four virtual companions (out of 400 auditioned) have survived.

As for content so that “what you say” is as well represented as “how you say it,” companies like Google have that covered. Their LLM (Large Language Model) product was trained on content from over 10 million websites, including HealthCommentary.org. Google engineer, Blaise Aguera y Arcas says “Artificial neural networks are making strides toward consciousness.”

Where this all ends up for the human race remains an open question. What is known is that the antidote for loneliness and isolation is relationships. But of what kind? Who knows? Oxford’s Evolutionary Psychologist Robin Dunbar believes he does.

Altman likely paid close attention to this review by Atlantic writer Sheon Han in 2021: “Robin Dunbar is best known for his namesake ‘Dunbar’s number,’ which he defines as the number of stable relationships people are cognitively able to maintain at once. (The proposed number is 150.) But after spending his decades-long career studying the complexities of friendship, he’s discovered many more numbers that shape our close relationships. For instance, Dunbar’s number turns out to be less like an absolute numerical threshold than a series of concentric circles, each standing for qualitatively different kinds of relationships.… All of these numbers (and many non-numeric insights about friendship) appear in his new book, Friends: Understanding the Power of Our Most Important Relationships.”

But what many experts now agree is that voice seems to unlock the key. Shorthand for Altman: Pick the right voice and you might just trigger the addition of 149 “friends” for each ChatGPT “buyer.”

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex.(Grove/2020)

It’s in the Blood

By KIM BELLARD

People are fascinated by blood. Well, it would seem so, given our fondness for vampires, gory movies, and true crime stories. I’m not so keen on any of those, but I was struck by several recent developments about how blood tests can help diagnose medical problems faster, more definitively, and less invasively.

Because, really, shouldn’t that be what our healthcare system always should strive for?

Take concussions. If you are a football fan, you’re very familiar with the problem that it seems very subjective about whether a player has suffered a concussion. They’re not the only ones. Millions of people suffer concussions each year – the vast majority of whom are not athletes – and more than half never get it evaluated.

In April Abbott received FDA approval for a rapid blood test, producing results in 15 minutes. It can be done at a patient’s beside, and not require a lab. “Clinicians have needed an objective way to assess patients with concussions,” said Beth McQuiston, M.D., medical director in Abbott’s diagnostics business. “When you look at all the other diseases, or other organs in the body, they all have blood tests to help assess what’s happening. Now, we have a whole blood test that can help assess the brain right at the patient’s bedside – expanding access to more health providers and therefore patients.”

Expect to see the Abbott’s i-STAT TBI cartridge and portable i-STAT® Alinity® instrument in emergency rooms, not to mention on NFL sidelines.

Or Alzheimer’s disease. Many realize that it has historically been very difficult to diagnose, often not definitively until after death. Now a new study suggests a blood test can accurately diagnose it 90% of the time, which is much higher than even neurologists can do. The test is more accurate the later the stage of Alzheimer’s a person has.

Specifically, it measures “the ratio of plasma phosphorylated tau 217 (p-tau217) relative to non–p-tau217 (expressed as percentage of p-tau217) combined with the amyloid-β 42 and amyloid-β 40 plasma ratio (the amyloid probability score 2 [APS2]).” Got that?

“We’d love to have a blood test that can beused in a primary care physician’s office, functioning like a cholesterol test but for Alzheimer’s,” Dr. Maria Carrillo, chief science officer of the Alzheimer’s Association, told CNN. “The p-tau217 blood test is turning out to be the most specific for Alzheimer’s and the one with the most validity. It seems to be the front-runner.”

It’s not quite ready for use in your doctor’s office, though. “Right now, we don’t have guidelines for the use of these tests,” Dr. Eliezer Masliah, director of the division of neuroscience at the National Institute on Aging, warned NPR. Dr. Suzanne Schindler, an associate professor of neurology at Washington University School of Medicine in St. Louis, added: “Blood tests have developed incredibly fast for Alzheimer disease and I think [doctors] aren’t used to that rate of change.”

“The field is moving at a pace I never imagined 10 years ago,” Dr. Heather Whitson, a professor of medicine at Duke University, marveled to NPR.

We’re increasingly seeing FDA approved drug treatments for Alzheimer’s, so it’d be nice if we had FDA approved blood tests to more accurately use them. 

Last but not least, there’s colorectal cancer (CRC). The FDA recently approved Guardant Health’s Shield™ blood test for colorectal cancer screening, and is the first such blood test approved by the FDA as a primary screening option. A Guardant study found that it identified 87% of cancers that were at an early and curable stage, although it does less well at finding precancerous growths. The test is aimed at adults 45 and older who are at average risk.

It’s not so much that it is better than colonoscopies – it’s not — as it is that it should be easier to convince people to use. Despite the fact that CRC kills over 50,000 Americans annually, more than a third of older Americans are not getting screened. Even worse, more than three-fourths of those who die from CRC are not up-to-date with their screening.

“The persistent gap in colorectal cancer screening rates shows that the existing screening options do not appeal to millions of people,” said Daniel Chung, MD, gastroenterologist at Massachusetts General Hospital and Professor of Medicine at Harvard Medical School. “The FDA’s approval of the Shield blood test marks a tremendous leap forward, offering a compelling new solution to close this gap.”

Dr. Sapna Syngal, director of strategic planning for prevention and early cancer detection at the Dana-Farber Cancer Center in Boston agrees, telling NBC News: “If this test increases the number of people getting screened, it’s going to have a huge impact.” 

The test is on the market now, and Guardant expects approval for coverage by Medicare and commercial insurance.

Most of us are used to getting routine blood tests for things like blood counts or cholesterol levels, so it’s exciting that blood tests are started to be used for other important health issues.

————–

Blood tests are all well and good, but they’re not (yet) the kind of test you’d routinely expect to use at home on your own. ARPA-H has even bigger aspirations. It just announced the Platform Optimizing SynBio for Early Intervention and Detection in Oncology (POSEIDON) program, the goal of which is “to develop first-in-class, at-home, synthetic Multi-Cancer-Early Detection (MCED) tests for the most sensitive and specific stage I detection of 30+ solid tumors* using only breath and/or urine samples.”

No blood draw or lab tech needed, just breath or urine samples done yourself at home. That’s something to shoot for.

“Access to a low-cost cancer screening test that does not need a lab test is so critical to preventing late-stage diagnoses, increasing survival rates, and reducing high treatment costs,” said ARPA-H Director Renee Wegrzyn, Ph.D. “With POSEIDON, we could put the power of cancer screening into homes in the U.S. and around the world.” 

“But what if any adult could, at their discretion, take an at-home test that could detect Stage I cancer? POSEIDON aims to create a future in which any adult can take a simple, over-the-counter test to screen for and detect 30+ cancers at Stage I, when they are still localized, to drastically improve the chances of curative treatment and survival,” said Ross Uhrich, DMD, MBA, ARPA-H POSEIDON’s Program Manager.

“But what if…” indeed.  ARPA-H is thinking big — as it should. And as should we all.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor

What the Health System Can Expect from a Second Trump Term

By JEFF GOLDSMITH

Though the results of the November election are by no means a foregone conclusion, it is worth thinking about how a second Trump administration might affect the nation’s $4.7 trillion health system. People were not the problem with the first Trump term; his healthcare team was strong and capable: Alex Azar, Scott Gottlieb, Seema Verma,. Bret Giroir, Brad Smith etc.  

After the embarrassing political failure of Repealing and Replacing ObamaCare in 2017 (for which blame look to his White House staff), his healthcare team settled in to a quiet and unremarkable term until the COVID wave broke over them and helped drive them out of office. It was not merely ironic but deeply disturbing that MAGA politics prevented Trump from claiming credit for the Operation Warp Speed vaccine miracle his team produced. 

A second Trump term would likely be very different- both more ideologically driven but also fiscally constrained. The people part is completely unreadable at this early hour. But health policy will almost certainly be a second tier priority because trade and tariffs, conflicts with our traditional allies and trading partners, and inflamed social issues like illegal immigration, wokeness, and abortion will crowd out changes in health coverage, costs and payment policy.   

Show Me the Money! 

However, fiscal pressures will force a second Trump administration to confront federal health spending and set him on a collision course with the hospital and pharmaceutical industries, two of the three largest organized actors in healthcare. Trump inherits a 2024 $5 trillion federal budget with a $1.7 trillion deficit, an anomalous degree of fiscal stimulus at the height of an economic boom. That deficit is also a major driver of the inflation Trump has promised to conquer.   

Trump is committed to reauthorizing the individual tax cuts from his 2017 Tax Cuts and Jobs Act which are scheduled to expire in 2025, which would add $3.3 trillion to the deficit over the next ten years. He also wants to reduce the corporate tax rate from 21% to 15%. If Trump does nothing meaningful about federal spending, his FY 26 budget, due shortly after he arrives in the White House, would harbor immense out year deficits and completely gross out both the bond and currency markets–a “Liz Truss” moment for the new regime. The promise of immediately reducing inflation which Trump made in his RNC acceptance speech goes sailing out the window.  

Savaging Medicaid Spending  (or Trying to)

Trump has tied his budgetary hands by committing to not cutting a single penny from Medicare and Social Security, which are forty percent (!) of the federal budget. This commitment appears both in the Republican platform and in Agenda47, which is the Trump campaign’s compilation of commitments made in his speeches. Trump has also committed to not reducing the $850 billion spent on Defense.

Ringfencing Social Security, Medicare and Defense leaves the more than trillion dollar Medicaid program (state and federal combined) as the largest single potential source of potential budgetary savings to avoid inflationary blow-out growth in the federal deficit. At its peak in March of 2023, Medicaid/CHIP enrolled 94 million people, or 28% of the US population. Expect an incoming Trump administration to attack Medicaid spending, both by accelerating the decline in enrollment that began in 2023 with the expiration of the COVID Public Health Emergency and by cutting rates and payments to Medicaid Managed Care providers. Some 24 million Medicaid beneficiaries have been “redetermined” and over 15 million have lost coverage. KFF says present Medicaid enrollment is about 80 million in mid-2024 but that number is certainly moving down 

While Trump has distanced himself from the Heritage Foundation’s Project 2025, that policy blueprint characterized the ObamaCare Medicaid expansion as “inappropriate” and the program itself as a “cumbersome, complicated and unaffordable burden on nearly every state”. It advocated ending what it called “financing loopholes” (e.g. provider taxes that have trued up Medicaid rates to hospitals and physicians vs. Medicare), tightening Medicaid eligibility, and imposing both work requirements and cost sharing, “reforming” disproportionate share payments, time limits and lifetime caps on Medicaid benefits and ending coverage for “middle and upper income beneficiaries”! We can certainly expect inflammatory publicity from a Trump White House on states that have expanded Medicaid eligibility to  “undocumented aliens”, followed by pressure on Congress to prohibit this coverage by statute.   

When former Trump press secretary and present Arkansas Governor Sarah Huckabee Sanders, announced her removal of 400 thousand Arkansans from Medicaid enrollment, she said she was “liberating them from dependency”.  It is likely that that millions more Americans will be “liberated from dependency” on Medicaid during the first two years of a second Trump Administration. There will be work requirements (with politically damaging pressure on the 11 million very poor or disabled “dual eligibles” eg. Medicare plus Medicaid) population), as well as cost sharing and an voucher option to purchase private insurance (!?) for Medicaid beneficiaries. An aggressive effort to “re-welfare-ize” the Medicaid program will raise numerous bureaucratic barriers to Medicaid enrollment, scaring off a lot of otherwise eligible beneficiaries. 

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My Trip To Paris This Week

By MIKE MAGEE

While others regale in the accomplishments of quirky pommel horse specialist, Stephen Nedoroscik, from Worcester, MA, or Celine Dion’s remarkable performance at the closing of the Olympics Opening Ceremonies in Paris this week, I time-traveled to Paris this week on a different mission.

I was there to visit Germaine de Staël. The French writer, who in 1803 tangled with Napoleon at the height of his power and asked him, “Who is the greatest woman in the world?”  His reply was immediate,  “She who has borne the greatest number of children.” The question alone earned her an exile from Paris to Switzerland.

It called to mind the JD Vance 2021 interview on FOX, where he tied women’s worth to birthing, stating that “We should give miserable, childless lefties less control over our country and its kids…” and claimed that their choice of cats over babies had created a collection of disgruntled women politicians who “are miserable.”

In 1803, Germaine de Stael had the last laugh, decamping to the bucolic Le château de Coppet on Lake Geneva in Switzerland. She spent the next 10 years organizing his opposition, until fleeing to Austria, then St. Petersburg, while carefully avoiding Napoleon’s northward advancing troops. On Napoleon’s defeat, she returned to Paris in 1814.

Napoleon’s campaign of terror, and ultimate defeat were also the subject of Leo Tolstoy’s legendary 1869 literary feat, War and Peace. But he could have as easily been reflecting on our two MAGA leaders and their Project 2025 sycophants a century and half later. And yet, as with Germaine de Staël, they appear to have missed that Vice President Harris was born to lead, something Tolstoy would surely have highlighted.

In his brilliant Epilogue (p.1131), Tolstoy undresses Napoleon while pointing a contributory finger at an endless array of knowing followers. Written 155 years ago, his expose’ is poignant and devastating, and worth careful consideration from all those concerned with ethical leadership, governance, and compliance.

On The Rise To Power

“(The launch requires that) …old customs and traditions are obliterated; step by step a group of a new size is produced, along with new customs and traditions, and that man is prepared who is to stand at the head…A man (like Trump) without conviction, without customs, without traditions, without a name (like Vance)…moves among all the parties stirring up hatreds, and, without attaching himself to any of them, is borne up to a conspicuous place.”

Early Success

“The ignorance of his associates, the weakness and insignificance of his opponents, the sincerity of his lies, and the brilliant and self-confident limitedness of this man moved him to the head…the reluctance of his adversaries to fight his childish boldness and self-confidence win him…glory…The disgrace he falls into…turns to his advantage…the very ones who can destroy his glory, do not, for various diplomatic considerations…”

Fawning and Bowing to Power

“All people despite their former horror and loathing for his crimes, now recognize his power, the title he has given himself, and the ideal of greatness and glory, which to all of them seems beautiful and reasonable….One after another, they rush to demonstrate their non-entity to him….Not only is he great, but his ancestors, his brothers, his stepsons, his brothers-in-law are great.”

Turning a Blind Eye

“The ideal of glory and greatness which consists not only in considering that nothing that one does is bad, but in being proud of one’s every crime, ascribing some incomprehensible supernatural meaning to it – that ideal which is to guide this man and the people connected with him, is freely developed…His childishly imprudent, groundless and ignoble (actions)…leave his comrades in trouble…completely intoxicated by the successful crimes he has committed…”

Self-Adoration, Mobs, and Conspiracy

“He has no plan at all; he is afraid of everything…He alone, with his ideal of glory and greatness…with his insane self-adoration, with his boldness in crime, with his sincerity in lying – he alone can justify what is to be performed…He is drawn into a conspiracy, the purpose of which is the seizure of power, and the conspiracy is crowned with success….”

The Spell is Broken by a Reversal of Chance

“But suddenly, instead of the chances and genius that up to now have led him so consistently through an unbroken series of successes to the appointed role, there appear a countless number of reverse chances….and instead of genius there appears an unexampled stupidity and baseness…”

The Final Act – Biden Anoints Kamala

“A countermovement is performed…And several years go by during which this man, in solitude on his island, plays a pathetic comedy before himself, pettily intriguing and lying to justify his actions, when that justification is no longer needed, and showing to the whole world what it was that people took for strength while an unseen hand was guiding him…having finished the drama and undressed the actor.”

As both Trump and Vance are learning the hard way, celebrity in America is a double-edged sword. In an inaugural speech, prosecutor met defendant head on.

“I took on perpetrators of all kinds. Predators who abused women, fraudsters who ripped off consumers, cheaters who broke the rules for their own gain. So hear me when I say, I know Donald Trump’s (and JD Vance’s) type.”

Kamala Harris #understands the assignment.

Mike Magee MD is a Medical Historian and a regular THCB contributor. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex. (Grove/2020)

No, Health Care Is NOT Brat

By KIM BELLARD

Until last week, I thought “brat” referred to an obnoxious child. I was vaguely aware of Charli XCX, but I wasn’t aware that earlier this summer she’d dropped a new album with that name, or that the cultural zeitgeist subsequently declared this to be Brat Summer. Then last weekend in the space of a day, Joe Biden dropped out of the Presidential race, Vice President Harris became the presumptive Democratic presidential nominee, and Charli XCX tweeted “kamala IS brat.”

V.P. Harris’s campaign exploded. Most of us had kind of been dreading the campaign between two eighty-year-old white guys, and then suddenly we had a mixed heritage woman as a candidate, who even at 59 seemed positively youthful by comparison. And brat to boot!

It’s been hilarious to watch people like Stephen Colbert or Jake Tapper try to explain brat to their viewers. Charli XCX herself described it on TikTok as:

That girl who is a little messy and likes to party, and maybe says dumb things sometimes, who feels herself but then also maybe has a breakdown but parties through it. It’s very honest; it’s very blunt—a little bit volatile, does dumb things, but, like, it’s brat. You’re brat. That’s brat.

It’s been taken much further than that, of course. An article in The Guardian described it: “Because, as we all know by now, brat – inspired by Charli’s most recent album – is more than a name, it’s a lifestyle. It is noughties excess, rave culture. It’s “a pack of cigs, a Bic lighter, a strappy white top with no bra”. It’s quintessentially cool.”  Shirly Li, in The Atlantic, opined: “The essence of “brat”is not defining people as such; it’s being simultaneously provocative and vulnerable.”

But, more to the point, Xochitl Gonzalez, also writing in The Atlantic, made clear how we should think about brat: “If you don’t know what that means, it doesn’t matter.” After all, if you’re not in on the joke, you are the joke.

The Harris campaign is all in on the joke. It fully embraced the appellation, even changing its campaign logo on social media to the easily identifiable lime green of the Brat album cover. The KHive is busy creating memes, posting TikTok clips, and filling the world with coconut emojis (long story). Some have claimed that brat summer is already over, but maybe not so fast.

Whether it is the brat effect or simply a honeymoon period for Ms. Harris, her favorability and enthusiasm ratings have soared, and the Presidential race polls again show a dead heat, after President Biden’s polls had tanked following his disastrous debate performance earlier this month. The simple fact that the Dems have a candidate who can become a cultural meme, in a good way, feels refreshing, especially in a campaign that heretofore had evoked more dread and resignation than enthusiasm.

I wish healthcare was brat.

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Succeeding in Fighting the Loneliness Epidemic

By JOSHUA SEIDMAN

In 2023, U.S. Surgeon General Vivek Murthy boldly declared that our country has a “loneliness epidemic.” In the Surgeon General’s public health advisory, “Our Epidemic of Loneliness and Isolation,” he draws on decades of empirical evidence demonstrating the tremendous toll that loneliness has on people’s quality of life, and how it also increases the risk of premature death by 26%.

The question is: What can be done to tackle this intractable public health crisis? Perhaps even more pointedly, what is anybody actually doing that successfully reduces loneliness?

Steps Required to Reduce Loneliness

The first thing we have to do, as the Surgeon General said in his report, is “consistently and regularly track social connection using validated metrics.” Without ongoing measurement, we can’t even assess the problem, understand whether it’s getting better or worse, and know what interventions might be helping.

Furthermore, we need to tie those measurements to some sort of payment model. In order to focus providers and other stakeholders on the importance of loneliness, we need to hold them accountable for outcomes. Since we know that loneliness dramatically impacts both the quality and length of people’s lives, we should raise it as a priority for providers by tying some portion of their payment to their success in reducing loneliness.

We need to orient the health care system toward addressing factors that substantially affect the health of the population. Since the powers that be in the health care world accept smoking cessation as a valid performance measure, then it absolutely makes sense for payers and purchasers to hold providers accountable for addressing loneliness, a condition that the Surgeon General’s research equates to smoking 15 cigarettes per day.

Case Study of Success in Tackling Loneliness

Just as with any other proposed performance measure used to hold providers accountable, it’s fair to demand evidence that providers can actually influence outcomes for their patients. New research from Fountain House does just that —making clear that, with the right interventions, it is absolutely possible to measure and dramatically reduce loneliness in a way that meaningfully improves lives.

Fountain House pioneered the clubhouse model, a psychosocial rehabilitation model that supports people with serious mental illness (SMI). By addressing social drivers of health, we not only facilitate recovery, but we also reduce Medicaid costs by 21% relative to a comparable high-risk SMI population. An economic model we built also found that clubhouses reduce overall costs to society by more than $11,000 per person annually (when factoring in costs for mental and physical health, disability, criminal justice, and productivity/lost wages).

More to the point here, our population (and people with SMI generally) faces tremendous economic and social isolation and therefore are 2 to 3 times more likely than the general population to be lonely. Furthermore, research demonstrates that loneliness can be more intractable in the SMI population and failure to address it compromises their recovery and raises risk for an array of acute health events.

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Non-profit health systems driving income inequality

If you follow along with my rantings on THCB, Twitter and Linkedin you’ll know that I am unhappy with America’s growing inequality, both in wealth and income. Now, there are a few signs that so long as we have full employment the income picture for the lowest paid is getting a little better. But wealth inequality is clearly not getting better. 

You may remember this video explaining wealth inequality. Worth a watch if you haven’t seen it.

Well that was made in 2011. Back then Elon Musk was barely a billionaire, and more than a decade of massive stock market appreciation later, we know that the rich have gotten a lot richer, and their taxes went down following the Trump tax cuts in 2017.

Meanwhile, something similar has been going on in health care. The health economy has amazingly not taken much more of the overall economy since 2010. It went from 13% to 17% of GDP between 2000 and 2010 but has amazingly stayed around there–only popping up during the Covid recession and then heading down again. But the amount of money flowing into health care has stayed at a constant rate. And the American people continue to hate their experience with the health system.

They’re aren’t many selfless heroes. Payers, providers, doctors, pharma, equipment suppliers are all doing well. Wendell Potter has continued to show how health insurance companies have consolidated and gotten richer over the past decade plus. Big Pharma has managed the translation away from the mass market blockbusters of the 1990s to the high priced niche drugs of today, and now with GLP-1s is managing to keep those high prices. Despite lots of whining by the AHA, hospitals–which got massive handouts from the CARES Act during Covid–are all doing well again. But it’s always good to check in with the big non-profit systems. This isn’t the first time I’ve written about this. Early this year in a larger rant I wrote:

Over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. 

One of the things that the non-profits have to do is file the 990 form with the IRS. Among other things it shows how much money the organization’s executives make. Now it’s not like non-profit health system execs are the only ones coining it. In 2022 the biggest for-profit chain HCA’s CEO made $20m and 4 others there made over $5m. But at least HCA is a nakedly capitalist organization, and it pays taxes.

Recently one of the bigger hospital systems, UPMC put out a new 990. Unlike the previous version they put out, the 990 on their website is a photocopy that can’t be searched. Maybe that’s an accident, although any non-profit can put out an easily searchable document. For instance here’s the one from a teeny non-profit that I control. You can search the words “Reportable Compensation” and find that sadly I got paid zilch for my efforts. Not sure why UPMC can’t do the same.

Luckily for those of us who care, Propublica is a little more aggressive. They reproduced a searchable version. The way ProPublica did it was to download an xls from the IRS. One reason it’s worth looking at was that this year as opposed to 2022, UMPC didn’t post its compensation in $$ order.

I’m not knocking UPMC too much. Very few other big non-profit health systems put anything like as much effort into detailing who makes what amount on their 990s. They usually stop after the first 10-20 employees. UPMC goes down to 220+

So I copied and repasted the compensation information from ProPublica and did the necessary editing of 230 cells to be able to sort by compensation. You can find the spreadsheet here. (Feel free to copy & paste and do your own edits).

So what does it tell you? 

UPMC had a CEO called Jeffrey Romoff who worked there his whole career. Romoff became President in the 1990s and took over as CEO in 2006. Using aggressive M&A, and some very sharp elbows including against the unions, Romoff essentially created the massive local monopoly that is the modern UPMC. His biggest moment in the national spotlight was when he went on 60 Minutes in 2011 and forgot his salary (he said it was $7m but then corrected it to $6m). Ten years later Romoff’s salary was a tad under $13m. If you are wondering, the median annual wage in the US in 2011 was $34,460. By 2022 it was $45,760. So the average salary increased 34% in nominal terms over that time. Romoff’s went up by more than 100%.

But that’s all well and good. Romoff retired at the age of 75 in August 2021 and was replaced by Leslie Davis.

So for the period covering July 2022 to June 2023, who was the highest paid person at UPMC?

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IVF ban shows us the thin edge of the theocratic wedge

By MIKE MAGEE

In order to save the Republican party, we all need to vote Democratic this year.

Without hyperbole, Project 2025 feels similar to Germany in the early 1930’s. Their website introduction reads:

“It is not enough for conservatives to win elections. If we are going to rescue the country from the grip of the radical Left, we need both a governing agenda and the right people in place, ready to carry this agenda out on Day One of the next conservative Administration.”

Alabama’s 73-year old Justice Tom Parker is clearly one of those “right people.” He did not flinch in his February 16, 2024 decision in “LePage v. Center for Reproductive Medicine.” Citing an 1872 Alabama state law that allows for individuals to sue over the “wrongful death of a minor,”  he confidently declared that 8-cell embryos cryopreserved in fertility clinics were people. He then added insult to injury. He tied  the decision to declaring that individuals responsible for the mistaken loss of the cells liable for damages to the state’s (Dobbs decision enabled) 2019 law banning abortion. A messy backlash against and for IVF soon followed.

Not content to be both lawyer and doctor, Parker added theologian to his credentials stating in his decision: “In summary, the theologically based view of the sanctity of life adopted by the People of Alabama encompasses the following: (1) God made every person in His image; (2) each person therefore has a value that far exceeds the ability of human beings to calculate; and (3) human life cannot be wrongfully destroyed without incurring the wrath of a holy God, who views the destruction of His image as an affront to Himself.”

Determined radicalized leaders, fueled with a religious fervor, long ago rejected the Founding Fathers commitment to separation of Church and State.

Consider the words of James Madison, in a speech to the House of Representatives in 1789: “The civil rights of none, shall be abridged on account of religious belief or worship, nor shall any national religion be established, nor shall the full and equal rights of conscience be in any manner, or on any pretext infringed.”

As we now turn the corner on our way to a November election, it is important to acknowledge that the threat we face is larger than Trump alone. To not acknowledge the leaders of Project 2025 and beyond at this moment in our history would be equivalent to believing that WWII was only about Hitler, Mussolini, and Hirohito, when in fact the challenge was far greater than that.

Stated simply, the human species in the Axis societies had gone off the rails and channeled themselves into a death spiral. “Breaking the spell” required unprecedented force and ultimately the use of atomic bombs, followed by multi-decade investments through the Marshall Plan to reestablish civilized human societies.

It is for this reason that “limping to the finish line” is no longer an option for our nation. Project 2025, the Supreme Court’s recent Chevron decision, and the multi-pronged assault on women’s reproductive freedom all suggest that an overwhelming defeat of Republicans down ballot will be required to lay the ground for recovery of a healthy two-party Democracy.

Anything less will embolden an already captive Supreme Court and MAGA insurrectionists. A two-party system of Democracy has delivered reliable and peaceful transition of power for over two centuries until 2020. One of those parties has been usurped, placing our treasured Democracy at risk. The quickest way to reset a viable two-party system is to decisively defeat Trump and all MAGA down-ballot allies across the United States in November.

Mike Magee MD is a Medical Historian and regular contributor to THCB. He is the author of CODE BLUE: Inside America’s Medical Industrial Complex (Grove/2020).

Vote, for Health Sake

By KIM BELLARD

If you had on your political bingo card that our former President Trump would survive an assassination attempt, or that President Biden would drop out of the race a few weeks before being renominated for 2024, then you’re playing a more advanced game than I was (on the other hand, the chances that Trump would get convicted of felonies or that Biden would have a bad debate almost seemed inevitable). If we thought 2020 was the most consequential election of our lifetimes, then fasten your seat belt, because 2024 is already proving to be a bumpier ride, with more shocks undoubtedly to come.

I don’t normally write about politics, but a recent report from the Commonwealth Fund serves as a reminder: it does matter who you vote for. It is literally a matter of life and death.

The report is the 2024 State Scorecard on Women’s Health and Reproductive Care. Long story short: “Women’s health is in a perilous place.” Lead author Sara Collins added: “Women’s health is in a very fragile place. Our health system is failing women of reproductive age, especially women of color and low-income women.”

The report’s findings are chilling:

Using the latest available data, the scorecard findings show significant disparities between states in reproductive care and women’s health, as well as deepening racial and ethnic gaps in health outcomes, with stark inequities in avoidable deaths and access to essential health services. The findings suggest these gaps could widen further, especially for women of color and those with low incomes in states with restricted access to comprehensive reproductive health care.

“We found a threefold difference across states with the highest rates of death concentrated in the southeastern states,” David Radley, Ph.D., MPH, the fund’s senior scientist of tracking health system performance, said in a news conference last week. “We also saw big differences across states in women’s ability to access care.”

Joseph R. Betancourt, M.D., Commonwealth Fund President, said: “Where you live matters to your health and healthcare. This is having a disproportionate effect on women of color and women with low incomes.” Dr. Jonas Swartz, assistant professor of obstetrics and gynecology at Duke Health in Durham, North Carolina agreed, telling NBC News: “Your zip code shouldn’t dictate your reproductive health destiny. But that is the reality.”

The study evaluated a variety of health outcomes, including all-cause mortality, maternal and infant mortality, preterm birth rates, syphilis among women of reproductive age, infants born with congenital syphilis, self-reported health status, postpartum depression, breast and cervical cancer deaths, poor mental health, and intimate partner violence. To measure coverage, access, and affordability, it looked at insurance coverage, usual source of care, cost-related problems getting health care, and system capacity for reproductive health services.

There are, as you can imagine, charts galore.

The lowest performing states – and I doubt these will be a surprise to anyone — were Mississippi, Texas, Nevada, and Oklahoma. The highest rated states were Massachusetts, Vermont, and Rhode Island.

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Medicare Catheter Scam Sparks Calls for Reform

By ISSAC SMITH

According to a recent report in the Washington Post, a $3 billion scam involving urinary catheters has brought to light serious flaws in Medicare, prompting strong calls for reform. Apparently, several companies have been accused of gaming the system by submitting fraudulent bills for millions of catheters using patient and doctor information. This isn’t the first time Medicare has faced such challenges; fraudsters often target the system, especially in cases involving unnecessary medical equipment. With a budget nearing $1 trillion, the agency has faced significant challenges in tackling fraudulent claims for durable medical equipment. Leaders at CMS have appealed to Congress for more resources to strengthen their efforts against potential scammers.

Healthcare providers and lawmakers are now pushing for tougher measures to crack down on these companies and improve fraud prevention efforts. The National Association of Accountable Care Organizations (ACOs) has praised CMS for taking steps to address suspicious billing practices related to catheters, underscoring the importance of policy changes to protect against future abuses.

“This is unlike anything we have seen before in terms of its size and scope,” said Clif Gaus from the National Association of Accountable Care Organizations, which played a crucial role in uncovering and drawing attention to the alleged fraud.

Several accountable care organizations (groups of hospitals and doctors) said they could each lose more than $1 million if the fraudulent billing issue isn’t fixed.

In a proposed rule released on Friday, CMS stated that an investigation is currently underway, and that initial steps have been taken in response.

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