Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday August 31 at 1pm PST 4pm EST are the small but mighty pairing of Kim Bellard (@kimbbellard); and patient safety expert and all around wit Michael Millenson (@mlmillenson).
You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
Editor Note: This article was published a week after the Republican Party Primary debate
BY MIKE MAGEE
This evening, the Republican Party will sponsor their first Primary Debate. It will be historic in featuring the absence of their lead contender for the 2024 Presidential campaign, a candidate who appears committed to the destruction of their own political party
Events over the past year clearly have confirmed that we are a “work in progress” even as we stubbornly affirm our good intentions to create a society committed to “life, liberty, and the pursuit of happiness.”
With the Dobbs’ decision, our Supreme Court has unleashed long-abandoned regressive state laws designed to reinforce selective patriarchy and undermine the stability and confidence of America’s women and families. As a result, our nation’s health professionals, and the patients they care for, potentially find themselves “on the wrong side of the law.”
Three months ago, our former President decided to deliver a message to North Carolina Republican supporters claiming that he was engaged in the “final battle” with “corrupt” forces, most especially the “Deep State” that was “out to get him.” This is the same state that politically birthed Mark Meadows, former Congressman from the 11th District of North Carolina, a position he resigned to become Trump’s Chief of Staff on March 21, 2020. That ultimately landed him a position on the roster of 19 individuals indicted by District Attorney Fani Willis on RICO charges for conspiracy and racketeering.
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BY KIM BELLARD
When I first read the reports about some Silicon Valley billionaires wanting to start a new city, I figured, oh, it’s just a bunch of rich white guys wanting to take their toys and go to a new, better home. After all, they’ve seen what’s been happening to downtown San Francisco (or Portland, or Chicago – pick your preferred city).
Cities these days may be an what one expert calls an “urban doom loop” – struggling to recover after having been hollowed out by the pandemic. These so-called elites probably figured it’s easier to build something new rather than to try to fix what already exists. And, you know, they may be right.
Now that I think about it, the same may be true of our healthcare system.
The group, fronted by a mysterious entity called Flannery Associates, has been busy buying up land outside San Francisco for the past five years, spending a reported $1b for some 57,000 acres in Solano County. The proximity of its purchases to Travis Air Force Base had already raised concerns. Believed to be behind the group are a number of well known tech names, including LinkedIn co-founder Reid Hoffman; former Sequoia Capital partner Michael Moritz; venture capitalists Marc Andreessen and Chris Dixon; Stripe co-founders Patrick Collison and John Collison; Laurene Powell Jobs, Steve Jobs widow.
It doesn’t help that earlier this year Flannery sued dozens of local landowners for colluding to drive up prices, or that they’ve been so secretive. John Garamendi, one of the area’s Congressmen, said: “Flannery Associates has developed a very bad reputation in Solano County through their total secrecy and mistreatment of generational family farmers.”
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This is the last of the classics that THCB will run to celebrate our 20th birthday. And we are finally tackling the most important of questions. Is what we call this thing one word or two? Back in 2012 Michael Millenson had the definitive answer–Matthew Holt
By MICHAEL L. MILLENSON
A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.
The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.
Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”
Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.
The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”
A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.
Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.
So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.
When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.
At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.
The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.
However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”
Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.
Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.
I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.
Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.
As the 20th Birthday rolls on I thought I’d bring out a more recent piece first published in October 2020, albeit one that relies heavily on 25 year old data to make a point. This is some evidence to back up Jeff Goldsmith’s comment on the original that for all the talk “ ‘Value based” payment is a religious movement, not a business trend’ ” By the way, Humana updated these numbers last year and there’s been basically no change — Matthew Holt
Humana is out with a report saying that its Medicare Advantage members who are covered by value-based care (VBC) arrangements do better and cost less than either their Medicare Advantage members who aren’t or people in regular Medicare FFS. To us wonks this is motherhood, apple pie, etc, particularly as proportionately Humana is the insurer that relies the most on Medicare Advantage for its business and has one of the larger publicity machines behind its innovation group. Not to mention Humana has decent slugs of ownership of at-home doctors group Heal and the now publicly-traded capitated medical group Oak Street Health.
Humana has 4m Medicare advantage members with ~2/3rds of those in value-based care arrangements. The report has lots of data about how Humana makes everything better for those Medicare Advantage members and how VBC shows slightly better outcomes at a lower cost. But that wasn’t really what caught my eye. What did was their chart about how they pay their physicians/medical group
What it says on the surface is that of their Medicare Advantage members, 67% are in VBC arrangements. But that covers a wide range of different payment schemes. The 67% VBC schemes include:
What Humana doesn’t say is how much risk the middle group is at. Those are the 7% of PCP groups being paid “FFS + care coordination payment + some shared savings” and the 36% getting “FFS + some share savings.” My guess is not much. So they could have been put in the non-VBC group. But the interesting thing is the results.
By KIM BELLARD
Since the early days of the pandemic, conspiracy theorists have charged that COVID was a manufactured bioweapon, either deliberately leaked or the result of an inadvertent lab leak. There’s been no evidence to support these speculations, but, alas, that is not to say that such bioweapons aren’t truly an existential threat. And artificial intelligence (AI) may make the threat even worse.
Last week the Department of Defense issued its first ever Biodefense Posture Review. It “recognizes that expanding biological threats, enabled by advances in life sciences and biotechnology, are among the many growing threats to national security that the U.S. military must address. It goes on to note: “it is a vital interest of the United States to manage the risk of biological incidents, whether naturally occurring, accidental, or deliberate.”
“We face an unprecedented number of complex biological threats,” said Deborah Rosenblum, Assistant Secretary of Defense for Nuclear, Chemical, and Biological Defense Programs. “This review outlines significant reforms and lays the foundation for a resilient total force that deters the use of bioweapons, rapidly responds to natural outbreaks, and minimizes the global risk of laboratory accidents.”
And you were worried we had to depend on the CDC and the NIH, especially now that Dr. Fauci is gone. Never fear: the DoD is on the case.
A key recommendation is establishment of – big surprise – a new coordinating body, the Biodefense Council. “The Biodefense Posture Review and the Biodefense Council will further enable the Department to deter biological weapons threats and, if needed, to operate in contaminated environments,” said John Plumb, Assistant Secretary of Defense for Space Policy. He adds, “As biological threats become more common and more consequential, the BPR’s reforms will advance our efforts not only to support the Joint Force, but also to strengthen collaboration with allies and partners.”
Which is scarier: that DoD is planning to operate in “contaminated environments,” or that it expects these threats will become “more common and more consequential.” Welcome to the 21st century.
Continue reading…Early this month I caught up with Torben Nielsen who is now CEO of Uptiv Health. Another one from the Redesign Health factory, Uptiv Health came out of stealth recently with the goal of improving the experience and reducing the cost of those patients who have to have regular infusion treatments. Uptiv Health just raised $7.5m and is opening its first location in Detroit at the end of August 2023, with a goal of becoming the health home of those chronic disease patients. Why do we need a new offering in infusion care? Torben will tell you–Matthew Holt
BY MIKE MAGEE
On September 25, 1939, Southern California woke with fear of The Lash of St. Francis or El Cordonazo on the horizon. The term refers to northwestern tracking, cyclone-laden storms that can hit the western shores of Mexico and California most commonly around the Feast of Saint Francis, on October 4th. This one made landfall at San Pedro, California.
The calamity that day in Southern California was a rare event, the only one of its kind in the 20th century. The last one to hit, prior to this was in San Diego on October 2,1858. The Earth’s rotation normally assures that such cyclones in this region move from east to west, and out to sea. But the 1939 storm was the exception, and the big problem was the rain, some 5 1/2 inches over a 24-hour period (though the town of Indio, in the Coachella Valley of Southern California’s Colorado Desert region experienced 7 inches and buried the valley in 4 feet of water. Forty-five died on land, and 48 perished at sea. One positive – the storm marked the end of a 1-week heat wave where Los Angeles reached 107 F degrees and claimed 100 lives.
History repeated itself 84 years later this weekend, with a memorable “Lash” on the backend of a summer heat wave. The human, economic, and ecological tolls remain to be calculated. But one thing is for certain, global warming has arrived, and with it the production of both heat and water and a new, all too familiar meteorological phenomenon, the “atmospheric river.”
NOAA defines “atmospheric river” this way: “Atmospheric rivers are relatively long, narrow regions in the atmosphere – like rivers in the sky – that transport most of the water vapor outside of the tropics. While atmospheric rivers can vary greatly in size and strength, the average atmospheric river carries an amount of water vapor roughly equivalent to the average flow of water at the mouth of the Mississippi River. Exceptionally strong atmospheric rivers can transport up to 15 times that amount. When the atmospheric rivers make landfall, they often release this water vapor in the form of rain or snow.”
To be clear, these drenching above-ground collections of water are generally a blessing because they provide most of the much-needed precipitation to California’s dry areas and replenish the water cycles in the region. But as the Earth has warmed, they more frequently represent “too much of a good thing”, and are now responsible for 90% of California’s flood damage.
Continue reading…By UWE REINHARDT
One of the greatest pleasures of running THCB has been to get to know and host the writings of some of my health policy heroes. This week I have already published work from Jeff Goldsmith, and Ian Morrison & Michael Millenson among others will be featured next week (as the party won’t quite stop). Perhaps one of the most amazing things was that the doyen of health economists, Uwe Reinhardt, offered to write some original pieces for THCB…prodded by former editor John Irvine. This is one of my favorites, riffing on a talk I heard him give in (I think) 1993 about how HCFA was like the Kremlin and how free market Reaganite Republicans had made it so. This piece is from Jan 2017 and Uwe sadly died that November.–Matthew Holt
Although, unlike most other nations, the U.S. has only two parties worth the name, their professed doctrines compared with their actions strikes me as more confusing than the well-known Slutsky Decomposition which, as everyone knows, can be derived simply from a straightforward application of Kramer’s rule to a matrix of second partial derivatives of a multivariable demand function.
The leaders of the drug industry, for example, probably are now breaking out the champagne in the soothing belief that their aggressive pricing policies for even old drugs are safe for at least the next eight years from the allegedly fearsome, regulation-prone, price-controlling Democrats. My advice to them is: Cool it! Follow me through a brief history of Republican health policy, to learn what Republicans will do to the health-care sector when it ticks them off.
Republicans like to tar Democrats over allegedly socialist policy instruments such as price controls, global budgets and deficit-financed government spending. Democrats usually roll over to take that abuse, almost like hanging onto their posteriors signs that says “Kick me.” I say “abuse,” because Republicans have never shied away from using the Democrats’ allegedly left-wing tactics when health care chews up their budgets or turns voters against them.
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By MIKE MAGEE
This week, as a fourth indictment came due, a tragic Donald Trump headed back to social media, digging himself into a hole that will eventually lead to some personal hell. But before Donald Trump, there was William Frederick Kohler.
He made his appearance on the American stage on February 28, 1995, an historian who had just completed his “Great Work” – The Guilt and Innocence of Hitler’s Germany. He was odd and dark and duplicitous. His life’s work was ready to go. All that was left was to write the introduction to his book. Instead his attention was diverted, as he followed his impulse to memorialize his own story dedicated to the “concealment of history beneath my exposition of it.”
Secretive and opaque, he was focused on a very special audience he labeled the “Party of the Disappointed People”, a group with whom he shared the affinity “that the loss has been caused in great part by others.” He hid the pages of the new and very personal (but incomplete) story from wife Marta inside the pages of the near completed Nazi history. And for some reason, he inexplicably headed to his basement and began to dig a tunnel to escape (or uncover) evil.
Kohler, like Trump, was not normal. Those who have analyzed his character describe him this way: “Preoccupied with evil, the nature of truth, and the effects of an individual’s relationship with others, he recalls his bookish childhood with a mother who drank to remember the ‘good old days’ and a bigoted father; graduate work in prewar Germany, where he hurled a brick on Kristallnacht; his unhappy marriage; and the lost love of his life, Lou, a former student. Kohler’s story exhibits the same inconsistencies and deceits he finds in history: Kohler, the personal memoirist … is as unreliable as Kohler, the eminent historian. A virtuoso performance without a grand finale.”
Kohler is the fictional creation of philosopher and novelist William H. Gass, author of the award winning novel, “The Tunnel.” The author is described in the opening line of his 2017 New York Times obituary as “a proudly postmodern author who valued form and language more than literary conventions like plot and character.” He died on December 7 of that year, at age 93, in St. Louis, where he had taught philosophy and linguistics for 30 years. Born in Fargo, North Dakota, he was translocated to Warren, Ohio at 6 months, and raised according to his own account by “an abusive, racist father and a passive, alcoholic mother.” These revealing personal details trace back to a writing style he developed and labeled, “metafiction,” or stories in which the author inserts himself.
Of more relevance to America’s current political dilemma is that Gass received his PhD from Cornell in 1954, in return for his dissertation “A Philosophical Investigation of Metaphor.” A metaphor, as we know, is “a figure of speech in which a word or phrase literally denoting one kind of object or idea is used in place of another to suggest a likeness or analogy between them (as in drowning in money).”
Gass’s love of metaphor is on full display in “The Tunnel”. You can almost hear the beloved high school advanced placement English teacher pleadingly asking her sleepy students “What do you think the tunnel represents?” Of the novel, one critic wrote, “As the novel progresses we see the lies, half-truths, violent emotions, and relative chaos of Kohler’s life laid bare, and while he continues to dig away at the memories of his past he also begins digging a tunnel out from the basement where he works, a reflection of his tunneling through himself.”
Beyond Gass’s own story line, and that of William Frederick Kohler, one can easily catch glimpses of Donald Trump. As he entered the strange world of politics, he embraced the use of metaphor with memorable 3 and 4 world phrases like “drain the swamp”, “the system is rigged,” and “take our country back.”
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