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I Have Some Silly Questions

BY KIM BELLARD

Last year I used some of Alfred North Whitehead’s pithy quotations to talk about healthcare, starting with the provocative “It is the business of the future to be dangerous.”  I want to revisit another of his quotations that I’d like to spend more time on: “The silly question is the first intimation of some totally new development.” 

I can’t promise that I even have intimations of what the totally new developments are going to be, but if any industry lends itself to asking “silly” questions about it, it is healthcare. Hopefully I can at least spark some thought and discussion.  

In no particular order:

Why do we prefer to spend money on care when people are no longer healthy than we do on keeping them healthy?

The U.S. healthcare system well known for being exorbitantly expensive while delivering rather mediocre results.  Everyone laments it but we keep throwing more money into the system that is producing these results. 

We’d be smarter to invest in upstream spending.  Like making sure people get enough to eat, with foods that are good for us.  We’d rather spend money on diabetes or obesity drugs rather than addressing the root causes of each disease.  Or like making sure the water we drink, the air we breathe, the things we eat, aren’t polluted (how many toxins or microplastics have you ingested today?).  Not to mention reducing poverty, improving education, or fixing social media

We know the kinds of things we should do, we say we want to do them, but we lack the political will to achieve them and the infrastructure to ensure them.  So we end up paying for our neglect through our ever-more expensive healthcare system.  That’s silly.

Why is everything in healthcare so expensive? 

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Coverture – Could History Repeat?

BY MIKE MAGEE

All eyes were on Wisconsin – not last week, but in 1847. That’s when Wisconsin newspaperman and editor of the Racine Argus, Marshall Mason Strong, let loose in a speech on the disturbing trend to allow women the right to buy and sell property. It seems the state had caught the bug from their neighbor, Michigan, which was considering loosening coverture laws.

“Coverture”  is a word you may not know, but should. It was a series of laws derived from British Common Law that “held that no female person had a legal identity.” As legal historian Lawrence Friedman explained, “Essentially husband and wife were one flesh; but the man was the owner of that flesh.” From birth to death, women were held in check economically. A female child was linked by law to father’s entitlements. If she was lucky enough to be married, she lived off the legal largesse of her husband. They were one by virtue of marriage, but that one was the husband, as signified by taking his last name.

The practice derived from British law. Women were held in matrimonial bondage in England with the aid of ecclesiastical courts and the officiating presence and oversight of an Episcopalian clergyman. This meant control over getting married as well as well as the capacity to escape a marriage marred by abuse or desertion. Not that there was much call for divorce. Britain was a divorceless society. The richy rich occasionally could be freed by a special act of Parliament. But this was exceedingly rare. Between 1800 and 1836, there were less than 10 divorces granted per year in England. For the unhappy rest, it was adultery or desertion.

The divorceless society held for the first half of the 19th century in most of the states below the Mason-Dixon line, with South Carolina being the most restrictive. But every New England state had a general divorce law before 1800, as did New York, New Jersey and Tennessee. “Grounds” (which varied from state to state) were presented in an ordinary lawsuit by the innocent party.

Demand for divorce grew as America grew in the first half of the 19th century. With mobility came hardship and “odious abuse’, and increasing recognition that “a divorceless state is not necessarily a state without adultery, prostitution and fornication. It is certainly not a place where there are no drunken, abusive husbands.” And then there was the issue of property rights and its ties to economic growth in this still young nation.

America was rich in land, which rapidly translated into a fast-expanding smallholder middle-class. Relationships could shift on a dime, resulting in property disputes and threats to the legitimacy of children and one’s heirs. The numbers of land owners, fueled by westward expansion were enormous, and each had a stake in society. When push came to shove, economics won out over Puritan instincts – but not without a fight.

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Obesity is crippling the US, but there are solutions

By STEPHANIE TILENIUS

Well over a third of Americans are obese — and the percentage keeps growing at a staggering rate. Over the last twenty years, obesity prevalence grew from 30% to 42% of the US population and rates of severe obesity nearly doubled. If we don’t make serious changes to our healthcare system, it’s scary to think where we’re headed in a few short years.

The fact is, obesity is far from a cosmetic condition. It can be a devastating disease and was classified as such by the American Medical Association in 2013. Obesity is the leading risk factor for deadly diseases like type 2 diabetes, heart disease, stroke, and at least 13 types of cancer.

If we don’t stop the obesity epidemic in its tracks now, we’re in for a world of hurt. People’s lives, the healthcare system, and, by extension, the US economy could be headed for collapse if we continue to ignore it. Cardiometabolic conditions like obesity, heart disease, stroke, and diabetes cost the US healthcare system upwards of $500 billion a year in healthcare costs and another $147 billion in lost workforce productivity for heart disease and stroke alone.

And yet private and government-sponsored health plans are dragging their feet to address obesity head on. They know most people jump from health plan to health plan every few years, so they’re willing to take the chance that their members with obesity won’t develop high-cost complications soon enough to justify treatment now. And yet treatment could reverse the effects of obesity and downstream chronic disease, saving lives and billions of dollars in the long run.

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Can we trust ChatGPT to get the basics right?

by MATTHEW HOLT

Eric Topol has a piece in his excellent newsletter Ground Truth‘s today about AI in medicine. He refers to the paper he and colleagues wrote in Nature about Generalist Medical Artificial Intelligence (the medical version of GAI). It’s more on the latest in LLM (Large Language Models). They differ from previous AI which was essentially focused on one problem, and in medicine that mostly meant radiology. Now, you can feed different types of information in and get lots of different answers.

Eric & colleagues concluded their paper with this statement: “Ultimately, GMAI promises unprecedented possibilities for healthcare, supporting clinicians amid a range of essential tasks, overcoming communication barriers, making high-quality care more widely accessible, and reducing the administrative burden on clinicians to allow them to spend more time with patients.” But he does note that “there are striking liabilities and challenges that have to be dealt with. The “hallucinations” (aka fabrications or BS) are a major issue, along with bias, misinformation, lack of validation in prospective clinical trials, privacy and security and deep concerns about regulatory issues.”

What he’s saying is that there are unexplained errors in LLMs and therefore we need a human in the loop to make sure the AI isn’t getting stuff wrong. I myself had a striking example of this on a topic that was purely simple calculation about a well published set of facts. I asked ChatGPT (3 not 4) about the historical performance of the stock market. Apparently ChatGPT can pass the medical exams to become a doctor. But had it responded with the same level of accuracy about a clinical issue I would be extremely concerned!

The brief video of my use of ChatGPT for stock market “research” is below:

Implementation May Be a Science, But, Alas, Medicine Remains an Art

By KIM BELLARD

I’ve been working in healthcare for over forty (!) years now, in one form or another, but it wasn’t until this past week that I heard of implementation science.  Which, in a way, is sort of the problem healthcare has. 

Granted, I’m not a doctor or other clinician, but everyone working in healthcare should be aware of, and thinking a lot about, “the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services” (Bauer, et. al). 

It took a JAMA article, by Rita Rubin, to alert me to this intriguing science: It Takes an Average of 17 Years for Evidence to Change Practice—the Burgeoning Field of Implementation Science Seeks to Speed Things Up.

It turns out that implementation science is nothing new. There has been a journal devoted to it (cleverly named Implementation Science) since 2006, along with the relatively newer Implementation Science Communications. Both focus on articles that illustrate “methods to promote the uptake of research findings into routine healthcare in clinical, organizational, or policy contexts.” 

Brian Mittman, Ph.D., has stated that the aims of implementation science are:

  • “To generate reliable strategies for improving health-related processes and outcomes and to facilitate the widespread adoption of these strategies.
  • To produce insights and generalizable knowledge regarding implementation processes, barriers, facilitators, and strategies.
  • To develop, test, and refine implementation theories and hypotheses, methods, and measures.”

Dr. Mittman distinguished it from quality improvement largely because QI focuses primarily on local problems, whereas “the goal of implementation science is to develop generalizable knowledge.” 

Ms. Rubin’s headline highlights the problem healthcare has: it can take an alarmingly long time for empirical research findings to be incorporated into standard medical practice.  There is some dispute about whether 17 years is actually true or not, but it is widely accepted that, whatever the actual number is, it is much too long.  Even then, Ms. Rubin reminds us, it is further estimated that only 1 in 5 interventions make it to routine clinical care.  

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THCB Spotlight: Glen Tullman, Transcarent & Aneesh Chopra, Carejourney

No THCB Gang today because my kid is in the hospital (minor planned surgery) So instead I am reposting this great interview from last week.

I just got to interview Glen Tullman, CEO Transcarent (and formerly CEO of Livongo & Allscripts) & Aneesh Chopra, CEO Carejourney (and formerly CTO of the US). The trigger for the interview is a new partnership between the two companies, but the conversation was really about what’s happening with health care in the US, including how the customer experience needs to change, what level of data and information is available about providers and how that is changing, how AI is going to change data analytics, and what is actually happening with Medicare Advantage. This is a fascinating discussion with two real leaders in health and health techMatthew Holt

Trump As Catalyst For Legal and Cultural Reform

BY MIKE MAGEE

Former President Donald Trump’s indictment this morning reinforces most Americans’ belief that “No man is above the law.” But few of us have taken the time to explore what that statement means when it comes to building a healthy nation, and why we believe it.

How do you create a healthy nation? 

This is at once a very simple and a very complex question. It is at the heart of successful and failed nation building. 

It applies equally to a self-assessment of our approach to rebuilding Germany and Japan as part of the Marshall Plan after WW II, and to our own struggles with autonomy and disparity in America where our very beginnings were (and continue to be) marred by a history of enslavement of blacks, forced migration and cultural destruction of Native Americans, and subjugation of women.

The law, a blend of agreed upon rules, regulations and boundaries, arose in layers over time, and reflected the communities where they emerged. Our own American legal system, on which we relied to launch this nation-building exercise in 1776, is dynamic and continues to evolve to this day. 

As legal historian Lawrence Friedman wrote, “Despite a strong dash of history and idiosyncrasies, the strongest ingredient in American law at any given time is the present – current emotions, real economic interests, and concrete political groups.” It is then “a study of social development unfolding through time…”

When building a nation, some countries like France and Germany, relied on written codified rules, statutes or “rational instruments” on which they leaned to create order and to base decisions. But our laws, upon which this nation was built, if they have a basis, were descendant from British law.

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I Have No Mouth, Yet Still I Scream

BY KIM BELLARD

In light of the recent open letter from AI leaders for a moratorium on AI development, I’m declaring a temporary moratorium on writing about it too, although I doubt either one will last long (and this week’s title is, if you hadn’t noticed, an homage to Harlan Ellison’s classic dystopian AI short story).  Instead, this week I want to write about plants. Specifically, the new research that suggests that plants can, in their own way, scream. 

Bear with me.

To be fair, the researchers don’t use the word “scream;” they talk about “ultrasonic airborne sounds,” but just about every account of the research I saw used the more provocative term.  It has long been known that plants are far from passive, responding to stimuli in their environment with changes in color, smell, and shape, but these researchers “show that stressed plants emit airborne sounds that can be recorded from a distance and classified.”  Moreover, they posit: “These informative sounds may also be detectable by other organisms.”  

It should make you wonder what your houseplant is saying about you when you forget to water it or get a cat.  

They basically tortured – what else would you call it? – plants with a variety of stresses, then used machine learning (damn – I guess I am writing about AI after all) to classify, with up to 70% accuracy, different categories of responses, such as too much water versus too little.  Even plants that have been cut, and thus are dying, can still produce the sounds, at least for short periods.  They speculate that other plants, as well as insects, may be able to “hear” and respond to the sounds.

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Can American Democracy Pass The Trump Stress Test?

BY MIKE MAGEE

As we enter a new and potentially historic week, with a former President doing his best to reignite a Civil War in our nation, we do well to take a breath and reread James Madison’s words from Federalist No. 51. But first, a few words of history.

When it came to checks and balances in this new national experiment in self governance, the Founders, while establishing three co-equal branches, left one of those branches the task of defining by practice its own power and influence.

The new Constitution in 1787 awarded one branch, the elected Congress, the daunting power to impeach, convict and remove representatives or appointed federal officials for due cause up to the President himself. But it also empowered a second branch, the Executive, through its President, veto power to check legislative excesses and the privilege of initiating appointments to the federal judiciary. Only the third branch of the government, the Judiciary, was left deliberately “elastic,” destined to grow into “the triangle of power.”

Thirteen years later, on February 17, 1801, Congress was forced to break a tie in the Electoral College vote, resolving a Constitutional crisis and declaring a victor in one of “the most acrimonious presidential campaigns” in U.S. history. Thomas Jefferson was awarded the victory, and John Adams acquiesced and was sent packing a month later. But two days before he departed, Adams unloaded multiple appointments of circuit justices and justices of the peace which the U.S. Senate quickly confirmed on March 3rd. In the rush, Adam’s Secretary of State, John Marshall (soon to become Chief Justice Marshall of the Supreme Court under President Jefferson) didn’t have time to complete a final necessary step, delivering the commissions, to some of the appointees.

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THCB Gang Episode 122, Thursday March 30

Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday March 30th at 1PM PT 4PM ET are Olympic rower for 2 countries and DiME CEO Jennifer Goldsack, (@GoldsackJen); patient safety expert and all around wit Michael Millenson (@mlmillenson); benefits expert Jennifer Benz (@Jenbenz); and our special guest health economist & Chief Research Officer at Trilliant Health, Sanjula Jain @sanjula_jain.

If you’d rather listen, the “audio only” version is preserved as a weekly podcast available on our iTunes & Spotify channels — Matthew Holt

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