Robert Frost once said, “Home is where, when you have to go there, they have to take you in.”
Increasingly, in our struggling society, that place is your local full service community hospital. During COVID, if it wasn’t your local hospital standing up testing sites, pumping out vaccinations and working double overtime helping patients breathe, we would have lost several hundred thousand more of our fellow Americans.
But it wasn’t just COVID where hospitals leaped into the breach. As primary care physicians’ practices collapsed from documentation overburden and chronic underpayment, hospitals took them in on salary. If it wasn’t for hospitals, vast swatches of the northern most three hundred miles of the US and large stretches of our inner cities would be a physician desert. Hospitals subsidize those practices to a tune of $150k a year to have a full service medical offering and keep their own doors open.
As our public mental health system withered, the hospital emergency department (and, gulp, police forces). became our main mental health resource. Tens of thousands of mentally ill folks languish overnight in hospital observation units because, despite not being “acutely ill”, there is nowhere for the hospital to place them. And as our struggling long term care facilities withered under COVID, those mentally ill folks were joined in observation by seriously impaired older folks too sick to be cared for at home. As funding for public health has withered on the vine, hospitals have become the de facto public health system in the US.
On one of the Sunday morning news programs Governors Spence Cox (UT) and Jared Polis (CO) promoted the National Governors Association initiative Disagree Better. The initiative urges that we practice more civility in our increasingly civilized political discourse. It’s hard to argue the point (although one can question why NGA thinks two almost indistinguishable, middle-aged white men should be the faces of the effort), but I found myself thinking, hmm, we really need to do that in healthcare too.
No one seems happy with the U.S. healthcare system, and no one seems to have any real ideas about how to change that, so we spend a lot of time pointing fingers and deciding that certain parties are the “enemy.” That might create convenient scapegoats and make good headlines, but it doesn’t do much to solve the very real problems that our healthcare system has. We need to figure out how to disagree better.
I’ll go through three cases in point:
Health Insurers versus Providers of Care
On one side, there are the health care professionals, institutions, organizations that are involved in delivering care to patients, and on the other side there are health insurers that pay them. Both sides think that the other side is, essentially, trying to cheat them.
Filling in the holes of recent stories in the New York Times, and Propublica on the outpatient care of patients with peripheral arterial disease
Most have gotten used to egregiously bad coverage of current events that fills the pages of today’s New York Times, but even by their now very low standards a recent telling of a story about peripheral artery disease was very bad.
The scintillating allegation by Katie Thomas, Jessica Silver-Greenberg and Robert Gebeloff is that “medical device makers are bankrolling doctors to perform artery clearing procedures that can lead to amputations”.
The reporters go on to tell a story about patient Kelly Hanna, who presented to a physician, Dr. Jihad Mustapha, in a private clinic with a festering wound. After being diagnosed with a poor flow to her leg that was likely contributing to the wound, Dr. Mustapha performed multiple procedures on her leg to improve blood flow in an attempt to ward off a future amputation. The procedures were unsuccessful, and Ms. Hanna ultimately did need an amputation.
Every time I get around to sending out the THCB READER I add a short & usually not to sweet commentary on some aspect of health care.–Matthew Holt
I saw the obesity crisis up close this week. And by that I’m not just referring to my addiction to Salted Caramel with Pretzel Ice Cream, bad though it is. Instead I felt thin because I went to Disneyland. But while I tip the scales at a BMI of 30 if I’m lucky, I genuinely felt that looking around Disneyland more than 50% of the crowd were obese and many morbidly so.
The rest of my trip to Southern California was quite a contrast because I’ve been watching a girls water polo tournament. Those young women and most of their families, as you’d expect, look very different. In this crowd I am definitely on the other end of the spectrum.
Obviously there’s a big socio-economic difference between the Disneyland attendees and a crowd centered around a sport largely played by rich, white kids. But at a time where we are arguing about whether Ozempic and its fellow anti-obesity drugs should be available via insurance, we seem to have no other strategies to fight the nation’s slide to obesity.
You’ve probably seen those photos of people on the beach in the 1960s where everyone is thin. I won’t claim to understand the science of what happened but clearly the prevalence of high fructose corn syrup and other highly processed food has much to do with it. As does the free rein food companies have had to advertise what are addictive products. I don’t know how we get to be a nation where everyone eats and exercises like a water polo player. But clearly we need significant changes in our agriculture and nutrition policies. We did it with smoking, so we know it can be done. If you don’t think we need it, I recommend a trip to Disneyland (and that’s the only reason I recommend one!)
Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work. (Sinsky et al, 2016)
If we only had the tools and the administrative support that just about every one of us has been asking for, there wouldn’t be a doctor shortage.
The quote here is from 7 years ago and things have gotten even worse since then.
Major league baseball players don’t handle the scoring and the statistics of their games. They just play ball.
Somehow, when the practice of medicine became a corporate and government business, more data was needed in order to measure productivity and quality (or at least compliance with guidelines). And somehow, for reasons I don’t completely understand and most definitely don’t agree with, the doctors were asked not only to continue treating our patients, but also to more than double our workload by documenting more things than we ourselves actually needed in order to care for our patients. Even though we were therefore becoming data collectors for research, public health and public policy, we were not given either the tools or the time to make this possible – at least not without shortchanging our patients or burning ourselves out.
We didn’t sign up to do all this, we signed up to care for our patients. And we were given awkward tools to work with that in many ways have made it harder to document and share with our colleagues what our clinical impressions and thinking are.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday July 20 at 1pm PST 4pm EST are futurists Jeff Goldsmith; patient advocate Robin Farmanfarmaian (@Robinff3); Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune); and our special guest Investor at Bessemer Sofia Guerra (sofiaguerrar)
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.
The All-in podcast is a fairly popular show that features successful silicon valley investors commenting about everything worth commenting on from politics to health. The group has good chemistry and interesting insights that breaks the mold of the usual tribal politics that controls legacy media analysis of current events.
Brad Gerstner, who is actually a guest host for this particular episode starts off by referencing something called Heartflow to evaluate the heart that has been recommended by one of the other hosts: Chamath Palihapitiya. Brad apparently asked his primary care physician about Heartflow and was instead directed to get a calcium scan.
Heartflow is a proprietary technology that purports to evaluate the presence of significant narrowing in the coronary arteries just by doing a heart CT scan. A calcium score is a low-dose CT scan used to identify the presence of calcium in coronary vessels.
The segment ends with a recommendation for everyone over the age of 40 to get some type of heart scan, so I thought it would be worth reviewing some of the main claims.
Question 1. Does Brad need a calcium scan?
Brad notes that his primary care physician told him he was young, fit, and had a low bad cholesterol (LDL) and needed a calcium scan rather than a heart flow scan. The answer to this question and the questions to follow depend on what outcome Brad is looking for. If the goal is to feel happier knowing if he has coronary calcium than the resounding answer is to get the calcium scan. But if the goal is to live longer and healthier, there is nothing to suggest a calcium scan will help. Most cardiologists believe that the lower the LDL, the better cardiovascular outcomes are. So if a calcium scan convinces Brad to NOT lower his LDL further either naturally or with medications, a calcium scan may be detrimental.
We have zero evidence to suggest patients who get calcium scans lower their risk of future mortality.
As health care continues to move in the direction of unaffordability, policy makers are considering a range of options to bring down health care costs. The Health Affairs Committee on Health Care Spending and Value has identified four broad areas for reform, including administrative savings, price regulation and supports for competition, spending growth targets, and value-based payment. These measures appropriately target health care’s supply side and the excesses that exist in the health care system.
In this blog, I would like to highlight another avenue for savings: one that focuses on the demand side of the equation. It is possible to reduce health care expenditures by reducing the demand for care. This is distinct from rationing, which is the denial of needed care. I’m referring to genuine health improvements that make health care less necessary in the first place. This type of health improvement is the sweet spot of health care cost containment, benefiting both patients and purchasers.
In a previous blog, I posed the question: in an ideal world, how much would we spend on health care? I posited that in a perfect world, we would spend zero on health care because no one would be sick. While such a perfect world may be unachievable, having the goal in mind can serve to guide our way in the present moment—like entering a destination into GPS.
Measures that promote genuine health improvement can alleviate the burden of illness while at the same time reducing the cost of care. They move us in the direction we want to go. In this blog I provide several such examples.
OK, for you amateur (or professional) epidemiologists among us: what are the leading causes of death in the U.S.? Let’s see, most of us would probably cite heart disease and cancer. After that, we might guess smoking, obesity, or, in recent years, COVID. But a new study has a surprising contender: poverty.
It’s the kind of thing you might expect to find in developing countries, not in the world’s leading economy, the most prosperous country in the world. But amidst all that prosperity, the U.S. has the highest rates of poverty among developed countries, which accounts in no small part for our miserable health outcomes. The new data on poverty’s mortality should come as no surprise.
The study, by University of California Riverside professor David Brady, along with Professors Ulrich Kohler and Hui Zheng, estimated that persistent poverty – 10 consecutive years of uninterrupted poverty – was the fourth leading cause of death, accounting for some 295,000 deaths (in 2019). Even a single year of poverty was deadly, accounting for 183,000 deaths.
“Poverty kills as much as dementia, accidents, stroke, Alzheimer’s, and diabetes,” said Professor Brady. “Poverty silently killed 10 times as many people as all the homicides in 2019. And yet, homicide firearms and suicide get vastly more attention.”
The study found that people living in poverty didn’t start showing increased mortality until in their 40’s, when the cumulative effects start catching up. The authors note that these effects are not evenly distributed: “Because certain ethnic and racial minority groups are far more likely to be in poverty, our estimates can improve understanding of ethnic and racial inequalities in life expectancy.”
In George Packer’s classic 2013 New Yorker article titled “Change the World: Silicon Valley transfers its slogans – and its money – to the realm of politics,” there is a passage worth a careful reread now a decade latter.
Packer shares an encounter with a 20-something techie critiquing his young colleagues who said, “Many see their social responsibility fulfilled by their businesses, not by social or political action. It’s remarkably convenient that they can achieve all their goals just by doing their start-up. They actually think that Facebook is going to be the panacea for many of the world’s problems. It isn’t cynicism—it’s arrogance and ignorance.”
Packer’s assessment at the time was “When financiers say that they’re doing God’s work by providing cheap credit, and oilmen claim to be patriots who are making the country energy-independent, no one takes them too seriously—it’s a given that their motivation is profit. But when technology entrepreneurs describe their lofty goals there’s no smirk or wink.”
Or, as others might say, “They believe their own bull shit.” Where many of us are currently focused on issues of values, fairness and justice, those in the shadows of Silicon Valley see the challenge to be inefficiency and incompetence, and the solution amenable to technologic engineering.