InsideSources

One of us is an economist, the other a doctor, and both of us look forward to uberizing healthcare. Healthcare will be the better for absorbing some of the technologies that made Uber a great success story. In the popular imagination, “uberization” has many meanings, so we’ll be more specific.

Uber created a fast, convenient means of requesting that an automobile pick you up at some spot. A Google search on “uberization of medicine” and “uberization of healthcare” suggests that many people using these terms focus mostly on the ease and speed of making appointments and reaching doctors. The popular KevinMD.com site, for example, says that Uberization will, “bring consultations by physicians to patients via their smartphones, on-demand, wherever and whenever they request them.” But that’s only part of Uber’s success. In multiple ways, Uber offered markedly improved quality over traditional taxis.

As we’ve written elsewhere, Uber makes it easy for anyone with a smartphone to summon a ride with just a few taps. But Uber also accumulates vast data on roadways and destinations to improve the quality of the ride. During peak-demand periods, it raises prices to minimize wait times and smooth patterns of demand and supply. It provides riders with second-by-second progress on the car’s whereabouts before and during the ride. It offers drivers real-time advice on optimal routes—with a constant awareness of traffic jams, accidents, and closures—giving novice drivers virtual geographic expertise that would otherwise take years to accumulate. (See “Gigs, Jobs, and Smart Machines,” by Graboyes, on Uber versus London cabbies.)

Uber enables rapid evaluation of driver and passenger quality, expedites payments, and provides passengers and drivers with precise records of the times and route. Riders and drivers receive information on one another before they meet—imparting a degree of safety that taxis cannot replicate. And Uber makes all of these processes highly intuitive to both driver and rider.

Uberization of healthcare means the development of digital technologies that similarly ease the process of connecting patients and providers, expedite their care, offer clinical advice along the way, simplify record-keeping and payments, enable patients and providers to monitor progress and results, and accumulate indicators of quality and safety—all in intuitive, convenient ways.

We’re confident that in the not-so-distant future, a 52-year-old man who feels thumping in his chest will open a medical smartphone app and be connected in seconds to a qualified healthcare professional. Not only will this clinician have immediate access to a fully digitized record of the patient’s past medical history, but also the results of vital signs and an EKG transmitted by sensors from the patient’s smartwatch. Algorithms will incorporate the patient’s past and current conditions into the provider’s data. The system will generate a diagnosis-and-treatment plan.

If the patient needs prompt medical care, an ambulance will be dispatched to bring him to an emergency room. If the situation is less dire, an Uber driven by a medic will be on its way. If further consultation with a specialist is advisable, that can be accomplished within minutes by telemedicine.

Pregnant women with cramps, diabetics with vomiting, and children with a cough and fever will get similarly rapid attention, regardless of the time of day or night. The medical organization to which the patient subscribes will have participating healthcare providers around the globe in different time zones. There will always be awake, alert, well-trained, certified clinicians available when the patient opens the app. Importantly, patient satisfaction will be continuously monitored. Competition between different healthcare plans will help keeps costs down and quality high.

Will patients and providers want uberization? We can only respond with a question: In 2008, how many Americans wanted a button on their cellphones that would summon a total stranger, driving his own car as a side gig, to pick them up late at night in a dicey neighborhood and drive them to their home? Very likely, few would have said “yes.” But Uber correctly gambled otherwise.

To quote another high-tech entrepreneur, Apple CEO Tim Cook, “Our whole role in life is to give you something you didn’t know you wanted. And then once you get it, you can’t imagine your life without it.”

Cyber attacks on hospitals and healthcare providers have become a regular occurrence.  On Feb. 1, it was Easton Hospital in Easton, Pennsylvania. On Feb. 4, it was the Catawba Valley Medical Center in Hickory, North Carolina. On Feb. 20, it was the Calbrini Hospital in Melbourne, Australia.

As more and more hospitals suffer ransomware attacks, cybersecurity experts say the healthcare industry must up its cyber game before their patients suffer the consequences. Stuart Madnick, a professor of information technology and engineering systems at MIT’s Sloan School of Management, told InsideSources that hospitals are experiencing up to 70 percent of all ransomware attacks.

They’re an easy target, he said, because when hackers hold health records and sensitive patient data hostage, hospitals have no choice but to pay the ransom. Refusing to pay means patients could lose control over their personal health information (PHI), or worse, have life-saving surgeries postponed.

In 2017, North Korean hackers used a “WannaCry” ransomware attack on Great Britain’s National Health Service, which resulted in canceled operations and delayed medical appointments.

According to a July 2018 Maturitas study, electronic health records (EHR) and individual medical devices (like pacermakerss) are highly vulnerable to cybercrime. The study concludes that “cybersecurity is critical to patient safety, yet has historically been lax,” and the industry may need regulation to make cybersecurity “an integral part of patient safety.”

Digitized medical devices for patients, in particular, can pose a serious cyber risk to patients’ health.

“One of my nephews has diabetes and he has Wi-Fi connected insulin pumps and can control it from his phone, and when he goes to the doctor, the doctor can download the data,” Madnick told InsideSources.

Part of the problem lies in the healthcare supply chain. Hospitals almost never focus on cybersecurity as a top priority, so when they order new equipment — which is increasingly digitized and connected to the cloud — they don’t necessarily ensure the equipment hasn’t been tampered with or ensure it isn’t susceptible to malware.

“When it comes to buying a new MRI machine or a new firewall, it’s easy to understand where the emotions lie. They’re not thinking about putting their patients at risk,” Madnick said.

Suppliers are to blame as well, he said. As technology advances rapidly, the priority for a healthcare supplier is to develop new, affordable equipment and get it to market as quickly as possible and thus solidify its place as the primary supplier.

But another major contributor to cyber vulnerability is the decentralized nature of the healthcare system. The industry is increasingly specialized, so there’s not always an incentive for cardiologists to talk to a neurologist about cyber concerns with regard to medical equipment and computers. Because many departments may not talk to each other, developing a bird’s eye view of the cyber ecosystem within any particular hospital is difficult.

“A lot of the clout rides in the practices, so there isn’t a good way to rally people together,” Madnick said. “You go to the head of cardiology and say, we want to take some of your budget and invest in cybersecurity instead of a new MRI machine, and that’s not an easy sell.”

A February 2017 Technology and Health Care study pointed out that hospitals are notoriously slow to update their technology, and as a result, do not “keep up with the [cyber] threats.” As hospitals race to modernize with new equipment and devices from healthcare startups, many don’t even realize the risks they’re taking.

To meet the need, more and more cybersecurity startups specialize in the healthcare industry. For example, ClearDATA provides information security for healthcare providers, ID Experts helps the industry combat fraud, Protenus monitors a patient’s EHR for suspicious activity and issues alerts, and Senrio offers cybersecurity services for medical devices.

As of 2018, there are more than 125 startups specializing in healthcare cybersecurity across the U.S. and Canada. But changes won’t happen overnight for an industry not known for its tech-savvy.

“Hospitals are beginning to respond,” Madnick said. “Two to three years ago, this wasn’t on their radar.”

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On Election Day, Democrats won a majority of seats in the U.S. House of Representatives, which means it will be nearly impossible for federal lawmakers on either side of the aisle to replace the Affordable Care Act in the next two years. However, that doesn’t mean important health care reforms can’t be achieved.

Obamacare has been a disaster, plain and simple. Among its highlights: unaffordable premiums, skyrocketing deductibles, huge increases in Medicaid rolls, and fewer options for health care providers. Not only has Obamacare been outrageously expensive and conflict-ridden, it’s also on the road to financial collapse. Because many young, healthy Americans have chosen not to enroll in Obamacare due to its high costs, older and sicker people are overly represented in exchanges, driving up costs even more and creating a death spiral for this massive government boondoggle.

Although almost all Democrats initially supported Obamacare, many on the left no longer favor the program. However, this does not mean they have reversed course on their health care philosophy. Rather than embrace free-market solutions to America’s health insurance crisis, most Democrats want to give even more power to the very same people that screwed up the health insurance industry in the first place: government bureaucrats and so-called “experts” like Obamacare architect Jonathan “the stupidity of the American voter … was really critical for the thing to pass” Gruber.

In fact, a majority of Democrats now support some form of Sen. Bernie Sanders’ (I-Vermont) “Medicare for All” plan — which could cost an alarming $32 trillion over 10 years, according to a report by the Mercatus Center.

 Despite Democrats’ growing affection for Medicare for All, there’s no chance the Republican-led Senate will ever go along with such a radical proposal. However, the very fact that so many Democrats have lost faith in Obamacare may open the door for a health care reform renaissance at the state level.

The Trump administration has already embraced federalism by encouraging state lawmakers in both parties to use Section 1332 State Innovation Waivers to enact short-term, limited-duration health plans; Medicaid work requirements; and association health plans, among other policies. And the presence of a divided Congress makes it far more likely the Trump administration, which has repeatedly said it’s eager to help lower health insurance costs, will issue even more state-friendly health care rule changes.

In the wake of the election, Trump administration officials have started to advocate for state-based reforms. For instance, on November 13, Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma tweeted, “Starting in April of last year, the Trump administration called for a new era of state-federal partnership in #Medicaid. I believe a great deal of progress has been made on that front already.”

Among the reforms Verma has thus far indicated CMS will roll out is a proposal to make it easier for Medicaid and Medicare recipients to receive telehealth services.

Echoing Verma’s statement, Department of Health and Human Services Secretary Alex Azar tweeted, “With a spirit of partnership between federal and state governments, we have tremendous potential to confront the serious health challenges our country faces.”

Azar’s agency, working in coordination with CMS, could potentially unbridle state-based health care reforms that would dramatically reduce health care costs while simultaneously increasing access to quality care. Just to name a few possibilities, HHS could expand the breadth of services eligible for payments with health savings accounts, as well as issue rule changes that would further degrade Obamacare’s centralized, one-size-fits-all approach.

Obamacare has become the lemon on the corner of the lot that few lawmakers want to test drive, much less buy, but thanks to the Trump administration’s push for federalism in health care, important reform options remain.

Modesty is an essential ingredient of good medicine and good policy.

I’ve taught the economics of health to hundreds of physicians, nurses, therapists, administrators and other professionals. There’s no telling how many tens of thousands of lives they’ve saved. Though lecturing to such students is profoundly humbling, one of my principal goals is harnessing economics to teach humility to those who have much reason for pride.

In the 20th century, physicians attained godlike stature, a process described in Paul Starr’s book “The Social Transformation of American Medicine.” But the border between pride and hubris is porous, and hubris is a dangerous tonic.

My job is mostly to ask questions and poke holes in conventional wisdom — not to provide answers. Four documents described below help me in this effort.

“Determinants of Health” is a complex, but comprehensible, graphic produced by Edwin Choi and Juhan Sonin of GoInvo (a digital studio focusing on health care). It asks, “What explains differences in health across individuals?”

For providers, it’s sobering to see that medical care explains only 11 percent of the variation. Individual behavior (alcohol, drugs, diet, etc.) explains 36 percent; social circumstances (literacy, occupation, family circumstances, etc.), 24 percent; genetics and biology, 22 percent; and environmental factors, 7 percent.

This doesn’t mean medical care is unimportant. It might suggest that in pursuing health, one might spend the next million dollars on something other than medical care. It might suggest that health care isn’t to blame for America’s somewhat foreshortened average lifespan. The key is “might.”

“The Questionable Contribution of Medical Measures to the Decline of Mortality in the United States in the Twentieth Century” is a 1977 research paper by John and Sonja McKinlay. For my physician-students, a showstopper is the McKinlays’ graphs showing massive declines in deaths from measles, scarlet fever, tuberculosis and typhoid after 1900. Perplexingly, all four show effective medications (vaccine, penicillin, isoniazid, chloramphenicol) were introduced after the mortality declines, not before. What does this mean for health care? You decide.

Nobel economist Robert Fogel sought to explain why human mortality declined precipitously over the past few centuries. His 1996 paper “New Findings about Trends in Life Expectation and Chronic Diseases” mined centuries of data on agriculture, calories consumed in labor, military recruits’ height, incidence of bad teeth, and more. He found that medical care, public health and other conventional answers couldn’t explain the decline. The likeliest explanation, he found, was the decline in malnutrition during the first few years of life (including the months in the womb). No matter how well one eats later in life, poor nourishment in those early years, it seems, make organ failure and early death likely decades later.

A powerful implication is that in our well-nourished era, Americans may live longer than managers of pension funds (or Social Security) assume. Financial trouble ahead?

Finally, James A. Maccaro’s 1997 article “From Small Beginnings: The Road to Genocide” contrasted humility and hubris in mid-century European medicine. Leo Alexander, an American psychiatrist (and expert at the Nuremberg Trials) investigated why German doctors didn’t do more to stop the Nazis’ program of genocide and barbaric medical experimentation. He discovered they didn’t do more to stop the horrors because they were instrumental in creating them.

German doctors enthusiastically volunteered for servitude to, and leadership within, the Third Reich. Deputy Fuhrer Rudolf Hess declared Nazism “nothing but applied biology,” and many German doctors apparently agreed. They collectively decided that medicine’s primary purpose was building an economically productive populace — an emphasis that opened the floodgates for atrocities.

Dutch physicians, Alexander found, unanimously rejected this assumption after the Nazis conquered the Netherlands. They viewed their role as healing and comforting the sick and dying. Though threatened with punishment and death, humility assured that no Dutch doctors participated in the Holocaust.

Finally, let’s ponder the notion of humility with two fitting quotes: “Some of the biggest cases of mistaken identity,” economist Thomas Sowell wrote, “are among intellectuals who have trouble remembering that they are not God.” Novelist N.K. Jemisin once cautioned, “We can never be gods, after all — but we can become something less than human with frightening ease.”

Recent polling suggests that health care is still very much at the forefront of voters’ minds as we head into the homestretch before the midterm elections. For seniors and their families, the cost and affordability of prescription medications remains a chief concern.

Seeing the writing on the wall, Washington’s elite and the special interests they serve have coalesced around a predictable set of messages aimed more at scaring seniors than finding actionable solutions to help them. It’s a cynical ploy, and one that seniors and voters should not mistake for anything but a profit-driven enterprise.

Case in point, a new six-figure ad campaign from Patients for Affordable Drugs Now and AARP that calls on seniors to push back against cartoonish caricatures of “big pharma.” What’s the policy? How does this message benefit seniors? A casual, viewer would be hard pressed to answer those questions amid the dramatic music, flying money and photo-shopped cigars.

Pulling back the curtain reveals this push for what it is; an attempt by the insurance industry to safeguard its profits to the detriment of America’s seniors. The strong desire by the insurance industry to obfuscate and trick seniors to act against their own self-interest cannot be disentangled from these aggressive marketing tactics from AARP and Patients for Affordable Drugs Now. With undeniable ties to the insurance industry, seniors should take this latest advocacy push with a grain of salt.

Through recent litigation AARP was exposed as having made nearly 52 percent of its total operating revenue off commissions for new or renewed policies with its insurance partners. This kind of skimming by AARP was also brought to light in a class action lawsuit in which seniors alleged the “non-profit” AARP, along with its business partner UnitedHealthcare Insurance Company, artificially inflated Medicare supplemental health insurance charges for profit. The result? Senior citizens lost millions of dollars.

Washington has known this secret for years. In a 2011 investigative report by Reps. Wally Herger, R-California, and Dave Reichert, R-Washington, titled “Behind the Veil: The AARP America Doesn’t Know,” the authors found an organization run amok and lacking basic scrutiny. Not much has changed in the intervening years. AARP still runs a for-profit insurance arm that subsequently funnels money back into AARP for advocacy campaigns like the one in question. These conflicts of interest are, however, masked by an image of “senior empowerment,” which falls apart when you simply follow the money.

Patients for Affordable Drugs Now, on the other hand, is staffed by many former Obama administration officials responsible for the insurance company sweetheart deals present in the Affordable Care Act, which AARP strongly supported in 2010 over the overwhelming objections of its members.

While it’s easy for bad actors in our health care system to hide behind meaningless platitudes and scare tactics, a closer look reveals little substance to their claims. Without the right incentives in place, carefully balanced marketplaces get corrupted, creating perverse incentives and price distortions that ultimately cost consumers more.

Health care will be a critical issue come November, especially for seniors, but we should turn a skeptical eye toward the messages with a clear industry bent coming from the Washington swamp. Seniors should not be sold snake oil and told it is medicine. Lawmakers, to that end, should also carefully review the facts before taking AARP and Patients for Affordable Drugs Now at their word. Putting patients before profits will always result in pushback from special interests, but this is the vital work that we sent our representatives to Washington to do.

Iowa Gov. Kim Reynolds told reporters Tuesday that her administration will stay the course in proceeding with the state’s privatized Medicaid management system, just days after Managed Care Organization (MCO) Amerigroup notified the Iowa Department of Human Services (DHS) that it cannot take on any more members.

On Monday, it was posted on DHS’s website that those who elected to join Amerigroup after AmeriHealth Caritas announced its exit from the privatized Medicaid system this past October — ahead of the formal termination of services on November 31 —would be automatically enrolled in the state’s Fee-For-Service (FFS) program, Iowa Medicaid Enterprise (IME). Amerigroup, which currently has 186,000 Medicaid enrollees, told DHS that it currently does not have the capacity to take on new enrollees in its current structure.

Reynolds said that “around 9,000 people” in FFS enrollment are temporary until Amerigroup can “ramp up” its resources to take on new enrollees. DHS did not return inquiries about the total number of enrollees who had selected Amerigroup as their MCO and will now temporarily receive FFS.

“We’re in the transition,” Reynolds said. “We signed contracts with two providers, [United Healthcare] is taking the majority of the participants in the interim, until Amerigroup can build up their capacity, which we have every belief that they can.”

The remainder of just one MCO means that enrollees only have one choice when it comes to picking providers, however. Under federal rules and regulations for privatized Medicaid systems, qualifying enrollees must have access to a choice of providers, unless a particular state receives approval from the Centers for Medicare and Medicaid Services (CMS). DHS came under fire late last week after a memo began circulating among administration and legislative officials stating that the state had “received approval” to temporarily suspend MCO choice. DHS has since clarified its memo in illustrating the department’s authorities and responsibilities under the circumstance, and what’s allowable under state law. DHS did not return inquiries about whether or not the state will take on more of the approximately 213,000 enrollees remaining after the AmeriHealth Caritas departure.

Enrollees’ Medicaid benefits will be managed differently — one being FFS under the state, and the other in capitation (paid per enrollee and the services rendered). Typically, under an FFS system, states will simply pay care providers per service rendered, which is what drove Iowa’s spending from $2.4 billion in 2004 to $4.9 in 2015. Reynolds told reporters that the average rate of increase for FFS was 10.7 percent. In a capitation system, the state contributes funds per enrollee to MCOs, who then finance the services, shifting more of the cost burden to the companies. DHS did not return inquiries about whether or not services under FFS or capitation will be equal in quantity and quality.

Since former Gov. Terry Brandstad (now President Trump’s ambassador to China) made the announcement that the state would transition the Medicaid program back in 2015, the program and its administrators have had it anything but easy.

The implementation process was several months behind schedule, finally being handed off to the three out-of-state MCOs AmeriHealth Caritas, Amerigroup, and United Healthcare, in April 2016. Back in August 2016, AmeriHealth Caritas and Amerigroup reported losses of $42.6 million and $66.7 million, respectively, in covering healthcare costs. After one year’s worth of service, the three MCOs collectively estimated a total loss of nearly $450 million. In October 2017, AmeriHealth Caritas announced it was leaving the system after state negotiations to increase compensation for the MCOs failed. The state did agree to a 3.3 percent capitation increase for Amerigroup and United Healthcare.

Still, the Reynolds administration will continue the course.

“This is not perfect,” Reynolds said. “I never said it was perfect, but I will put in the time and the effort to show that Iowans get the care that they deserve in a managed and coordinated and more modern delivery system. I’m not going back.”

As to when Iowans would see their choices again, Reynolds was blunt, saying, “They’re going to have a choice. We’re going to work with them.”

The state of Iowa does have a request for proposal out to accept new providers into the system, however, a new MCO wouldn’t be able to enter the system until 2019.