By MIKE MAGEE

In his book, “The Age of Diminished Expectations” (MIT Press/1994), Nobel Prize winner, Paul Krugman, famously wrote, “Productivity isn’t everything, but in the long run it is almost everything.”

A year earlier, psychologist Karl E. Weich from the University of Michigan penned the term “sensemaking” based on his belief that the human mind was in fact the engine of productivity, and functioned like a biological computer which “receives input, processes the information, and delivers an output.”

But comparing the human brain to a computer was not exactly a complement back then. For example, 1n 1994, Krugman’s MIT colleague, economist Erik Brynjolfsson coined the term “Productivity Paradox” stating “An important question that has been debated for almost a decade is whether computers contribute to productivity growth.”

Now three decades later, both Krugman (via MIT to Princeton to CCNY) and Brynjolfsson (via Harvard to MIT to Stanford Institute for Human-Centered AI) remain in the center of the generative AI debate, as they serve together as research associates at the National Bureau of Economic Research (NBER) and attempt to “make sense” of our most recent scientific and technologic breakthroughs.

Not surprisingly, Medical AI (mAI), has been front and center. In November, 2023, Brynjolfsson teamed up with fellow West Coaster, Robert M. Wachter, on a JAMA Opinion piece titled “Will Generative Artificial Intelligence Deliver on Its Promise in Health Care?”

Dr. Wachter, the Chair of Medicine at UC San Francisco, coined his own ground-breaking term in 1996 – “hospitalist.” Considered the father of the field, he has long had an interest in the interface between computers and institutions of health care. 

In his 2014 New York Times bestseller, “The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age” he wrote, “We need to recognize that computers in healthcare don’t simply replace my doctor’s scrawl with Helvetica 12. Instead, they transform the work, the people who do it, and their relationships with each other and with patients.”

What Brynjolfsson and Wachter share in common is a sense of humility and realism when it comes to the history of systemic underperformance at the intersection of technology and health care.

They begin their 2023 JAMA commentary this way, “History has shown that general purpose technologies often fail to deliver their promised benefits for many years (‘the productivity paradox of information technology’). Health care has several attributes that make the successful deployment of new technologies even more difficult than in other industries; these have challenged prior efforts to implement AI and electronic health records.”

And yet, they are optimistic this time around.

Why? Primarily because of the speed and self-corrective capabilities of generative AI. As they conclude, “genAI is capable of delivering meaningful improvements in health care more rapidly than was the case with previous technologies.”

Still the “productivity paradox” is a steep hill to climb. Historically it is a byproduct of flaws in early version new technology, and status quo resistance embedded in “processes, structure, and culture” of corporate hierarchy. When it comes to preserving both power and profit, change is a threat.

As Brynjolfsson and Wachter put it diplomatically, “Humans, unfortunately, are generally unable to appreciate or implement the profound changes in organizational structure, leadership, workforce, and workflow needed to take full advantage of new technologies…overcoming the productivity paradox requires complementary innovations in the way work is performed, sometimes referred to as ‘reimagining the work.’”

How far and how fast could mAI push health care transformation in America? Three factors that favor rapid transformation this time around are improved readiness, ease of use, and opportunity for out-performance.

Readiness comes in the form of knowledge gained from the mistakes and corrective steps associated with EHR over the past two decades. A scaffolding infrastructure already exists, along with a level of adoption by physicians and nurses and patients, and the institutions where they congregate.

Ease of use is primarily a function of mAI being localized to software rather than requiring expensive, regulatory laden hardware devices. The new tools are “remarkably easy to use,” “require relatively little expertise,” and are “dispassionate and self-correcting” in near real-time when they err.

Opportunity to out-perform in a system that is remarkably inefficient, inequitable, often inaccessible and ineffective, has been obvious for some time. Minorities, women, infants, rural populations, the uninsured and under-insured, and the poor and disabled are all glaringly under-served.

Unlike the power elite of America’s Medical Industrial Complex, mAI is open-minded and not inherently resistant to change.

Multimodal, large language, self learning mAI is limited by only one thing – data. And we are literally the source of that data. Access to us – each of us and all of us – is what is missing.

What would you, as one of the 333 million U.S. citizens in the U.S., expect to offer in return for universal health insurance and reliable access to high quality basic health care services?

Would you be willing to provide full and complete de-identified access to all of your vital signs, lab results, diagnoses, external and internal images, treatment schedules, follow-up exams, clinical notes, and genomics?

Here’s what mAI might conclude in response to our collective data:

1. It is far less expensive to pay for universal coverage than pay for the emergent care of the uninsured.
2. Prior algorithms have been riddled with bias and inequity.
3. Unacceptable variance in outcomes, especially for women and infants, plague some geographic regions of the nation.
4. The manning table for non-clinical healthcare workers is unnecessarily large, and could easily be cut in half by simplifying and automating customer service interfaces and billing standards.
5. Direct to Consumer marketing of pharmaceuticals and medical devices is wasteful, confusing, and no longer necessary or beneficial.
6. Most health prevention and maintenance may now be personalized, community-based, and home-centered.
7. Abundant new discoveries, and their value to society, will largely be able to be validated as worthy of investment (or not) in real time.
8. Fraudulent and ineffective practices and therapies, and opaque profit sharing and kickbacks, are now able to be exposed and addressed.
9. Medical education will now be continuous and require increasingly curious and nimble leaders comfortable with machine learning techniques.
10. U.S. performance by multiple measures, against other developed nations, will be visible in real time to all.

The collective impact on the nation’s economy will be positive and measurable. As Paul Krugman wrote thirty years ago, “A country’s ability to improve its standard of living over time depends almost entirely on its ability to raise its output per worker.”

As it turns out, health data for health coverage makes “good sense” and would be a pretty good bargain for all Americans.

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).

Al’s son once complained to Al’s Aunt Tillie about an overbearing supervisor.  Aunt Tillie suggested that he try to work under a different supervisor.  Tillie was one of those people – and we all know them – who could be counted on to inadvertently provide punchlines when needed.  Conversely, Al is one of those people – and we all know them – who can’t resist setting up those punchlines.  So I lamented that this suggestion may not work because, “Aunt Tillie, it’s a sobering fact that 50% of all supervisors are below average.”

Tillie replied, “I blame our educational system for that.”

Likewise, we may need to blame our educational system for Keas’ new poll on workplace stress.  To begin with, the lead paragraph from Keas — which like many other companies is “the market leader” in wellness – “reveals” that “4 in 10 employees experience above-average stress.”

SAN FRANCISCO, CA – (Apr 2, 2014) – Keas (www.keas.com), the market leader in employer health and engagement programs, today released new survey data, revealing four in ten employees experience above average levels of job-related stress. Keas is bringing attention to these findings to kick off Stress Awareness Month, and is also providing additional insight and tips to bring greater awareness to the role of stress in the workplace and its impact on employee health.

Wouldn’t that mean some other employees – mathematically, also 6 in 10 – must be experiencing average or below-average levels of stress?   It would seem like mathematically that would have to be the case.   However, the Keas poll also “reveals” that while some employees are average in stress, no employee is below-average – a true paradox.  Hence Keas’ selfless reasons for publishing this poll:  All employees being either average or above average in the stress department means we have a major stress epidemic on our hands.  This perhaps explains why Keas is “bringing attention to these findings.”

In a further paradox, Keas also uses the words “average” and “normal” as synonyms, even though they are often antonyms:  All of us want our children to be normal but who amongst us wants their children to be average?

But Wait…There’s More

There appears to be a dramatic difference in stress according to gender:

The weight of stress on women – More than 7 in 10 women (72%) experience above average levels of stress, compared to 28% of men”

This 40% translates into “72% of women and 28% of men.”   Speaking of blaming our educational system, if you didn’t notice that 72% and 28% average to 50% rather than 40%, then at your next elementary school reunion, you should give your fifth-grade teacher what-for.  (And, yes, women do represent almost 50% of the workforce.)

What is the effect of all this stress?

High stress levels can cause, or worsen, a myriad of health issues for employees including heart disease obesity, cardiovascular issues, depression and diabetes (among others)

After revealing that women are almost three times as stressed as men, Keas goes on to list what it calls “the impact on employee health,” the five diseases that stress can “cause or worsen” — four of which, despite Keas’ claims of women’s stress and disease causality, are considerably more prevalent in men.  Yet again, in the immortal words of those great philosophers Gilbert & Sullivan, a most ingenious paradox.

So Educate Us:  What Does Keas Propose Doing About This?

There’s a good chance your employees are unhealthy. It’s nothing to be embarrassed about – employers at large companies are paying 36 percent more for health care than they were five years ago- but it is something that can be fixed.

Well, the good news is:  (1) unlike, for example, a spot on your tie, unhealthy employees are “nothing to be embarrassed about”; and (2) this is something that can be “fixed.”   How?  Glad you asked.  Coincidentally, Keas offers a solution — stress management.   But how will they know stress management works? Perhaps when they achieve a Lake Wobegon society in which everyone’s stress, instead of being average or above average as the Keas poll reports now, is below average.

The stress management solution they propose is simple.  To reach this elusive goal of everybody having less stress than average, you need only “actively promote health.”

If you do actively promote health – perhaps by sending a memo around saying that you are actively promoting health –your employees will become “three times more productive.”  Doing the math, this means you can lay off three-quarters of your employees without sacrificing performance.   The remaining employees will answer the phones three times faster, bag three times as many groceries, perform triple bypasses three times faster, fly planes 1500 miles per hour, and so on.

As an employer, you might question Keas’ logic and wonder whether a mass layoff could, paradoxically, make your remaining employees more stressed, thus creating a new epidemic all over again.  In that case, simply repeat all the steps in this posting, starting with fifth grade.

We’d love to end right there for dramatic effect, but at the risk of ruining a joke by explaining the punchline, we need to formalize this discussion by explaining why it is time for the wellness industry to shut up.   For 18 months we have been posting example after example of vendor outcomes — and now polls — proving the observation in Surviving Workplace Wellness that “in wellness you don’t have to challenge the data to invalidate it.   You simply have to read the data.  It will invalidate itself.”

It’s not just that companies are wasting their money, cutting real benefits in order to pay for these programs.  These programs distract employers from the major healthcare issues they should be focused on. Keas-style wellness sends corporate leaders on a fiscal wild goose chase, trying to save money on things that don’t cost them much money in the first place.  (Even as Keas says costs were increasing 36% over five years due to unhealthy employees, wellness-sensitive medical events were declining, and now represent only about 7% of corporate spending.)

Corporate leaders can lower their own stress levels, which will notably lower the stress levels of employees, by concentrating their energy on addressing the medical errors, overtreatment, and ineffective management of the small number of employees with complex conditions that cost them far more money than employees not eating enough broccoli.

Al Lewis is the author of Why Nobody Believes the Numbers, co-author of Cracking Health Costs: How to Cut Your Company’s Health Costs and Provide Employees Better Care, and president of the Disease Management Purchasing Consortium

Vik Khanna is a St. Louis-based independent health consultant with extensive experience in managed care and wellness. He is Wellness Editor-At-Large for THCB and author of the forthcoming Your Personal Affordable Care Act: Making Yourself Scarce in the Dysfunctional US Healthcare System. Vik and Al are co-authors of Surviving Workplace Wellness, THCB’s first e-book. 

The Accountable Primary Care Model: New Hope for Medicare and Primary Care

Primary care has long been something of an outcast in the medical profession — and despite convincing outcomes and a validated assessment tool, checkered reimbursement has brought the Institute of Medicine’s Primary Care Model to the brink of demise.

But the accountable care movement, and some Medicare Advantage plans in particular, have breathed new life into primary care and offered new hope for the struggling Medicare system. At St. Louis-based Essence Healthcare, a 4.5-star Medicare Advantage plan, network primary care physicians’ deep experience in providing accountable care has spawned innovations that advance primary care and make progress toward the “Triple Aim Plus One” (outlined in C9 below). Their success is the result of five years of active practice transformation and continuous improvement in a risk-bearing environment.

The best practice experience from these front-line physicians can be summarized in the Accountable Delivery System Institute’s Accountable Primary Care Model. This model embraces the four pillars outlined in the Institute of Medicine/Starfield model and expands them for Nine C’s of Accountable Primary Care Delivery. They are:

C1: First contact means that care is initially sought from the Primary Care Physician/Clinician (PCP) when new health or medical needs arise. In a nationally representative sample of more than 20,000 episodes of care, when these events began with PCP visits, as distinguished from some other source of care in the system, costs were 53% lower. This cost differential persisted after controlling for ER visits, health status, socio-demographics, and other relevant variables.

C2: Comprehensive care. PCPs offer a wide range of services across the entire spectrum of needs, for all but the most uncommon problems. In accountable primary care, office visits for older patients are scheduled for 30 minutes to address explicit and implicit needs proactively. Longer visits also enable the compliant documentation and accurate diagnosis coding required for comprehensive health-risk assessments. These assessments enable data-driven collaborative population management, as well as appropriate risk-adjusted revenue assignment in Medicare Advantage, ACOs, and many Medicaid programs.

C3: Continuous, longitudinal (over time), person-focused care. Physicians and patients work together to reach mutual decisions in the context of long-standing relationships that transcend episodic care. Person-focused care includes preference awareness, setting priorities, discussing expectations, and engagement with family, as well as the usual personalized prevention, screening goals, and advance care planning.

C4: Coordinated care is widely praised but narrowly understood and practiced in the U.S. After World War II, the nation had about a dozen categories of health care professionals and a half-dozen types of specialists. Now we have more than 200 categories of health care professionals with over 100 specialties. While transitions from ERs, inpatient settings, and skilled nursing facilities are high-stakes opportunities, every referral to a specialist may be viewed as a type of care transition. Much of this coordination work can be rendered unnecessary by shifting care back to PCPs through C2 and C3.

C5: Credible, trusting relationships between PCPs and patients. As one PCP describes it: “Without credibility, we are nothing but referral clerks.” Credibility is one of the fruits of providing the first four C’s, but it can also be bolstered through effective, explicit communication about expectations. While about 90% of clinicians surveyed thought it was important to ask patients about their expectations, only about 15% reported having such discussions and felt adequately trained to handle expectations.

C6: Collaborative care is the product of nontraditional payer-PCP relationships. Dr. Berwick wrote that an integrator is necessary to facilitate the Triple Aim. The accountable care movement calls for blending the traditionally separate payer and provider roles in health care. The Collaborative Payer Model delivers pre-paid, risk-adjusted funding by way of the primary care doctor-patient relationship as it realigns interests, incentives, and reciprocal responsibilities. Clinical and claims data transparency from across the continuum of care enables a collaborative approach to population management that transcends organizational boundaries.

C7: Cost-effective care naturally results from C1 thru C6, but is enhanced through proactive, intentional PCP-led efforts, which can be empowered by educational programs, data, and clinical decision support from the payer. In addition to providing vital clinical claims data cost transparency, collaborative payers have the incentives and resources to sift through the medical literature to glean evidence-based, fiscally-responsible care consideration messages that can help PCPs bend the cost curve, and to deliver such messages as close to the point of care as practically possible. However, individualized decisions weighing tradeoffs and patient preferences can only be made by providers and patients together.

C8: Capacity expansion. Health care systems cannot provide the first seven C’s without expanding the capacity and productivity of PCPs. A wide variety of approaches — including team/pod-based care, e-visits, better information technology and sharing of data, and the use of non-physicians in appropriate situations — have shown promising results to narrow or even eliminate the PCP to future needs gap.

C9: Career satisfaction is gaining more recognition in recent years. In the U.S., 36% of PCPs are not satisfied with their careers — two to three times the rate of PCPs in western European countries. While Lumeris (prior to forming the Accountable Delivery System Institute) articulated the physician satisfaction “fourth aim” as “Triple Aim Plus One” in 2009, it has been independently acknowledged by other thought leaders. Career satisfaction is dependent on monetary as well as nonmonetary considerations such as meaning, control, and order. Managing both population and individual patients under the previous eight C’s has been shown in Essence Healthcare’s experience to facilitate dramatic improvement in this last of the nine C’s.

Collectively, the framework of the Nine C’s of Accountable Primary Care Delivery offers new hope for our beleaguered health care system, and for primary care in particular. As health entities across the country seek to learn from the innovative, risk-embracing PCPs who have been thriving under and producing substantial accountable care outcomes under the Accountable Delivery System Institute’s Accountable Primary Care Model, it is now being disseminated to other emerging full-risk health care markets.

Tom Doerr is a primary care physician with a part-time geriatrics practice in St. Louis and a cofounder of Essence Group Holdings Company, where he focuses on innovation. research. He is also a limited partner with Kleiner Perkins Caufield & Byers and a faculty member of the Accountable Delivery System Institute.

A top executive I know recently decided to take Inderal before making high-pressure/high-anxiety presentations. The impact was immediate. She felt more relaxed, confident and effective. Her people agreed.

Would she encourage a comparably anxious subordinate to take the drug? No. But if that employee’s anxiety really undermined his or her effectiveness, she’d share her story and make them aware of the Inderal option. She certainly wouldn’t disapprove of an employee seeking prescription help to become more productive.

No one in America thinks twice anymore if a colleague takes Prozac. (Roughly 10% of workers in Europe and the U.K. use antidepressants, as well). Caffeine has clearly become the (legal) stimulant of business choice and Starbucks its most profitable global pusher (two shots of espresso, please).

Increasingly, prescription ADHD drugs like Adderall, dedicated to improving attention deficits, are finding their way into gray market use by students looking for a cognitive edge. When one looks at existing and in-the-pipeline drugs for Alzheimer’s and other neurophysiological therapies for aging OECD populations with retirements delayed, the odds are that far more employees are going to be taking more drugs to get more work done better.

Performance-enhancing (or degraded performance-delaying) drugs will become as common as that revitalizing cup of afternoon coffee.

Should that be encouraged? Or should management pretend those options don’t exist?

Most managers would believe they’re doing a good thing if they encouraged a hard-of-hearing employee to explore a hearing aid or a visually-impaired colleague to consider glasses. By contrast, encouraging an under-performing subordinate to lose 25 pounds, get a hair transplant or contact-lenses would likely inspire a formal complaint to Human Resources and/or a possible lawsuit. Ironically, the money isn’t the issue here; the business norms associated with perceived cosmetic and aesthetic concerns are radically different from those attached to job performance and productivity.

Putting aside the sporting world for the moment, the legal and political reality is that it’s (currently) neither a crime nor an ethical violation to pop a pill (or wear a patch) that helps you become less anxious, more alert, more energetic, more focused and/or more productive. Just as importantly, in a difficult economic environment, companies want their employees to be less anxious, more alert, more focused and more productive. Workers lacking those qualities may be first in line for that unfortunate round of layoffs.

Indeed, is it ethical to discourage or ignore an option that might help an employee be more productive and keep his or her job? Or is it unethical to encourage employees to seriously consider the pharmaceutical enhancement? Presumably, a manager couldn’t fire an employee for refusing to take a pill any more than they could sack a hearing-impaired employee who declined to wear a hearing aid. But if — or when — “job performance” and “performance enhancement” become inextricably intertwined, what then?

My own view: Depending on employment laws, employees shouldn’t be hired, fired or retained based on their willingness to use medically-approved performance-enhancing drugs. But companies should be allowed to create internal awareness about safe and legal performance-enhancing drugs as a workplace option. There should be neither stigma nor stimulus to their use.

Thus, the politics are as provocative as the ethics: In America, for example, employers are being required to provide “free” contraceptives as part of health care reform. But if a country is concerned about global competitiveness and economic growth, why shouldn’t health care coverage extend to safe and effective performance-enhancing drugs? The more governments become involved in health care, the more seriously they must consider the workplace productivity implications of their programs and policies. As people grow older, distinctions between “health care” and “performance enhancement” blur into semantic mush.

The aging workforces of a France and Germany don’t just need to avoid illness, they need to improve productivity. What a challenging public policy conundrum. Will Chinese or Russian or Indian bosses encourage their employees to take performance enhancing drugs? What an intriguing global context for economic competition.

Michael Schrage is a research fellow at MIT Sloan School’s Center for Digital Business. He is the author of Serious Play and the forthcoming Getting Beyond Ideas. This post first appeared at the Harvard Business Review Blog.