By KIM BELLARD

It’s Cyber Monday, and you’ve probably been shopping this weekend. In-stores sales on Black Friday rose 2.2% this year, whereas online sakes rose almost 8%, to $9.8b – over half of which was via mobile shopping. Cyber Monday, though, is expected to outpace Black Friday’s online shopping, with an estimated $12b, 5.4% higher than last year. 

Lest we forget, Amazon’s Prime Day is even bigger than either Cyber Monday or Black Friday.  

All that shopping means lots of deliveries, and here’s where I got a surprise: according to a Wall Street Journal analysis, Amazon is now the leading (private) delivery service. The analysis found that Amazon has already shipped some 4.8 billion packages door-to-door, and expects to finish the year with some 5.9bn. UPS is expected to have some 5.3bn, while FedEx is close to 3bn – and – unlike Amazon’s numbers — both include deliveries where the U.S. Postal Service actually does the “last mile delivery.” 

Just a few years ago, WSJ reminds us, the idea that Amazon would deliver the most packages was considered “fantastical” by its competitors. “In all likelihood, the primary deliverers of e-commerce shipments for the foreseeable future will be UPS, the U.S. Postal Service and FedEx,” the then-CEO of Fed Ex said at the time. That quote didn’t age well.

Amazon’s growth is attributed in part to its contractor delivery program, whose 200,000 drivers (usually) wear Amazon uniforms and drive Amazon-branded vehicles, although they don’t actually work for Amazon, and a pandemic-driven doubling of its logistics network. WSJ reports: “Amazon has moved to regionalize its logistics network to reduce how far packages travel across the U.S. in an effort to get products to customers faster and improve profitability.”

It worked.

But I shouldn’t be surprised. Amazon usually gets good at what it tries. Take cloud computing.  Amazon Web Services (AWS) in its early years was considered something of a capital sink, but now not only is by far the market leader, with 32% market share (versus Azure’s 22%) but also generates close to 70% of Amazon’s profits. 

Prime, Amazon’s subscription service, now has some 200 million subscribers worldwide, some 167 million are in the U.S. Seventy-one percent of Amazon shoppers are Prime members, and its fees account for over 50% of all U.S. paid retail membership fees (Costco trails at under 10%). There’s some self-selection involved, but Prime members spend about three times as much on Amazon as nonprime members.

The world’s biggest online retailer. The biggest U.S. delivery service. The world’s biggest cloud computing service. The world’s second largest subscription service (watch out Netflix!).  It’s “only” the fifth largest company in the world by market capitalization, but don’t bet against it. 

I must admit, I’ve been a bit of a skeptic when it comes to Amazon’s interest in healthcare. I first wrote about them almost ten years ago, and over those years Amazon has continued to put its feet further into healthcare’s muddy waters.

For example, it bought online pharmacy Pillpack in 2018. “PillPack’s visionary team has a combination of deep pharmacy experience and a focus on technology,” said Jeff Wilke, Amazon CEO Worldwide Consumer. “PillPack is meaningfully improving its customers’ lives, and we want to help them continue making it easy for people to save time, simplify their lives, and feel healthier. We’re excited to see what we can do together on behalf of customers over time.”

PillPack still exists as an Amazon service, but has broadened into Amazon Pharmacy. PillPack focuses more on people with chronic conditions who like the prepacked pills, while Pharmacy offers home delivery to other customers.  At its introduction, Doug Herrington, Senior Vice President of North American Consumer at Amazon, said: “PillPack has provided exceptional pharmacy service for individuals with chronic health conditions for over six years. Now, we’re expanding our pharmacy offering to Amazon.com, which will help more customers save time, save money, simplify their lives, and feel healthier.”

Amazon Pharmacy has since introduced RxPass, a $5/month subscription service for many common generic drugs, but it still hasn’t cracked the top ten U.S. pharmacies, so there’s work to be done. One pharmacy analyst writes: “Perhaps one day Amazon will be a true disrupter. For now, Amazon is choosing to join the drug channel not fundamentally change it.”

PillPack’s co-founders have recently left.   

Earlier this year, after all the fumbling around with Haven and Amazon Care, Amazon bought One Medical. “We’re on a mission to make it dramatically easier for people to find, choose, afford, and engage with the services, products, and professionals they need to get and stay healthy, and coming together with One Medical is a big step on that journey,” said Neil Lindsay, senior vice president of Amazon Health Services.

Then this month Amazon sought to entice Prime members to join One Medical by offering membership for $9/month, or $99 per year. “When it is easier for people to get the care they need, they engage more in their health, and realize better health outcomes,” said Mr. Lindsay. “That’s why we are bringing One Medical’s exceptional experience to Prime members—it’s health care that makes it dramatically easier to get and stay healthy.”

Of course, One Medical is only in 25 metro markets, with some 200 doctors office, and it doesn’t contract with every insurance plan. Plus, One Medical CEO Amir Dan Rubin is already on his way out of the door. Scaling will not be easy.

Amazon’s success with its healthcare ventures is hard to tell.  HT Tech reports that monthly active users of the One Medical app are up 16% since the acquisition, and that Amazon claims Amazon Pharmacy doubled its active customers from 2022 to 2023. Still, Lisa Phillips, an analyst with Insider Intelligence, scoffed: “It really hasn’t made a big dent. I don’t think anybody is scared of it anymore.”

Maybe. Healthcare is hard, and usually confounds outsiders who aren’t familiar with its byzantine structures. But I look at it this way: Amazon has been delivering its own packages for less than 10 years, and now it is bigger than UPS and FedEx. That’s not nothing. So for the first time I’m starting to think that maybe Amazon can make its mark in healthcare. 

Amazon the biggest healthcare company in ten years?  Don’t bet against it.

By ADRIAN GROPPER, MD

US healthcare is exceptional among rich economies. Exceptional in cost. Exceptional in disparities. Exceptional in the political power hospitals and other incumbents have amassed over decades of runaway healthcare exceptionalism. 

The latest front in healthcare exceptionalism is over who profits from patient records. Parallel articles in the NYTimes and THCB frame the issue as “barbarians at the gate” when the real issue is an obsolete health IT infrastructure and how ill-suited it is for the coming age of BigData and machine learning. Just check out the breathless announcement of “frictionless exchange” by Microsoft, AWS, Google, IBM, Salesforce and Oracle. Facebook already offers frictionless exchange. Frictionless exchange has come to mean that one data broker, like Facebook, adds value by aggregating personal data from many sources and then uses machine learning to find a customer, like Cambridge Analytica, that will use the predictive model to manipulate your behavior. How will the six data brokers in the announcement be different from Facebook?

The NYTimes article and the THCB post imply that we will know the barbarians when we see them and then rush to talk about the solutions. Aside from calls for new laws in Washington (weaken behavioral health privacy protections, preempt state privacy laws, reduce surprise medical bills, allow a national patient ID, treat data brokers as HIPAA covered entities, and maybe more) our leaders have to work with regulations (OCR, information blocking, etc…), standards (FHIR, OAuth, UMA), and best practices (Argonaut, SMART, CARIN Alliance, Patient Privacy Rights, etc…). I’m not going to discuss new laws in this post and will focus on practices under existing law.

Patient-directed access to health data is the future. This was made clear at the recent ONC Interoperability Forum as opened by Don Rucker and closed with a panel about the future. CARIN Alliance and Patient Privacy Rights are working to define patient-directed access in what might or might not be different ways. CARIN and PPR have no obvious differences when it comes to the data models and semantics associated with a patient-directed interface (API). PPR appreciates HL7 and CARIN efforts on the data models and semantics for both clinics and payers.

Consider the ongoing news about the data broker called Surescripts and the data processor called Amazon PillPack. The FTC is looking into whether Surescripts used its dominant data broker position illegally in restraint of trade. Surescripts, in a somewhat separate action, is claiming that barbarian PillPack is using patient consent to break down the gate it erected for its business purposes. From my patient perspective, does Surescripts have a right to aggregate my prescription history and then refuse me the ability to share that data with PillPack without special effort? 

The possible differences between CARIN and PPR pertain to how the barbarian is labeled and who maintains the registry or registries of the barbarians. The open questions for CARIN, PPR, and other would-be arbiters of barbary fall into four related categories:

1 – Labels Only

• Labels like the CARIN Code of Conduct or the PPR Information Governance Label are self-asserted by the app or service provider and, like other consumer product labels, would be enforced by the FTC. Who designs the labels?

2 – Registries Only

• For deployment efficiency, the the apps and services may be listed in controlled registries. The app could be registered by the developer of the app or by the operator (including a physician) that wants to use the app. This option is relevant because apps might have options the operator can choose that would change the criteria for a particular registry. Will registries support submissions by developers, operators or both?

• Aside from labels, patients tend to infer reputation on the basis of metrics like the number of users and the number of reviews for an app. Do the registries list software operators along with the software vendors in order to promote transparency and competition?

• Do the registries allow for public comment with or without moderation?

3 – Labels and Registries Combined

• What should be the number of registries and would they require one or more of the available labels?

• A typical app store policy is a low bar to enable maximum competition and reduce disputes over exclusion. Consumer rating bureaus, on the other hand, tend to issue stars or checkmarks in a handful of categories in order to reward excellence. Is our label and registry design aimed at establishing a low bar (“You must be this high to be a barbarian”) or promoting a “race to the top” (such as 0-5 stars in a few defined categories)?

• To improve fairness and transparency, should the orgs that define labels be separate from the orgs that operate registries?

4 – “Without special effort”

• Opening the gate to their own records is an established right for both the patient subject or the barbarian designated by the patient. Making this work “without special effort” requires implementation of standard dynamic client registration features that current gatekeepers have chosen to ignore. Should regulators mandate support for dynamic client registration, for any and all barbarians, as long as the app is only able to access the records of the individual patient exercising their right of access?

It seems that the definition of a barbarian is anyone who aims to get patient records under the current laws and the explicit direction of the patient. The opposite of barbarians, whoever they may be within the gates of HIPAA, are able to get patient records without consent or accounting for disclosures by asserting “Treatment, Payment, or Operations” as well as the pretense of de-identification. Meanwhile, these HIPAA non-barbarians are able to sell off the machine learning and other medical science teachings as “trade secret intellectual property” in the form of computer decision support and other for-profit algorithms. This hospital-led privatization of open medicine will contribute to the next round of US healthcare exceptionalism. 

And as for the patients, no worries; we’ll just tell them it’s about patient safety.

Adrian Gropper, MD, is the CTO of Patient Privacy Rights, a national organization representing 10.3 million patients and among the foremost open data advocates in the country.