By KIM BELLARD

Like many of you, I’m watching the war in Ukraine with great interest and much support. For all the fuss about expensive weapons — like F-16 fighters, Abrams tanks, Stryker and Bradley armored fighting vehicles, Patriot missile defense systems, Javelin anti-tank missiles, Himars long range missiles, and various types of high tech drones — what I’m most fascinated with is how Ukraine is using inexpensive, practically homemade drones as a key weapon.

It’s a new way of waging war. And when I say “waging war,” I can’t help but also think “providing health care.” It’s not so much that I think drones are going to revamp health care, but if very expensive weapons may, in fact, not be the future of warfare, maybe very expensive treatments aren’t necessarily the future of healthcare either.

Just within the last two weeks, for example, The New York Times headlined Budget Drones Prove Their Value in a Billion-Dollar War, AP said Using duct tape and bombs, Ukraine’s drone pilots wage war with low-cost, improvised weapons, ABC News reports: Inside Ukraine’s efforts to bring an ‘army of drones’ to war against Russia, and Defense News describes how Cardboard drone vendor retools software based on Ukraine war hacks.

This is not the U.S. military-industrial complex’s “shock-and-awe” kind of warfare; this is the guy-in-his-garage-building-his-own-weapons kind of warfare.

Ukraine’s minister for digital transformation, Mykhailo Federov, says the government is committed to building a state-of-the-art “army of drones.” He promises: “A new stage of the war will soon begin.”

NYT detailed:

Drones made of plastic foam or plastic are harder to find on radar, reconnaissance teams said. Ukraine buys them from commercial suppliers who also sell to aerial photographers or hobbyists around the world, along with parts such as radios, cameras, antennas and motors. The drone units mix and match parts until they find combinations that can fly past sophisticated Russian air defenses.

“The doctrine of war is changing,” one Ukrainian commander said. “Drones that cost hundreds of dollars are destroying machines costing millions of dollars.” The AP discusses how an elite drone unit – “a ragtag group of engineers, corporate managers and filmmakers” — “assembled with just $700,000, has destroyed $80 million worth of enemy equipment.”

Dmytro Kovalchuk, CEO of drone manufacturer Warbird, told ABC News: “In Ukraine, not a single state enterprise is producing drones. It’s all private enterprises, sometimes partnerships…It [the drone] costs $1,000 and can destroy a tank that costs $500,000.”

And it is not just attacking tanks or just from the air; Just last month, Ukraine used a sea drone to damage an expensive Russian warship. 

One of the many reasons the war in Ukraine is important is because China is watching closely to see what might happen if it were to invade Taiwan, and I’m hoping Taiwan and its allies, including the U.S., are paying close attention to the importance of drones. NYT is skeptical, charging: “A new generation of cheaper and more flexible vessels could be vital in any conflict with China, but the Navy remains lashed to big shipbuilding programs driven by tradition, political influence and jobs.”

“The U.S. Navy is arrogant,” said retired admiral Lorin Selby, who used to head the Office of Naval Research. “We have an arrogance about, we’ve got these aircraft carriers, we’ve got these amazing submarines. We don’t know anything else. And that is just wrong.” Another former officer agreed: “Right now, they are still building a largely 20th-century Navy.”

“We are trying to improve Navy power, but we need to do more than that: We need to reimagine Navy power,” he also said. “We’re kind of at a pivotal point in history. It is vital that we throw off old conventions.”

It’s not that the Navy is unaware of the potential of drones; as NYT acknowledged, it has been testing integrating “drone boats, unmanned submersible vessels and aerial vehicles capable of monitoring and intercepting threats over hundreds of miles.” It’s more that it isn’t a priority; the budget devoted to it, one officer lamented, is “the dust particle on the pocket lint of the budget.”

The Wall Street Journal was more optimistic, reporting on details of a recent speech from Kathleen Hicks, the deputy secretary of defense. She vowed that DoD “plans to spend hundreds of millions of dollars to produce an array of thousands of air-, land- and sea-based artificial-intelligence systems that are intended to be ‘small, smart, cheap’”

Of course, when fighter planes now can cost $135 million each, aircraft carriers cost $13b apiece, and the overall DoD budget is closing in on $1 trillion annually, spending “hundreds of millions” on alternative weapons does kind of sound like pocket lint. The Pentagon admits that China is “displaying growing numbers of autonomous and teaming systems,” including “a substantial amount of development displaying efforts to produce swarming capability for operational applications.” They’re taking this seriously.

“The hundreds of millions of dollars range, while a great start, would only provide hundreds of the truly capable ocean drones we need to establish true deterrence to China and other adversaries,” Kevin Decker, chief executive of Ocean Aero, told WSJ. “They’ve got to start somewhere, and they’ve got to start now.”

“Quite frankly, industry is well ahead of us,” Marine Lt. Gen. Karsten Heckl, deputy commandant for combat admitted. “So we’re trying to catch up but [there is] a lot of promise.”

As the Ukrainian commander said, the doctrine of war is changing.  Weapons systems started in the 1990’s (F-35 fighter) or early 2000’s (the Gerald Ford aircraft carrier) are just going into service and are already outdated.  Admiral Selby has it right: “It is vital that we throw off old conventions.”

———–

So it is with healthcare. Capital sinks like hospitals are healthcare’s aircraft carriers – once essential, but now vastly expensive and hugely vulnerable. Prescription drugs that can cost hundreds of thousands, if not millions, of dollars annually are 20^th century pricing in a world of AI drug development, CRISPR, and 3D printing, to name a few innovations. Adding facility fees to even telehealth visits is (stupid) 20^th century thinking. Health insurance premiums that are unaffordable even to middle class customers reflect 20^th approaches.

Similarly, I’m not worried that healthcare won’t find many uses for AI; rather, I’m worried that it will co-opt AI into making existing cost structures even higher, rather than using it to make healthcare become “small, smart, and cheap.”

The doctrine of healthcare must change.  Where is its ragtag team of engineers, computer scientists, physicians, and entrepreneurs making it faster, smaller, smarter, cheaper, more personal, and definitely more effective?

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and a regular THCB contributor.

This is the last of the classics that THCB will run to celebrate our 20th birthday. And we are finally tackling the most important of questions. Is what we call this thing one word or two? Back in 2012 Michael Millenson had the definitive answer–Matthew Holt

By MICHAEL L. MILLENSON

A recent contributor to this blog wondered about the correctness of “health care” versus “healthcare.” I’d like to answer that question by channeling my inner William Safire (the late, great New York Times language maven). If you’ll stick with me, I’ll also disclose why the Centers for Medicare & Medicaid Services is not abbreviated as CMMS and reveal something you may not have known about God – linguistically, if not theologically.

The two-word rule for “health care” is followed by major news organizations (New York Times, Washington Post, Wall Street Journal) and medical journals (New England Journal of Medicine, JAMA, Annals of Internal Medicine). Their decision seems consistent with the way most references to the word “care” are handled.

Even the editorial writers of Modern Healthcare magazine do not inveigh against errors in medical care driving up costs in acutecare hospitals and nursinghomes. They write about “medical care,” “acute care” and “nursing homes,” separating the adjectives from the nouns they modify. Some in the general media go even farther, applying the traditional rule of hyphenating adjectival phrases; hence, “health-care reform,” just as you’d write “general-interest magazine” or “old-fashioned editor.”

Most importantly of all, the Associated Press decrees that the correct usage is, “health care.” That decision is not substantive – there is absolutely no definitional difference between “health care” and “healthcare,” despite what you might read elsewhere — but stylistic. As in The Associated Press Stylebook.

The AP is a cooperative formed back in 1846 by newspapers to share reporting via a wire service. Today, the AP calls itself the backbone of global news information, serving “thousands of daily newspaper, radio, television, and online customers….On any given day, more than half the world’s population sees news from the AP.” When that news arrives in text format, its spelling is determined by the AP stylebook. Which means a few billion people see the spelling, “health care.”

A stylebook? Isn’t spelling determined by dictionaries? Perhaps, but when you’re sharing content on deadline across the world, it helps if everyone agrees to refer to, say, the Midwest, not the Mid-West, and to use other common linguistic conventions.

Stylebooks differ. The AP would say that health care is two words; the Chicago Manual of Style, popular in academia, would write that as 2 words, but agree with the premise.

So why isn’t that the end of the issue? Because conventions are not set in concrete. For example, at the time the Internet first became popular, the AP preferred the term “Web site” over “website” because the World Wide Web is a proper name. A successful lobbying campaign on behalf of the lower-case form helped persuade the AP to adopt the new spelling in its 2010 stylebook update.

When Modern Hospitals changed its name to become Modern Healthcare back in 1976, it did so in part to seem, well, modern. It hadn’t been that many years, after all, since airplanes were flown by air lines, not airlines. Then, in the business-oriented 1980s, “healthcare system” became a convenient linguistic upgrade of the dowdy “hospital” that had gobbled up ownership of doctors’ offices providing outpatient (not out-patient) care.

At the same time, a growing number of companies decided to make this expansive new word part of their proper name or, at the very least, their style sheet. For instance, HCA, founded in 1968 as Hospital Corporation of America, today describes itself as “the nation’s leading provider of healthcare services.” The Reuters news service, heavily involved in business news, now uses “healthcare” in its stories.

The 2001 Institute of Medicine report Crossing the Quality Chasm provides a snapshot of the term’s transition. The report declares, “Between the healthcare we have and the care we could have lies not just a gap, but a chasm.” The author of that ringing statement is the Committee on the Quality of Health Care in America.

However, I think a tipping point for fusing “health” and “care” was reached with the federal legislation setting up the Agency for Healthcare Research and Quality at the end of 1999. AHRQ was a renamed and refocused version of the old Agency for Health Care Policy and Research, created in 1989. AHCPR, in turn, had almost been named the Agency for Health Care Research and Policy until an alert Senate staffer realized that the abbreviation would be pronounced, “ah, crap.”

Speaking of abbreviations, Tom Scully, the first administrator of the Center for Medicare & Medicaid Services, once explained to me why it is known as CMS, not CMMS. It seems that Health and Human Services Secretary Tommy Thompson wanted an agency name with a catchy three-letter abbreviation, like FTC or CIA, to replace the old HCFA (Health Care Financing Administration). So a legal opinion was obtained from the HHS counsel that employing an ampersand to separate the words “Medicare” and “Medicaid” permitted the use of the CMS designation. Some might suspect this Solomonic ruling of caving in to a bit of pressure from above.

Which brings us to God. Some years back, the AP decided that while “God” would remain capitalized (the pope was not similarly blessed), the second reference would be “his,” not “His.” As influential as the AP might be in this world, those concerned with a Higher Authority still write about God as if He were something more than an ordinary man.

I keep waiting for the AP editor who made that decision to be struck down with lightning by the Deity. But, on the other hand, She may have a sense of humor.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age”.

By KIM BELLARD

America, like most cultures, claims to love and value children, but, gosh, the reality sure seems very different. Three recent reports help illustrate this: The Pew Research Center’s report on the expectation of having children, Claire Suddath’s searing look at the childcare industry on Bloomberg, and a UNICEF survey about how young people, and their elders, view the future.   

It’s hard to say which is more depressing.

———

Pew found that the percentage of non-parents under 50 who expect to have children jumped from 37% in 2018 to 44% in 2021. Current parents who don’t expect to have more children edged up slightly (71% to 74%). The main reason given by childless adults for not wanting children was simply not wanting children, cited by 56% of those not wanting children. Among those who gave a reason, medical and financial reasons were cited most often. Current parents were even more likely – 63% – to simply say they just didn’t want more.

This shouldn’t come as a huge surprise. Earlier this year the Census Bureau reported that the birthrate in America dropped for the sixth consecutive year, the largest percentage one year drop since 1965 and the lowest absolute number of babies since 1979. It’d be easy to blame this on the pandemic, but, as sociologist Phillip N. Cohen told The Washington Post: “It’s a shock but not a change in direction.” 

In many ways, having children seems like ignoring everything that’s going on. We have a climate change/global warming crisis that threatens to wreak havoc on human societies, we’re still in the middle of a global pandemic, and our political/cultural climate seems even more volatile than the actual climate. One Gen Xer told The New York Times: “As I think of it, having a child is like rolling dice with the child’s life in an increasingly uncertain world.”

Yikes.

——–

The mess that is America’s child care industry (nurseries, daycare, preschool) may help explain why people are reluctant to have kids/more kids.  If you’ve had a child or known people who have, you’ve heard the complaints about child care. It’s hard to find good ones, harder to get into them, and harder still to pay for them. The people who work in them are, for the most part, wonders, but there are too few of them and they’re woefully underpaid…despite how expensive the child care is.

Ms. Suddath writes: “Child care in the U.S. is the rare example of an almost entirely private market in which the service offered is too expensive for both consumers and the businesses that provide it.” She quotes Treasury Secretary Janet Yellen: “The free market works well in many different sectors, but child care is not one of them.”

At least in healthcare, some people are making money.

The workers are paid less than they’d make at Amazon or Walmart, but, between staffing ratios and other regulatory requirements, the costs can approach college tuition levels. It keeps many women out of the workforce, hampering both their careers and our overall economic development. Even worse, lack of preschool has lifelong impacts on children’s development. She quotes Catherine Wolfram at the U.S. Treasury: “There’s very robust, strong economic literature that documents the positive effects of early childhood education. Educating kids has all these benefits for the rest of society.”

The Build Back Better Act is supposed to address some of the child care issues, such as limits on how much parents have to spend on it and improving wages for the workers, but Ms. Suddath warns, not so fast.  The bill is, she suggests, more aspirational than prescriptive:  

States can decide to take money for preschool but reject additional funds to subsidize other forms of child care. Or a state could call all this communism and do nothing.

Beyond that, there’s not a lot of detail in the bill. States have no guidance on how to help child-care businesses pay higher wages, for example.

Think all those Red states that have defied masks/vaccine mandates/Medicaid expansion are going to rush into fixing the child care problems?  

———-

The UNICEF survey, which included respondents from 21 countries, found that, overall, young people (15-24) thought children in their country would be better off than their parents – but, in the U.S., only 43% thought so, with 56% disagreeing. It could have been worse; the “worse off” percentages were worse in many other developed countries. The older respondents were even more pessimistic (64%). 

Laurence Chandy, the UNICEF official who oversaw the survey, said: “In a lot of the developing world, there is a bit more optimism that yes, with each generation our living standards are improving.  But there’s a recognition in the West that’s stopped happening.”  In point of fact, U.S. children born in 1980 or later are no longer likely to earn more than their parents, a startling reversal of the trends from 1940 to 1980.  

Young Americans still cite “hard work” as the key to success, but just narrowly edging out “Family wealth or connections,” which is in contrast to their elders, who are much more likely to still believe in hard work.  Education is a distant third. 

We’re supposed to be the country where success is about getting a good education and working hard, not about who your family and friends are. We’re not that country anymore.

No wonder our young people are pessimistic about their futures. 

——-

When it comes to children’s health, of course, the U.S. should hang its head. We have too many children in poverty, too many children going hungry, too many children without health insurance. Our infant (and maternal) mortality rates are positively third world. Compared to other developed countries, our kids are too overweight, too likely to have diabetes, too likely to get pregnant, too likely to use illegal drugs. 

We have some of the best children’s hospitals in the world, but we pay pediatricians lower than any other physician specialty, and, as a result, have a shortage. It’s similar to those child care workers or elementary school teachers: we say we want the best for our children, but we don’t seem to be willing to pay for the best. And it shows.

——–

I wish I had some good news. I wish I had some solutions. When I look at the young people in my life I admire their spirit, but I fear for their futures. Why politicians fight things like universal preschool, affordable childcare, or paid family leave – each of which is undeniably good for children – I’m at a loss. 

We can do better for our children. We must.

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.

By MIKE MAGEE

In my course this Fall at the University of Hartford, titled “The Right to Health Care and the U.S. Constitution”, we have concentrated on the power of words, of precedents, and the range of interests with which health has been encumbered over several hundred years.

The topic has been an eye-opener on many levels. On the most basic level, it is already clear that the value of this “right” depends heavily on your definition of “health.”

We’ve highlighted three definitions worth sharing here. 

The first is attributed to Eleanor Roosevelt. In 1948, as lead for the United Nations Declaration of Human Rights, she defined health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” She also made clear at the time that each of us, as responsible citizens, bore a level of personal responsibility for our own health. By virtue of the choices we make, and the behaviors we exhibit, we raise or lower the chances of being “healthy.”

The second voice highlighted was also a woman. She is a physician from Norway, born on April 20, 1939, in Oslo, the daughter of a physician and politician. She received her Medical Degree from the University of Oslo and went on to earn a Master’s in Public Health at Harvard. She served three separate terms as Norway’s Prime Minister, never having fewer than 8 women in her 18-member cabinet. Her name is Gro Brundtland. In 1998, she was confirmed as director-general of the World Health Organization (WHO).

In one of her first WHO directives in 1998, she took on the definition of health which she described as “Part Goodness and Part Fairness.” She went on to explain, “Goodness in the sense that our professionals are well trained and qualified; our institutions well outfitted and safe; our processes engineered to perfection; our teamwork a reflection of training and excellent communication.” 

“Fairness in the sense that these skills and capabilities are fairly and equitably distributed to the broadest population possible.”

The third featured definer of health was a Catholic Cardinal from Chicago during those early Brundtland years. His name was Joseph Bernardin. He had terminal cancer in 1996 and was ultra-focused on health delivery when he addressed the Annual Meeting of the American Medical Association. He said, “There are four words in the English language that have common English roots. They are heal, health, whole, and holy. To heal in the modern world, you must provide health. But to provide health, you must keep the individual, the family, the community, and society whole. And if you can do all that, that is a holy thing.”

As the Earth and its inhabitants entered the new millennium, it was clear that the delivery of health care – whether local, national, or global – was a complex human endeavor. Even if you declared it a “universal right” as the UN and the WHO did, you would still need responsive programs, trained professionals, equal access, continuity of care, funding, compassion, understanding, and partnership. And even these would not be enough without forward-planning, anticipation, scientific discovery, and reliable funding.

When the Covid-19 pandemic hit, it rapidly revealed the cost of lack of U.S. planning, investment, and capacity. Specifically, the complex supply chain, including materials, human capital, and science failed. More alarming than these however was the damage and confusion that flowed directly from flawed leadership at the top. What Trump revealed was that trust, truth, and integrity were critical elements when it came to health delivery.

Weaknesses in this regard have been with us since the birth of this nation. But they have never quite been called out with such penetrating clarity as they were by Rev. Martin Luther King Jr., when he addressed the crowd at the Poor People’s Campaign on March 25, 1966, and said, “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

As I said to my students, we could learn a great deal by pondering whether Dr. King was right, and if so, why? At the time, President Lyndon Baines Johnson was struggling to make real his “Great Society.” The three-prong “Martyr’s Cause (as he labeled his efforts to honor JFK’s death), included the implementation of The Civil Rights Act, The War on Poverty, and Medicare. All three, integrated and interdependent, were necessary if justice was to prevail as suggested by the U.S. Constitution. 

Mike Magee, MD is a Medical Historian and Health Economist, and author of “CodeBlue: Inside the Medical Industrial Complex.“

There are few better positioned to speculate on what’s next for telehealth than Roy Schoenberg, co-CEO & President, of Amwell. After 15 years, more than $710M in total funding, and probably the best analogies out there for describing telehealth’s potential as a disruptive technology, Roy weighs in on just how unprecedented COVID19 has been for the uptake and evolution of virtual care.

“Historically, people thought, could telehealth be as good as a physical visit? The reality of COVID,” says Roy, “has literally opened the door to the question, can telehealth be better?”

From the near-term “new wave” of telehealth that has already begun to “eclipse the urgent care telehealth” to how Amwell’s clientele of clinicians, healthcare delivery systems, and payers are shifting to accept the idea of the technology as “the start of healthcare,” Roy talks of a future of telehealth that is “entrenched inside the system.” And how Amwell is meant to act as “facilitator.”

“When we start thinking about telehealth as a switchboard — not as a product, but as an infrastructure for the redistribution of healthcare — we’re talking about a completely different experience for us as Americans on what healthcare is available to us and how we can consume it.”

“To me, and I’ll fast forward to the end here, we want to get to the point that telehealth changes our expectation when we grow old as to where we can grow old. We want to be in a place where we can stay at home…where we don’t have to be in the ‘belly of the beast’ to get healthcare.”

How far away is this future that Roy describes, midway through telehealth’s biggest year yet? Is the appetite there among incumbents? And what of those Amwell IPO rumors? How might that kind of funding help rush things along? Tune in to this episode of ‘WTF Health – What’s the Future, Health?’ with Jessica DaMassa to find out.

Full Transcript of the Interview:

Jessica

Hey, it’s Jessica DaMassa with “WTF Health – What’s the Future, Health?” We are getting insight scoop on everything happening in health tech from some of the biggest names in the industry. And so what conversation about telehealth would be complete without this guy right here? We have Roy Schoenberg. He is the president and co-CEO of Amwell. Roy, it is so exciting to talk to you. How are you?

Roy:

Thank you. It’s great to be with you, Jessica.

Jessica DaMassa:

Oh my gosh, I can’t imagine how busy you must be.

Roy:

We don’t complain. We can’t complain. Telehealth seems to be the name of the game right now. So we’re riding the wave, I think with many others, but it is a big time for telehealth.

Jessica DaMassa:

Oh my gosh. Okay. So I want to hear all about exactly what kind of a big time this is. And Amwell… obviously, your company, you’re one of the leaders in this category and there is lots of news going on about not only the industry, but also about Amwell. We’ve heard some IPO rumors that we may or may not address later. You guys closed a massive funding round, $194 million in May. So tell me a little bit, I guess about, let’s start with what’s going on. So what have you been putting that funding to use for so far?

Roy:

Well, I’m sure that everybody at this point is a little bit aware of the role of telehealth in COVID. It started off maybe even four or five months ago as the thing you use for convenience maybe to, in the middle of the night, if your child is crying or you have a rash or a flu to get a simple antibiotic. And it has literally almost overnight became the first line of defense for everything in healthcare. Not only that most Americans, especially during March and April, and now actually more so in some parts of the country, were asked to stay at home and socially isolate. And not only that they were concerned about COVID, but anything else that they had going on in terms of healthcare, all of the places that you would normally go to get healthcare were locked up, physician offices and urgent care centers and retail clinics. And nobody wants to be in a waiting room of a hospital right now. All of these disappeared.

Roy:

At the same time, a lot of the clinicians of all the different disciplines were also home. Many of them were told, “You can’t come in if you’re a primary care physician or whatever it is, you’re going to be isolating, sheltering in place as well.” So they were stuck in their homes. And the reality is that at that point in time, telehealth became from a novelty or from something that people thought, “Oh that’s a good way for healthcare to modernize,” became almost overnight the only way by which clinicians could do their job and practice their art and do what they were responsible for doing with their patients. So literally within the course of a couple of weeks, we have seen an incredible, we call it unprecedented, the title where fill in the blanks in terms of what kind of giant word you want to put in there.

Roy:

But we’ve seen an incredible, incredible hiking in telehealth. It started off with a wave of urgent care telehealth, which everybody’s familiar with. That was, and it is still about 10 times what it was at the beginning of this, some time in March. But I think more importantly, we’ve seen an entire avalanche of a new kind of use of telehealth where clinicians who actually have a relationship with patients with chronic patients and cancer patients and so on, physicians who are in a hospital are now using telehealth in order to support, maintain, and follow up on those patients. And that wave of telehealth has somewhere along the way eclipsed the urgent care telehealth, which was the name of the game just until February or March. And that has grown in some cases 30 times, 40 times the volume that it was a couple of months ago. And what people say is that this, I think the term is that that genie is not going back in the bottle or that toothpaste is not coming back into the tube. And that really is forcing everybody to completely rethink how the healthcare system should operate in a world post COVID. So it’s definitely been a fun time in telehealth.

Jessica DaMassa:

All right. I want to unpack some of this stuff, because you said a lot there. I want to address this toothpaste that has come out of the tube. I don’t think I’ve heard that one yet in reference to telehealth. That’s pretty cute. And so I want to go back though to what you’re talking about in terms of how unprecedented this is. And I would like to get your input on this. Amwell is a company that’s been around since the beginning. You guys have birthed the sector more or less with a few others. 15 years, is this really as unprecedented a time in telehealth as we think it is?

Roy:

Yeah. So you really can break it down to a lot of the historical barriers of telehealth, which I think everybody has heard about over and over again, so they’re not that interesting to repeat. Reimbursement, licensure, all of that kind of fun stuff. I think we’ve seen over the last couple of years a growing acceptance of telehealth by consumers, funnily enough, who are for lack of a better word, are open to embracing technology that makes their life better. So there was less of a concern there and that worked really well. The part that really, really changed is actually on the clinician side of things.

Jessica DaMassa:

Tell me more about that.

Roy:

That’s kind of a little bit of an unusual observation, but I would say that historically, and that’s true for us and for Teladoc and for other companies as well, most of the telehealth that’s out there in terms of volume that’s doing urgent care is utilizing clinician services of clinicians who are participating in telehealth programs. But the vast majority of healthcare doesn’t happen with the clinician that are on our network or Teladoc network or whatever it is. Most healthcare happens by clinicians who are in their offices in the hospitals and everything else. And for the most part, adoption by them has been growing steadily, but nothing to write home about. Nothing that is a headline in the newspaper. That changed.

Roy:

And the reason for that was that almost overnight, a lot of the health care institutions, we don’t think about it when we think about COVID, but a lot of the health care institutions out there, the way they survive is by essentially doing patient encounters, which translates to a lot of fun stuff like claims, submissions, and adjudication and everything else, but that’s how they get paid. And that’s how they pay for the buildings and everything else.

Roy:

And that disappeared overnight. So suddenly the financial reality of the healthcare industry that is tightly driven to the volume of patient encounters was under an existential threat. And the translation of that was, it is no longer to be the discretion of everybody to decide if they want to try it out or taste it and maybe opine on it and maybe try it on a Sunday afternoon when they have time. We have to, as an industry, transition to telehealth to survive. And that drive to telehealth has a completely different kind of firepower than the curiosity about telehealth. And the result of that is that the number of clinicians around the country that have been not only exposed to telehealth, but have been literally asked to transition everything they do into telehealth in order to continue to work in the institutions that they belong to, that has forced a completely different adoption curve of telehealth to clinicians.

Roy:

And the one thing that we all know, like it or not, healthcare is driven by the clinicians. We as patients, we actually do as we’re told. We’re probably the one person that it doesn’t matter how strong our character is, when we sit in the doctor office and the doctor tells us, “This is what you need to do,” we say, “Yes. Okay. That’s what I’m going to do.” So the reality is that a lot of healthcare is really driven by the physician’s decision of what’s the right thing to do next. And the fact that physicians now, in huge numbers, are telling their patients to use telehealth, that is a very different reality than before COVID. And to me, that is kind of the secret ingredient of why that toothpaste is not coming back.

Jessica DaMassa:

Okay. How do you make sure that that stays the case? How do you prevent these clinicians from going back? Right now they’re more or less, as you said, they’re forced to deliver care this way because inpatient visits are not necessarily an option, especially in some places that are hotspots. So how do you make sure that their experience with telehealth right now is so sticky that they want to stick around and continue to provide telehealth or deliver certain kinds of care via telehealth services, as opposed to returning back to the same old office visit and what they’re comfortable with? How do you do that?

Roy:

I think, maybe to be a little bit humble about it, I actually don’t think you can make clinicians do anything. Or maybe that’s an exaggeration, but for the most part-

Jessica DaMassa:

Spoken like a true clinician, right?

Roy:

Well, years ago when I was doing clinical care, but the reality is that what they do is driven from true good motivation of, I want to do something that is the right thing for the patient and something that allows me to sustain my ability to care for the patient long term, which is to maintain a practice and have a life and everything else. And it is the balance of those that at the end of the day drives what they do. I think the reality is… it’s not about, payment is important. Of course you have to pay clinician for the work they do like any other person that works.

Roy:

But I think that the experience the clinician had over COVID is that their ability to interact with a patient is so gratifying and liberating to the patients that they care about, that it is going to be almost unreasonable for them to withdraw those services and say to patients, “Hey, even though you are 82 and you’re frail, and you have all of these different things that make it really hard for you to keep the cadence of followup that we need to do to take care of you, and even though we actually did it really, really well over the last three months in telehealth, take the bus.”

Roy:

At some point, that doesn’t make any sense anymore. And when all the pieces of the puzzle that are necessary, like making sure that it is encrypted and secure and making sure that it is paid for and making sure that it is tied into the EHRs and it’s tied into the scheduling system and how my staff as a clinician can support me in handling patient. When you’re taking all of these barriers out of the equation, which many of them have been taken out of the equation, you’re left with a, I don’t call it a humanitarian or human question of, how can I say no to this when this is such a powerful way to make the life of my patients better?

Jessica DaMassa:

Yeah.

Roy:

And that will resonate differently with different people. But I think at the end of the day, this isn’t about Amwell persuading people. It just makes sense. And that’s very powerful.

Jessica DaMassa:

No, it is very powerful. And I’m curious too, as you talk about some of the things that have traditionally provided barriers against uptake have been kind of lifted in all of this. And I think it’s interesting to hear you talk about what you feel like individual clinicians are learning about telehealth as a result of having some of those old constraints lifted. What are some of the other things that you have been learning about the appetite for telehealth, maybe on the consumer side, or I know that private practice product that you guys just launched is giving you kind of these insights into the physician part of things. But you’ve got a lot of health plan clients. I mean, some big health plan clients, and you guys have big healthcare provider clients as well. So what have you been hearing on that side? What new things have been revealed now that the restrictions have been lifted on that side of the world as well?

Roy:

So where do I start? How much time do we have? I think we are, as I said, we’re in a very unique position. I think very unlike many of the other telehealth operators out there. The difference with us is that we’re kind of equally footed. We have one very strong foot on the consumer, employer, payer side of things, and we serve big chunk of the country there. And we have an equally strong footing on the clinician side of things, on the provider and practice, and very importantly hospital and delivery network and health system part of things. And the systems are actually built to bridge the two. Now, this isn’t the pitch for one architecture or another, but the fact that we are essentially being a conduit between the patient side of things or the consumer side of things and the delivery side of things opens up the door to real opportunities that we never thought about.

Roy:

So for example, I can tell you that we are turning a corner in thinking. Historically people thought about, could telehealth be as good as a physical visit? For more than a decade, that was the name of the game. Can it be safe and good enough and whatever it is? The reality of COVID has literally opened the door to the question, can telehealth be better? And the reason for that is not to say that a remote physician is better than a physician that’s in front of you.

Roy:

But rather to say if we think of the way that we envelope a patient that has a serious medical condition and we throw telehealth into it so it allows us to, for example, check up on them for a couple of minutes, three times a week without actually incurring office visits and the whole hoopla that goes around that. Does that allow us to actually be much more attentive to the changes in their condition? Maybe changing their medication more frequently, to understand if there are side effects. If they have cancer, can support them by other ways… by way of nutrition and behavioral support and everything else. Can we actually rethink the way we surround patients with healthcare in the presence of telehealth that will allow us to change the cookbook of medicine, medical practice?

Jessica DaMassa:

Yeah.

Roy:

And I know that this sounds almost pithy, it’s almost kind of high level, but the fact that this conversation is literally now carried in both the health system side of our customers, as well as on the payer side, the health plan, side of our customers, who are saying, “Let’s actually kind of not throw telehealth as an added thing into everything that we offer. Let’s actually think from the ground up and say, maybe telehealth is the start of healthcare. Maybe that is the gate by which people enter when they have an issue.” And I can tell you that that translates into some really astounding conversations, both on the delivery side of healthcare as well as well as on the care side.

Jessica DaMassa:

If you want to gossip about those astounding conversations, feel free to let us know what you’re thinking there. One question I have for you is, I guess from your perspective, what’s the next iteration of this then? You talked about this as like, okay, if this is the way in to developing a better opportunity for care delivery for patients, we’ve been hearing all sorts of things. Just earlier this week, Glen Tullman published on it, an article about this “consumer directed virtual care” as he’s calling it, talking about how telehealth is important, remote monitoring has a place, but there’s also this kind of other set of services that get added on there where we’re looking at data and things are ambiently collected so that patients can kind of take initial steps to prevent things from going wrong before we get there. What do you think is going to get added on to telehealth in order to make this new care delivery model really come to life? What’s the next thing in terms of what you’re looking at right now?

Roy:

So I think, maybe to use an analogy here, and I’m sure that people are sick of Amazon analogies, they’re used everywhere. But, Amazon started by selling books and it was actually a very brilliant choice by Jeff Bezos at the time, because he really kind of introduced the notion of online retail in many ways, and books are a great product to flush the pipes with. They don’t go bad. You know what you’re getting. You ship them, you can track them, you can pack them, they’re square. You can actually pack them very neatly. And he figured out the notion of FedEx and credit card billing and PSI, all of the different kinds of compliance elements and returns. So it was a really, really good way to flush the pipes of online retail.

Roy:

And then he extended it into the store that sells more things. And then further went into the third stage, which is now Amazon sells stuff that actually are not in Amazon warehouses. You have a lot of things that you buy from end producers of merchandise that goes through Amazon to you, but Amazon is not the one fulfilling it.

Roy:

Funnily enough, I actually think that telehealth is going to go exactly through those stages. History tends to repeat itself. Urgent care was the books. It’s the way to get everybody comfortable. It’s not very sophisticated medicine. It’s not life threatening to anybody. It’s convenience. It’s simple. No big deal if it didn’t work very well. Of course, it needs to work very well. But it’s a really, really simple kind of product to get people to feel comfortable. Then, the next step was a lot of the delivery side of healthcare – big  health systems are starting to use telehealth with their own patients that’s a little bit more like the Amazon store that has a lot of Amazon products in its facilities and sends it to patients. So that’s where we see a lot of health system.

Roy:

But the third step is the one that is the most exciting, which is, if we’re able to connect the pipes and make this feel like a network – which, by the way, the technology is built like — we’re able to have a completely different understanding on how healthcare services can travel. Which opens up the door for things that historically we never thought about, like load balancing of healthcare around the country. Think about places in the country that are flushed with healthcare, with good healthcare, and areas around the country that are not necessarily flushed with them. Think about areas that are devastated by hurricanes and fires and viruses. Think about the notion that there are cancer patients in certain parts of the country that don’t have the knowledge of how to treat cancer that exists in large metropolitan areas.

Roy:

When we start thinking about telehealth as a switchboard — not as a product, but as an infrastructure for the redistribution of healthcare — we’re talking about a completely different experience for us as Americans on what healthcare is available to us and how we can consume it. To me, and I’ll kind of fast forward to the end here, what that translates into (and I think that’s the part that I’m personally very, very passionate about) we want to get to the point that telehealth changes our expectation when we grow old as to where we can grow old. We want to be in a place where we can stay at home, where we don’t have to be in the belly of the beast to get healthcare, and all of the different disciplines surround us, rather than force us to go and seek, and, worse, try to patchwork the different disciplines that we need to see. I think that opportunity is right in front of us. And in that sense, telehealth is going to work like retail and it’s inevitable. It’s not me or you or Amwell or anybody else. I think that train is out of the station.

Jessica DaMassa:

All right. I am going to turn your analogy on you, my friend.

Roy:

Sure.

Jessica DaMassa:

And I’m going to ask you if all right, if you’re going to make an Amazon analogy here, to telehealth, right. So if you’re the Bezos here.

Roy:

I didn’t say that. [laughter]

Jessica DaMassa:

I am just saying if you’re…[laughter] Clearly, there’s only a handful of companies that I think at this point, right now, have the capital, the size, the scale, and the reach to be considered the Amazon of telehealth.

Roy:

I think the reach is important.

Jessica DaMassa:

Yeah. Right. Okay. Fair enough. Okay. But I’ve got you here with me right now. And so I’m curious, especially, and not to go… I know you can’t comment on the IPO rumors one way or the other, but the fact that they are there, I think indicates something about the market for this and where things are going potentially next. So as far as you’re concerned, you’re at the helm of this Amazon-like empire here that could completely redefine the way that we grow old in the future. What are you looking at next for the business? You have a lot of funding right now. You’re growing. Things are going well. We know you’ve launched some new products, like I mentioned earlier, that physician private practice one, which I think is very cool. It’s like a Shopify almost for telehealth in terms of private clinician practices. But where do you have your sights set then in terms of what’s next for Amwell?

Roy:

So I think you actually kind of hit a lot of different of the important kind of things on the head there. First of all, and I can’t comment about IPO rumors or whatever it is, I’m aware of the fact that they’re out there. And it’s great to be in a position where people can talk about those kinds of options, because telehealth is real.

Jessica DaMassa:

Yeah, exactly. Yeah.

Roy:

The adoption curves and the volumes and everything else and, literally, from the Rose Gardens through HHS and Medicare and everything else, telehealth is the name of the game. Which of course makes companies who do telehealth be in the center of things, which of course opens up a lot of opportunity. And you mentioned our funding and so on. The one thing that I would say, however, is that this is also the point where you can make mistakes. You have an avalanche of adoption and we fully feel the responsibility to make sure that we are actually not the bottleneck, that we are the facilitator. We’re the ones that allow natural evolution of adoption of that technology to happen. And if we do a good job, then we actually don’t matter that much. We’re in the background. We are allowing clinicians and patients to interact naturally. We facilitate that under the hood, but it’s not about teaching people how to use Amwell.

Roy:

To do that, that’s actually very, very hard to do. That’s kind of the transition, and I know I use too many analogies, but that’s a transition of when Google was a search engine to “Google” becoming a verb, right?

Jessica DaMassa:

Yeah.

Roy:

You don’t think about it, you Google stuff. And I think that is something that we see on the horizon, where telehealth becomes part of the natural way in which patients and clinicians interact. To do that, however, you have to care about the details. You have to really, really understand clinician workflow. You need to understand their reality. You need to understand the rules of engagement that are very complicated in healthcare. And to do that right, to become transparent, there is tremendous amount of investment that needs to go into there. And that’s a lot of the stuff that we’re doing. You mentioned some of the new products that were introduced.

Roy:

At the end of the day, there is a common theme between all of these, which is try to assimilate into the reality of traditional healthcare. Not create a product, an app for urgent care, which is a godsend when you need it, but is sitting aside of the regular healthcare delivery. But rather be entrenched inside the system. That’s a very, very significant lift. We would not be able to do it unless we were, as I mentioned, equally nested on the payer/consumer/patient side of things, as well as on the provider delivery side of things. But that is an incredible opportunity that we have in front of us. And we’re very serious about that.

Jessica DaMassa:

How do we not mess this up? Because you started that by saying we don’t want to, with all the eyes on this and this opportunity in front of us. And just even listening to you talk about everything up until this point in terms of how thinking around telehealth has changed and the conversation has shifted. So how do we not mess this up? And I say “us,” not just the telehealth companies, but even more broadly, the other health tech companies that are maybe in things that are adjacent? Digital health, digital therapeutics, remote monitoring. How do we not mess this up right now?

Roy:

I think we have to listen. Which is really important when you deal with healthcare. And I think it’s really important to always take a step back and ask yourself if what you’re doing is actually going to move the needle on where it matters. You can move a lot of needles, but for example, I’ll be the first one to tell you that I think that the application of telehealth for urgent care is really, really important. But the vast majority of healthcare paying and expenditure and volume is not in the flu, it’s in diabetes and heart failure and what Glen is doing and some of those things, and maybe that helps Glen in some way. But I think that the reality is we need to look at where healthcare happens, tough as it may be, and find a way for technology to weave into that and give it wings. And if we’re able to do that, then we’ve moved the needle on people’s right to expect better health care experience going forward than what was before. And we are seeing that happening in front of our eyes.

Jessica DaMassa:

All right. Last thing for you, toothpaste back in tube, what do you think? No? Yes?

Roy:

No.

Jessica DaMassa:

Are you sure? No, it’s not going back.

Roy:

It is not.

Jessica DaMassa:

This is it. This is here to stay.

Roy:

This is here to stay. Yes.

Jessica DaMassa:

All right. Well, you have to come back and talk to us if there is any news in September that we had heard, you have to come back and talk to us, even if you acquire something cool. I would like to hear about it.

Roy:

It’d be a pleasure.

Jessica DaMassa:

Thank you so much for letting me pick your brain.

Roy:

Happy to come back whenever you want.

Jessica DaMassa:

Fantastic. And I have to say, I really like that little Amwell throw pillow behind you.

Roy:

Oh yeah.

Jessica DaMassa:

That is super nice. For a big pillow fight later, right? Right. Thank you so much for stopping by and letting us pick your brain. It’s so exciting to hear about your vision for the future of the sector of the industry. I really can’t thank you enough. Thank you again for joining us. I’m Jessica DaMassa here with Roy Schoenberg, the co-CEO and president of Amwell. Thanks to everybody for watching. We’ll talk to you guys soon. Check out more of these videos up on wtf.health, or find me on YouTube. Just search WTF Health. Thanks so much for joining us.

Roy:

Thanks everyone.

Episode 11 of “The THCB Gang” was live-streamed on Thursday, May 27th and you can see it again below

Joining me were three regulars, patient safety expert Michael Millenson (MLMillenson), writer Kim Bellard (@kimbbellard), health futurist Ian Morrison (@seccurve), and two new guests: digital health investment banker Steven Wardell (@StevenWardell) and MD turned physician leadership coach Maggi Cary (@MargaretCaryMD)! The conversation was heavy on telemedicine and value based care, and their impact on the stock-market, the economy and the health care system–all in a week when we went over 100,000 deaths from COVID-19.

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

By ETIENNE DEFFARGES

1) What is the likelihood the ACA will be repealed?

This straightforward question has a very simple answer: It depends on the results of the upcoming November 6 U.S. congressional elections.

If the Republicans retain control of both the House and the Senate, the probability that the ACA will be repealed is very high: The Republicans would be emboldened by such a victory and would most probably attempt in 2019 to repeal the health care law—again. It is worth remembering that in July of last year, the repeal of the ACA (a version of which had passed the House in May) was defeated in the Senate by the narrowest of margins, because three Republican Senators, Susan Collins, Lisa Murkowski, and the late and much regretted John McCain, voted against the repeal. This is very unlikely to happen again, although one would also have to consider the margins by which the Republican would have gained control both Chambers after these November midterms. In July of 2017, the Republicans held a 52-48 advantage in the Senate. Given ever-increasing polarization, such a margin, plus Republican control of the House, would likely spell the end of the ACA in 2019.

If the Democrats gain control of either the House of Representatives or the U.S. Senate, then the ACA will remain the law of the land. The only issue in the horizon will be the lawsuit filed in February of this year by a coalition of 20 states, led by Texas and Wisconsin. This lawsuit claims that Obamacare is no longer constitutional after the Republicans eliminated in December of 2017 the tax penalty associated with the ACA’s individual mandate. The 20 Republican attorney generals argue that without the tax penalty, Congress has no constitutional authority to legislate the individual mandate. Even if this case reaches the Supreme Court, one has to remember that the Court affirmed twice the constitutionality of the ACA, in June of 2012 and then 2015, with Chief Justice John Roberts voting with the majority on both occasions.

2) What do recent congressional changes to the ACA mean for those who buy insurance on health care exchanges?

The answer to this question has to be more nuanced: What will happen this year on the ACA healthcare exchanges can only be predicted at this stage, because the enrollment period for the 2019 ACA plans available on the exchanges has not started yet—it runs from November 1 to December 15. Let’s start by what we do know:

• The ACA remains the law of the land, including the mandate to purchase health insurance (the ACA’s “individual shared responsibility provision”).
• What was repealed in the Republican tax bill signed into law on December 22, 2017, is the tax penalty one would owe under the ACA if one failed to maintain “minimum essential coverage.” Most medical plans qualify for this under the ACA, as long as they meet a number of requirements, such as not charging more for pre-existing conditions and offering ten essential health benefits.
• This means that an individual could elect to purchase one the alternative and non-ACA compliant coverage options the Trump White House has directed health agencies to implement, and not pay any tax penalty. These short-term insurance plans are low-cost and low-benefit and do not adhere to ACA standards such as minimum essential coverage and availability to those with pre-existing conditions.
• In June of this year, the Department of Labor issued the regulatory guidelines that put in place a version of such alternative coverage—association health plans for small businesses and self-employed individuals. This was immediately followed by litigation from 12 states, their attorney generals noting that such low regulation plans have led to fraud and insolvency in many cases in the past.

Now for what we don’t know:

How will the above changes to the ACA affect the cost of insurance on the exchanges? My prediction is that these costs will not change much, and the number of available insurance plans in the exchanges will actually increase.

Why do I say that? After all, one theory is that many healthy and low-income people will choose some of the new, low cost and non-ACA compliant plans now on offer. This will mean that there will be fewer people buying coverage on the exchanges and that these people will be less healthy on average. Insurance companies selling plans on the exchanges will thus have to raise their prices—a negative consequence for those who buy insurance on health care exchanges.

Ah yes, but that is the theory. Actual events have taught us that a few facts run counter to this argument.

First, we have the actual 2017 ACA exchange enrollment data. Despite the Trump administration cutting funds for advertising and outreach to the exchanges by 90%, enrollment essentially stayed flat: According to the Henry J. Kaiser Family Foundation, 11.8 million Americans purchased coverage on the exchanges for 2018, versus 12.2 million enrolled in the ACA in 2017, and 10.4 million in 2016.

Second, the new low cost and non-ACA compliant plans are still in early stage, far from representing an option for lots of people, and there are many concerns about their quality. Some people may also elect not to have any health coverage at all, but in all likelihood, there will not be enough of them to affect pricing on the exchanges significantly. Preliminary data state-by-state appears to confirm this, compensating in some way for the widespread price increases seen in 2018.

Third, all the subsidies available for low-income families and individuals under the ACA remain in place, which means that people who qualify for the subsidies will not pay more than today. Preliminary data also shows new insurers entering the exchanges, unlike what was seen in 2017: Increased competition will help keep prices flat.

The reality as shown by the above figures is that there is a large number of Americans who want both quality and affordable health coverage, despite ongoing efforts by the Trump administration to derail the ACA.

3) Why are so many Americans misinformed about the ACA, and about open enrollment?

This question has an easy answer: Because of the actions that were taken by the Trump administration after the Republican-led U.S. Senate failed to pass a bill repealing the ACA in July of 2017. Since then, the Trump administration has undermined the ACA through executive orders and its tax bill.

Specifically, the Republican tax bill signed into law on December 22, 2017, repealed the tax penalty one would owe under the ACA if one failed to maintain “minimum essential coverage.” This action did not end the ACA, not even its mandate to purchase health insurance. Yet, on December 26, 2017, Trump tweeted: “Based on the fact that the very unfair and unpopular Individual Mandate has been terminated as part of our Tax Cut Bill, which essentially Repeals (over time) Obama Care, the Democrats & Republicans will eventually come together and develop a great new HealthCare plan!” This statement is one of many made by Trump and Republicans that likely have confused a lot of people regarding the actual status of the ACA.

Furthermore, the Trump administration started pushing, via executive orders, low-cost health plans not compliant with the ACA. This means that an individual could elect to purchase non-ACA compliant coverage options the Trump White House has directed health agencies to implement, and not pay any tax penalty. As seen above, after some of these low-costs and low-benefits alternative plans were put in place by the Labor Department, 12 states sued the federal government. Given this ongoing litigation, the status of these plans is unclear, adding to the confusion.

The Trump administration has also ensured that the ACA no longer benefits from advertising and outreach efforts to explain how to enroll, what benefits to expect, and how to navigate the websites to prospective buyers. As seen above, 90% of the funds for advertising and outreach to the ACA exchanges were cut in 2017. It is also important to remember that 19 states, all led by Republican governors, have refused the very popular extension of Medicaid provided in the ACA. This extension is funded at 100% during its first few years by the federal government, so governors who have opposed this extension are denying fellow state citizens their share of federal dollars that could have been allocated to their state. Obviously, these state governments are not engaged in any type of effort promoting enrollment and information about the ACA, including its November 1 to December 15 enrollment period.

4) What can be done to make people more aware of the ACA and the open enrollment period?

First, the good news: despite all the Republican efforts to undermine the ACA, Obamacare remains very popular, and enrollment remains very healthy. Can more be done?

To increase awareness about the ACA, one has to rely on the health departments on the 31 states (plus the District of Columbia) that have expanded Medicaid, and local efforts by hospitals and health insurers, who can serve as an important link to ACA health coverage.

Hospitals support the ACA: They have a legal obligation to treat uninsured patients through their Emergency Departments, a very expensive proposition since those are staffed by physicians trained to save lives in emergency situations, not to act as general practitioners for the uninsured. Therefore the fewer uninsured there are, the better for hospitals. Plus, hospitals and physicians are trusted by most.

Insurers too want more patient insured. This is why the “repeal and replace” efforts by the Republican Congress in 2017 achieved the rare feat of triggering unanimous opposition from the whole medical sector, hospitals, health insurers, associations of physicians, etc. Local NGOs helping patients navigate our complex health care system and the ACA exchanges are also lining up to supplement local outreach efforts by states and health providers.

5) What should healthcare insurance buyers do to maximize their ACA experience? 

First, they should get as much advice as possible: from their physicians, local hospitals, and local associations helping promote the ACA.

Second, they need to learn to navigate the ACA websites; again if possible with the advice of colleagues, friends, and medical professionals they know.

Third, they should keep in mind a key, and counterintuitive feature of most ACA websites, which can lead to an unwarranted “sticker shock.” The first quotes for coverage one will see do not take into account the subsidies one is likely to be eligible for. These subsidies have not been touched by the Trump administration, and provide protection against potential nominal price increases first seen on the website. Therefore, health insurance buyers should go through the whole journey on their ACA website, keeping in mind that the actual, real price they will pay is not what they will have seen quoted first, but what they will see at the end when those subsidies have been factored in. Navigating these sites is not easy, so again insurance buyers should get all the advice and help they can garner.

Etienne Deffarges has counseled, created, and invested in countless organizations during his professional life as a management consultant, business executive, and entrepreneur

By HANNAH MARTIN MPH, RD; JENNY BOGARD; WILLIAM DIETZ, MD; ANNE VALIK; NICHOLE JANNAH; CHRISTINE GALLAGHER; ANAND PAREKH, MD, MPH; DON BRADLEY MD

The United States has been facing a mounting obesity epidemic for over a generation, but our health care system has struggled to keep up. Given the complexity of obesity and the pace of curricular change, obesity education for our health-provider workforce is still lacking. There are wide disparities in quantity and quality among programs and disciplines. Similarly, public and private payers have taken vastly different approaches towards coverage for obesity treatment and prevention, which even leaves the most educated providers unsure of what services each patient can access. Because coverage decisions are based partly on what providers are prepared to provide and curricula are based partly on what services are typically covered, these problems reinforce one another. Despite these challenges, several important steps have been taken recently to tackle both sides of the problem. The steps include the development of new Provider Competencies for the Prevention and Management of Obesity and the launch of the My Healthy Weight pledge to standardize coverage for obesity counseling services.

Why We Must Act

In the US, more than one-third of the adult population and nearly one-fifth of the children have obesity. Adult obesity prevalence is projected to reach nearly 50 percent by 2030. Adult diabetes prevalence currently hovers around ten percent and is further projected to affect one-third of the adult population by 2050. Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion, with billions more lost in productivity due to absenteeism and presenteeism. Obesity is also a national security issue. As of 2010, 27 percent of young adults were disqualified for military service due to obesity.

Improving Obesity Education for Health Care Providers

Despite these shocking rates of obesity, fewer than one in four physicians feel that they received adequate training in counseling patients on diet or physical activity. Obesity concepts are underrepresented on medical licensing examinations and substantial gaps in provider knowledge related to obesity care have been recently documented. This is not surprising considering that less than 30 percent of medical schools meet the minimum recommended number of nutrition-related content hours.

The decision to develop interprofessional obesity competencies grew out of two related activities. A 2013 convening and 2014 white paper that we organized and authored on training doctors for prevention-oriented care, established that a major barrier to improving the knowledge base was a lack of clarity on what exactly should be taught. At the same time, a publication by several members from an Innovation Collaborative associated with the National Academy of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions pointed to the need for integrated approaches to obesity prevention and management.

These led to the formation of a working group consisting of 24 diverse organizations representing a dozen health professions involved in the care of people with obesity. Over the course of 18 months, the working group developed 10 core competencies for obesity education that include demonstrating knowledge of obesity as a disease and its epidemiology, recognition of bias and stigmatization, interprofessional collaboration, and the need for patient-centered communication and physical accommodations.

To promote the integration of the obesity competencies into training programs, we launched an Innovation Award for Health Care Provider Training and Education to recognize health professional training programs that provide innovative nutrition, physical activity, and obesity counseling education and have incorporated one or more obesity competencies into their curricula. Now in its second year, the Innovation Award recognizes the leadership of inventive educational models from all health disciplines and serves to inspire others with examples of what can be achieved.

Improving Reimbursement for Obesity Services

Payments to providers for counseling in nutrition, physical activity, and behavioral health for obesity are another major barrier to the prevention and management of obesity. Although some health insurers have increased coverage for preventive care services, adequate reimbursement for obesity care is rarely a top priority. A survey of Medicaid coverage of obesity services shows that coverage is highly variable and often deficient across states.

To address the lack of coverage and standardization with the insurance marketplace, we convened over 20 private insurers, large self-insured employers, and state Medicaid agencies to devise a standardized benefit obesity counseling services. These forward-leaning payers collaborated for over a year to develop the My Healthy Weight pledge, which launched in November 2017 and now boasts 11 signatories who collectively cover over 10.5 million lives. Key components of the pledge include covering intensive behavioral interventions and evidenced-based community programs for both adults and children with specified risk factors. While these benefits are currently structured for a fee-for-service payment model, we hope to move towards quality-based payment models for obesity in the future.

Looking to the Future

Moving the needle on the obesity epidemic will require all schools and programs that train health professionals to integrate obesity education into their curricula. To facilitate this effort, we have created a database of curricular resources for educators and will continue to recognize exemplary training programs annually through the Innovation Award. We will also identify and address profession-specific gaps in provider education and training on obesity prevention and management.

To capitalize on the momentum of the founding members of My Healthy Weight and support their continued leadership in this process, we will provide ongoing technical assistance and resources as our first cohort of signatories works to implement the benefit for the plan year 2019. We are also working with additional payers to sign the pledge for the plan year 2020.

The costs of obesity emphasize the need for revising care delivery and the importance of clinical-community partnerships to effectively mitigate the obesity epidemic. These improvements cannot come overnight and will require that educators, students, health care providers, health systems, payers, employers, and governments make obesity prevention and care a high priority.

Hannah Martin, MPH, RD, Senior Policy Analyst, Bipartisan Policy Center

Jenny Bogard, MPH, Founder and Managing Partner, Commonality

William Dietz, MD, Ph.D., Director of Sumner M. Redstone Global Center for Prevention and Wellness, George Washington University

Anne Valik, MPH, Founder and Managing Partner, Commonality

Nichole Jannah, Research Assistant, STOP Obesity Alliance, Redstone Center, George Washington University

Christine Gallagher, MPA, Research Project Director, STOP Obesity Alliance, Redstone Center, George Washington University

Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center

Don Bradley, MD, MHS-CL, Associate Consulting Professor, Duke University School of Medicine

By ANISH KOKA MD

Everyone agrees that health care is bankrupting the nation. The prevailing winds have carried the argument that a system that pays per unit of health care delivered and thus favors volume over value is responsible. The problem, you see, was the doctors. They were just incentivized to do too much. This incontrovertible fact was the basis for changes in the healthcare system that favored hospital employment and have made the salaried physician the new normal. Yet, health care costs remain ascendant.

Why?

It turns out overutilization in the US healthcare system isn’t what its cracked up to be.

Figure 1. Utilization rates in different health care systems

A recent analysis (Figure 1) by Papanicolas et al., in JAMA demonstrates that while the United States is no slouch with regards to volume of imaging and procedures in a variety of different categories, it does not explain a health care system twice as expensive as its nearest competitor. The problem turns out not to be volume, rather its the unit price of healthcare in the United States.

Health Care Costs and Glass Houses

There are many stones cast by all the various players in healthcare when it comes to cost, and of course, everyone bears some degree of responsibility, but it’s also clear that some folks live in larger glass houses than others. The most beautiful of all the glass houses are those built by hospitals. From 1996 to 2013, it was not population growth, health status, doctors visits, or prescription drugs that drove spending increases. Sixty-three percent of the increase in cost over an almost 20-year time span can be attributed to hospital stays and testing during doctor visits. Consider that the average hospital stay in the US costs $18,142, and lasts 4.9 days compared to other industrialized countries where average hospital stays last 7.7 days, and cost $6,222. But despite these exorbitant prices hospital systems in the United States complain they barely stay afloat.

Physicians blame administrators, administrators blame physicians, woke liberal venture capitalists blame the Koch Brothers, and economists blame everyone. Ambling through hospitals for the better part of the last two decades suggests real culpability strikes disturbingly close to home. Physicians work in a hospital climate where they are utterly oblivious to the cost of the health care they deliver. No one has any idea what an X-ray, a bag of saline, or an antibiotic costs. Insulation from cost isn’t all bad – it’s nice to know physician decisions are being made irrespective of the ability to pay, but the flip side of this is that there is precious little incentive to be efficient about health care delivery. Physicians ask for the moon and usually get it. Hospital administrators poorly versed in clinical matters respond to high costs by doing what they do best: pushing doctors to see as many patients as possible, and rewarding physician rainmakers that bring in the most clinical revenue. So, hospital administrators don’t choose to run inefficient enterprises, they just happen to be constrained by clinical partners with no incentive to be remotely efficient.

Consider the change over time in how hospitals are staffed. It used to be that hospitals were staging grounds for physicians who owned and operated their practices, managing busy outpatient clinics, and managing patients in the hospital when the need arose. In this setup, the hospital had no role in paying physicians directly, rather physicians paid themselves out of the clinical revenue generated from seeing the patient in the hospital. Driven by a system that moved to pay hospitals per diagnosis rather than by a number of days, and thus put a premium on shortening the length of stay, the inpatient hospitalist was born. Hospitalists are physicians who specialize in the care of hospitalized patients and are almost always employed by hospitals. It soon became standard for outpatient physicians to stay in clinics, and have hospitalists take care of inpatients. In theory, this would allow for better care of inpatients, and allow primary care physicians to see more outpatients. In the real world, as the outpatient practice of medicine was made more onerous and less lucrative, doctors flocked to do hospital shift work upon graduating.

The results in hospitals were wondrous to behold. The same small hospital I frequented that a decade prior operated with a skeleton full-time physician crew now employs over 20 full-time hospitalists. Length of stays are certainly shorter, documentation of inpatient stays is robust, but of course, there is no evidence that real outcomes for patients are any better. Hospitalists initially were focused within general internal medicine, but have now quickly metastasized to specialty care as well. Innovation in hospitals seems to consist of creating a fresh class of hospitalists for every organ system. Soon there will be hospitalists that specialize only in the big toe. The documentation promises to be fantastic. Factoring in medical malpractice and benefits, the average hospitalist in a big city market costs a quarter million dollars yearly today, and there are 50,000 hospitalists now working in the United States. All of this contributes to hospital salt water that is the most expensive in human history. To be absolutely clear, I am not suggesting there is no value to hospitalists. Some of the best physicians I know belong to this group. I am suggesting that this is an utterly inefficient, fragmented way to deliver care supported by health care prices outside the bounds of reality.

Using the Evidence to Compound Health Care Costs
And this is only the tip of the iceberg. Hospitals are masterful in their ability to expend vast resources to achieve illusory goals. In all fairness, this is driven by a research industrial complex constantly publishing the next great therapies that may happen to reach statistical significance, but in reality, have at most Lilliputian effect sizes.
Consider a recent multidisciplinary ‘teaching’ conference I happened to attend that was focused on the management of pulmonary embolism (clots in the lung). The most important thing to know about pulmonary embolisms is what was not mentioned during the conference – the case fatality rate for the diagnosis has not changed in a quarter century. The chart below does demonstrate a doubling of the incidence of PE, but this would be because of ever more sensitive ways to image the pulmonary arteries that reveal clinically irrelevant pathology since there has been no change in deaths from PE over the same time span!

Nonetheless, this particular academic conference has interventional radiologists, cardiologists, pulmonary critical care doctors, vascular medicine physicians, and yes even hospitalists impressively arrayed to focus on improving the management of Pulmonary Embolism. The propose of this conference is to make a rare problem even rarer by creating a hospital Avengers team know as PERT (Pulmonary Embolism Response Team). The goal of the meeting is to convince the wider medical community to activate the PERT team to evaluate pulmonary embolisms for new therapies for PE.
Traditionally PE’s are treated with blood thinners (Heparin/low molecular weight heparin/Factor Xa inhibitors) that prevent propagation of clot or clot-busting drugs that actually break down the clot. A very small number of patients don’t respond to these therapies because the burden of the clot in the lungs is too great, and the thrombus needs to be surgically removed in a gory, but life-saving maneuver called a pulmonary thrombectomy.

More recently, interventional radiologists have developed techniques to thread catheters directly into the pulmonary arteries to dissolve clots – a technique known as catheter-directed thrombolysis (CDT). The clear message at the conference was that your next patient with a pulmonary embolism should be evaluated by the PE response team for advanced therapies such as these. The basis for all of this is sold as evidence-based commandments, but the reality is far from it. (Readers are advised to skip the next two paragraphs if they would like to just take my word for it)

The Evidence-Based House of Cards

The results of this approach are somewhat predictable and are encapsulated in an interesting paper described a single institutions experience with PERT. The study looked at a 20 month time window after PERT came to a New York Hospital. There were a total of 124 PERT activations – 43 in the first ten months, 81 in the last ten months. 21/25 patients taken for CDT were taken because of something called submassive PE. Submassive PE refers to strain seen on the right side of the heart as it attempts to pump blood around the clot. It used to be that right-sided strain was diagnosed based on a heart ultrasound, but recently a more sensitive, but less specific technique measuring proteins released by the straining right heart was included as part of the diagnostic criteria. The problem is that this biomarker elevation without sonographic evidence of right ventricular dysfunction isn’t a high-risk marker in isolation because any stretch of the ventricular chambers will cause some leakage of biomarkers. Only 13-14% who had an abnormal test in a case series ended up dying. While this is not a small number, it does argue against this test in isolation being able to discriminate a population that would significantly benefit from an intervention. Even if you add in the presence of sonographic right ventricular dysfunction, it is unclear that using clot-busting medications up front is beneficial. A 2003 study that compared a clot-busting drug to blood thinning was ‘positive’ only because more people in the blood-thinning arm eventually ended up getting a clot-busting drug. The PEITHO trial in 2014 showed similar results. More patients clinically decompensated in the blood-thinning only group (5.6% vs 2.6%) but overall survival was no different between the two groups, though there were more bleeds into the brain (2% vs 0.2%) with a clot-busting drug. So, in general, a strategy of blood thinning first with the addition of a clot buster in the case of clinical decompensation is a safe yet effective option.

CDT sought to capture the small benefit of systemic thrombolysis while reducing the risk of bleeding into the brain by infusing clot-busting drug directly into the artery where the clot resides. The SEATTLE II trial examine this strategy by taking 150 patients with central PE and performing CDT. Statistically, significant differences were seen before and after CDT with regards to pulmonary artery pressures and left to right chamber size ratio. I don’t mind relevant surrogate endpoints, but the problem here is that the clinical meaningfulness of these surrogate endpoints is questionable. Pulmonary artery pressures, as well as right ventricular chamber size, are notoriously dynamic in nature. Transient elevations in pulmonary artery pressures cause the thin-walled, compliant right ventricle to dilate frequently. Both parameters may quickly return to normal once the underlying cause of high pulmonary pressures has been treated. There was also no control arm to see how CDT performed relative to conventional blood thinning. The trial certainly did demonstrate safety but was far from convincing in demonstrating efficacy.

To be clear, I’m a fan of procedures with a large upside and little downside in patients in extremis. I don’t care that much about negative randomized control trials in this space because I don’t really care about average yardage gained when throwing a hail mary. But we all should care when protocols are put in place to trigger algorithms in patients that aren’t in extremis. This is usually what happens when a panel comes together to design protocols. In order for them to be practical, they are usually simple flow diagrams based on some easy to measure variable. You can’t have a protocol that says “if the patient looks sick” because that would be subjective and introduce that horror of all horrors: variability. Judgment is deferred to the PERT team that is more likely than not to be comprised of someone making a decision based on reading some other disconnected from the case physician report of an echocardiogram. That this is state-of-the-art medical care in 2018 would make Osler weep.

The change in practice pattern after PERT institution are remarkably predictable. If you set up a protocol to call a barber, you get a lot of haircuts. In the 20 months prior to PERT, there was 1 CDT. In the 20 months after PERT inception, there were 25. Recall the problem we are attempting to solve (Death related to PE) has a rare case fatality rate that has not changed in two decades. The majority of these PERT activations were due solely to the presence of a biomarker elevation, which almost surely means most of these interventions took place in patients that would likely have been fine with conventional anticoagulant therapy.

My bias and unwillingness to trust the surrogate endpoint improvement relates to a large number of patients who develop transient RV dysfunction during an acute event that normalizes after conventional therapy. There are a small minority of individuals who develop a chronic clot and elevated pressures, but it is impossible with what we know now to predict who that is, and we don’t have a good sense either mechanistically or in a trial setting if CDT would prevent this. So while it is wonderful to know there is another option for the decompensating patient with a PE, the PERT program appears designed to funnel more patients to a lab to get a procedure with questionable benefit.

The resources to marshall all of this are not cheap. A separate layer of PERT consult physicians are added to the mix, catheters to do the procedure need to be stocked, and staffing to accommodate 24/7 interventional radiology coverage for this procedure are marshaled. Outside community hospitals in the network even start to send patients to the hub just to have this procedure.  Costs spiral, physicians pat themselves on the back, patients thank the heavens their lives were saved, and hospital executives earnestly proclaim to politicians and those who pay for healthcare that providing state of the art healthcare in the United States is an expensive endeavor they can do nothing about.

Physicians are wont to point everywhere but themselves whenever high prices in health care are raised. I know all the arguments well, but the hard truth lurking beneath the covers is that physicians lie at the heart of all of this. Fixing this mess from the bottom up will require physicians to take ownership of a situation we have created lest we wish the solution be dictated to us by people without a clue.

The cartoonist Walt Kelley may have said it best: “We have met the enemy and he is us”.

Anish Koka is a cardiologist in private practice in Philadelphia.  He is fond of living in glass houses and can be followed on twitter @anish_koka

By MICHAEL MILLENSON

If your heart throbs with desire for the new Apple Watch, the Series 4 itself can track that pitter-pat through its much-publicized ability to provide continuous heart rate readings.

On the other hand, if you’re depressed that you didn’t buy Apple stock years ago, your iPhone’s Face ID might be able to discover your dismay and connect you to a therapist.

In its recent rollout of the Apple Watch, company chief operating officer Jeff Williams enthused that the device could become “an intelligent guardian for your health.” Apple watching over your health, however, might involve much more than a watch.

The iPhone models introduced at the same time as the Series 4 all deploy facial analysis software. The feature works in part by projecting a grid of more than 30,000 infrared dots on the user’s face in order to create a three-dimensional map for user recognition. This Face ID feature has been upgraded from the iPhone X by addition of a new chip, the A12 Bionic, which improves the ability of the phone’s artificial intelligence “neural engine.” Reportedly, those superior smarts will show up as clearer photos and FaceTime calls due to better detection of faces and bodies when taking pictures and video.

But that improved clarity has other applications. Research shows that your facial expressions can provide the information about your emotional or mental state that’s then analyzed by “emotion algorithms” – or, perhaps, overanalyzed in the absence of other context about your life.

Meanwhile, the smartphone’s microphone and other sensors can gather additional clues. Signals collected on facial expressions, voice quality, language use, physical activity, music choice, and geographical location can all be used “to predict and prevent mental health crises.”

The democratization of medical information being enabled by mHealth apps could truly empower individuals, rather than merely “engaging” them to do a better job of following doctors’ orders. (Which, I hasten to add, may often be appropriate, but also may not be.) Still, going from a company that helps us play music for every mood to one that actually measures that mood presents a perilous transition.

Yes, as the New York Times wrote, the Apple Watch’s “evolution from a fitness tracker into a health-monitoring device makes it vastly more interesting in the long term.” The introduction of the Series 4 watch promptly caused Fitbit shares to plunge.  According to analysts quoted by CNBC, the new watch could take a big chunk out of sales of traditional Swiss watches.

But as more Apple devices are used individually and collaboratively with each other to continually monitor of our bodies and our minds, the focus on diagnostic accuracy of these direct-to-consumer apps will increase – a topic I’ve recently researched and written about.

Moreover, there are serious concerns about how widely Apple may be sharing facial information, whether with advertisers or others. Information is power: to what extent will Apple’s devices empower individuals, and to what extent will they empower health care providers and health insurers, an array of marketers and advertisers or maybe even government?

One example: John Hancock recently said that all its life insurance policies will include incentives for policyholders to improve their fitness through using wearable devices such as the Fitbit or Apple Watch as part of the Vitality fitness program. While that shift certainly boosts individual empowerment for health, it also gives new power via the policyholder data collected to John Hancock, a unit of Manulife Financial Group.

Another example: AliveCor just announced its own electrocardiogram reader that works with the Apple Watch and will provide information on 100 diseases, not just the one (atrial fibrilliaton) Apple has trumpeted.  Again, that information empowers consumers, but how that information is shared and its impact remains to be seen.

Famed Apple design chief Jony Ive was spot-on when he summed up the impact of the Series 4 watch to The Washington Postby proclaiming: “Every bone in my body tells me this is very significant.” However, Ive, design genius though he may be, should remember that consumer expectations about “fitness” and “health care” are very different.

Winning our hearts and minds is not the same thing as constantly monitoring them.

Michael is a consultant specializing in quality of care, patient empowerment, web-based health, and is an adjunct Associate Professor of Medicine at Northwestern University’s Feinberg School of Medicine.