By MATTHEW HOLT

I am dipping into two rumbling controversies that probably only data nerds and chronic care management nerds care about, but as ever they reveal quite a bit about who has power and how the truth can get obfuscated in American health care. 

This piece is about the data nerds but hopefully will help non-nerds understand why this matters. (You’ll have to wait for the one about diabetes & chronic care).

Think about data as a precious resource that drives economies, and then you’ll understand why there’s conflict.

A little history. Back in 1996 a law was passed that was supposed to make it easy to move your health insurance from employer to employer. It was called HIPAA (the first 3 letters stand for Health Insurance Portability–you didn’t know that, did you!). And no it didn’t help make insurance portable.

The “Accountability” (the 1st A, the second one stands for “Act”) part was basically a bunch of admin simplification standards for electronic forms insurers had been asking for. A bunch of privacy legislation got jammed in there too. One part of the “privacy” idea was that you, the patient, were supposed to be able to get a copy of your health data when you asked. As Regina Holliday pointed out in her art and story (73 cents), decades later you couldn’t.

Meanwhile, over the last 30 years America’s venerable community and parochial hospitals merged into large health systems, mostly to be able to stick it to insurers and employers on price. Blake Madden put out a chart of 91 health systems with more than $1bn in revenue this week and there are about 22 with over $10bn in revenue and a bunch more above $5bn. You don’t need me to remind you that many of those systems are guilty with extreme prejudice of monopolistic price gouging, screwing over their clinicians, suing poor people, managing huge hedge funds, and paying dozens of executives like they’re playing for the soon to be ex-Oakland A’s. A few got LA Dodgers’ style money. More than 15 years since Regina picked up her paintbrush to complain about her husband Fred’s treatment and the lack of access to his records, suffice it to say that many big health systems don’t engender much in the way of trust. 

Meanwhile almost all of those systems, which already get 55-65% of their revenue from the taxpayer, received additional huge public subsidies to install electronic medical records which both pissed off their physicians and made several EMR vendors rich. One vendor, Epic Systems, became so wealthy that it has an office complex modeled after a theme park, including an 11,000 seat underground theater that looks like something from a 70’s sci-fi movie. Epic has also been criticized for monopolistic practices and related behavior, in particular limiting what its ex-employees could do and what its users could publicly complain about. Fortune’s Seth Joseph has been hammering away at them, to little avail as its software now manages 45%+ of all encounters with that number still increasing. (Northwell, Intermountain & UPMC are three huge health systems that recently tossed previous vendors to get on Epic).

Meanwhile some regulations did get passed about what was required from those who got those huge public subsidies and they have actually had some effect. The money from the 2009 HITECH act was spent mostly in the 2011-14 period and by the mid teens most hospitals and doctors had EMRs. There was a lot of talk about data exchange between providers but not much action. However, there were three major national networks set up, one mostly working with Epic and its clients called Carequality. Epic meanwhile had pretty successfully set up a client to client exchange called Care Everywhere (remember that).

Then, mostly driven by Joe Biden when he was VP, in 2016 Congress passed the 21st Century Cures Act which among many other things basically said that providers had to make data available in a modern format (i.e. via API). ONC, the bit of HHS that manages this stuff, eventually came up with some regulations and by the early 2020’s data access became real across a series of national networks. However, the access was restricted to data needed for “treatment” even though the law promised several other reasons to get health data.

As you might guess, a bunch of things then happened. First a series of VC-backed tech companies got created that basically extract data from hospital APIs in part via those national networks. These are commonly called “on-ramp” companies. Second, a bunch of companies started trying to use that data for a number of purposes, most ostensibly to deliver services to patients and play with their data outside those 91 big hospital systems.

Which brings us to the last couple of weeks. It became publicly known among the health data nerd crowd that one of the onramp companies, Particle Health, had been cut off from the Carequality Network and thus couldn’t provide its clients with data.

The supposed reason was that they were getting data without a “treatment” reason.

Now if you really want to understand all this in detail, go read Brendan Keeler’s excellent piece “Epic v Particle”. Basically Particle cried foul and unusually both Michael Marchant, a UC Davis Health employee & the Chair of the big health systems on the ”Care Everywhere Committee” (remember that from earlier?) and then Epic itself responded. Particle’s founder Troy Bannister in a linkedin post and an official release from Particle said that they had not received notice or any evidence of what they’d done wrong. Michael said they had. I started quoting the Dire Straits line “two men say they’re Jesus, one of them must be wrong.” (FD. Troy was briefly an intern at Health 2.0 long, long ago).

Then Epic publicly released a letter to its clients explaining that, contrary to what Troy & Particle said, it had been discussing this with Particle for months and had had several meetings before and after it cut them off. So unless Particle’s legal counsel was parsing its words very very carefully, they knew Epic and its clients were unhappy, and it was unlikely Troy was Jesus. Michael might still be, of course. (Update: as of 4/15/23 Particle says only some feeds were cut off not all of them as Epic suggested)

In the letter Epic named 4 companies who were using Particle’s data in a way it didn’t like– Reveleer and MDPortals (who are one not two companies as they merged in 2023 before this issue started), Novellia and Integritort. 

So what do they do with the data. Reveleer says that “leveraging our AI-enabled platform with NLP and MDPortals’ sophisticated interoperability allows us to deliver providers a pre-encounter clinical summary of patients within their EHR workflow at the point of care.” Sounds like treatment to me. But Reveleer also does analysis for health plans. You can see why hospitals might not like them.

Novellia is a PHR company, presumably using “treatment” to enable consumers to access their data to manage their own care. This was EXACTLY what Joe Biden wanted the 21st  Century Cures Act to give patients the right to do and what Epic CEO Judy Faulkner told him he shouldn’t want (depending exactly who you believe about that conversation). But it’s probably not a particular “treatment” under HIPAA, because who believes patients can treat themselves or need to know about their own data anyway? (I’ll just lock you all in a room with Dave deBronkart, Susannah Fox and Regina Holliday if you want the real answer). This is apparently the line where ONC folded in its ruling to the vested interests that providers (and their EMR vendors) didn’t have to provide data to patient requests.

Finally, Integritort does sound like it’s looking for records so it (or its law firm customers) can sue someone for bad treatment (or as it turns out defend them for it). Is that “treatment” under the HIPAA definition?  Almost certainly not. On the other hand, do the providers cutting them off have a vested interest in making sure no outside expert can review what they’ve been up to? I think we all know the answer to that question. 

But anyway it looks like Particle switched off Integritort’s access to Carequality on March 22nd before Particle was entirely switched off by Carequality sometime around April 1.

What is not answered in the letter is why, if Carequality can identify who these records are going to, it needed to switch all Particle’s access off. Additionally, you would think that Particle’s path of least resistance would be to cut off the named clients Epic/Carequality was concerned about and try to sort through things while keeping its system running–which it seems it did with Integritort. Whatever happened, instead of this negotiation continuing behind the scenes, we all got to witness a major power play–with clearly Epic & its big customers winning for now.

I think most people who are interested in getting access to data for patients are all agreed on the need for new “paths” which were already defined in the regulations but not implemented, and also presumably for agreed standards (with associated liability) of “know your customer laws” for the onramps like Particle to make sure that the clients using them are doing the right things vis a vis confirming patient identity et al. 

Slight digression: I am confused about why identity proofing is such a big deal. In recent weeks I have had to prove my identity for the IRS, for a credit union, and for the TSA. Not to mention for lots of other websites. There are companies like IDme, Clear and many others that do exactly this. I don’t see anything so specific about health care that is different from credit cards, bank accounts, airport safety, etc. Why can those agencies/organizations access all that data online but for some reason it’s a bridge too far for health care?

However you can see where the fault lines are being drawn. There are a lot of organizations, many backed by rich VCs or huge quasi-tech corporations, that think they can do a much better job of caring for Americans than the current incumbents do. (Whether they can or not is another matter, but remember we are spending 18% of GDP when everyone else spends 10-12%). Those organizations, which include huge health plans, tech cos, retail clinics, startup virtual care clinics, and a whole lot more, need data. Not everything they or the intermediaries they do will fit the “treatment” definition the current holders of that data want to use. On the other hand, the current incumbents and their vendors are extremely uninterested in any changes to their business model.

Data may be the new oil but, like oil, data needs refining to power economies and power health care services. We spent much of the last century fighting about access to oil, and we’re going to spend a lot of this one fighting about data. Health care will be no exception.

Matthew Holt is the publisher of The Health Care Blog

By KIM BELLARD

Nice try, Wendy’s. During an earnings call last month, President and CEO Kirk Tanner outlined the company’s plan to try a new form of pricing: “Beginning as early as 2025, we will begin testing more enhanced features like dynamic pricing and day-part offerings along with AI-enabled menu changes and suggestive selling.” 

None of the analysts on the call questioned the statement, but the backlash from the public was immediate — and quite negative. As Reuters described it: “the burger chain was scorched on social media sites.”

Less than two weeks later Wendy’s backtracked – err, “clarified” – the statement. “This was misconstrued in some media reports as an intent to raise prices when demand is highest at our restaurants,” a company blog post explained. “We have no plans to do that and would not raise prices when our customers are visiting us most.”

The company was even firmer in an email to CNN: “Wendy’s will not implement surge pricing, which is the practice of raising prices when demand is highest. This was not a change in plans. It was never our plan to raise prices when customers are visiting us the most.”

OK, then. Apology accepted.

At this point it is worth explaining a distinction between dynamic pricing and the more familiar surge pricing. As Omar H. Fares writes in The Conversation: “Although surge pricing and dynamic pricing are often used interchangeably, they have slightly different definitions. Dynamic pricing refers to any pricing model that allows prices to fluctuate, while surge pricing refers to prices that are adjusted upward.”

Uber and other ride sharing services are well known for their surge pricing, whereas airlines’ pricing is more dynamic, figuring out prices by seat by when purchased by who is purchasing, among other factors.

Wendy’s wouldn’t be the first company to use dynamic pricing and it won’t be the last. Drew Patterson, co-founder of restaurant dynamic pricing provider Juicer, told The Wall Street Journal that dozens of restaurant brands used his company’s software. The company’s website doesn’t publicize those brands, of course. Still, he emphasized: “You need to make it clear that prices go up and they go down.” 

Dave & Busters is public about its pricing strategy. “We’re going to have a dynamic pricing model, so we have the right price at the right time to match the peak demand,” Dave & Buster’s CEO Chris Morris said during an investor presentation last year.  On the other hand, Dine Brands (Applebee’s/IHOP) Chief Executive John Peyton said. “We don’t think it’s an appropriate tool to use for our guests at this time.”

The potential revenue benefits are obvious, but there are risks, as Wendy’s quickly found out. Mr. Fares says: “One of the biggest risks associated with dynamic pricing is the potential negative impact on customer perception and trust. If customers feel that prices are unfair or unpredictable, they may lose trust in the brand.”

What Wendy’s tried to announce is not ground-breaking. Catherine Rampell pointed this out in a Washington Post op-ed:

In other words, things will be cheaper when demand is low to draw in more customers when there’s otherwise idle capacity. Lots of restaurants do this, including other burger chains. It’s usually called “happy hour.” Or the “early-bird special.” Non-restaurants do it, too. Think the weekday matinee deals at your local movie theater or cheaper airfares on low-traffic travel days.

Indeed, The Wall Street Journal reported: “An estimated 61% of adults support variable pricing where a restaurant lowers or raises prices based on business, with younger consumers more in favor of the approach than older ones, according to an online survey of 1,000 people by the National Restaurant Association trade group.” 

I wonder what the support would have been if the question had been about healthcare instead of restaurants. 

Like it or not, some form of dynamic pricing will come to healthcare. Want a private room instead of semi-private? Surge pricing. Willing to see a nurse practitioner instead of a physician? Dynamic pricing. Want to buy prescription drugs in the U.S. instead of in Europe? Surge pricing. Want a doctor’s appointment Monday morning instead of Tuesday? Surge pricing. Need an ER visit Saturday night instead of Sunday afternoon? Surge pricing.

Some of these healthcare has been doing for years. Others, and even more insidious ones, are coming.

We have to know that the private equity firms that have invested in healthcare have to be interested. Yashaswini Singh and Christopher Whaley wrote in The Hill: “Over the last decade, private equity firms have spent nearly $1 trillion on close to 8,000 health care deals, snapping up practices that provide care from cradle to grave: fertility clinics, neonatal care, primary care, cardiology, hospices, and everything in between.”

They go on to warn: “Although research remains mixed on how it affects quality of care, there is clear evidence that private equity ownership increases prices. These firms aim to secure high returns on their investments — upwards of 20 percent in just three to five years — which can conflict with the goal of delivering affordable, accessible, high-value health care.”

Dynamic pricing has to look good to these firms. Surge pricing would look even better.              

But one doesn’t have to be owned by private equity to be rapacious in healthcare. Everyone is looking for margins, everyone is looking to maximize revenue, and consumers – A.K.A. patients – grumble about prices but pay them anyway, especially if their health insurance company is paying most of the cost. In today’s healthcare world, if you are a CEO or CFO and you’re not considering dynamic pricing, it’s close to malfeasance.

To me, the scariest part of Wendy’s plan wasn’t the dynamic pricing but the “AI-enabled menu changes and suggestive selling.” Upcoding has been a problem in healthcare for as long as there has been coding, but when we get an AI-enabled menu of treatment options and suggested selling (aka treatments), well, we haven’t seen anything yet.

Maximize away.  

Look, I’m not going to Wendy’s even if they pay me, but I take my wife out on Valentine’s Day even though I know the restaurant has surged the hell out of its prices. Some things you pay for, and, when it comes to healthcare pricing, every day is Valentine’s Day.

I’m resigned to the fact that dynamic pricing has a toehold in healthcare already, but I’m holding out hope that we can use AI to help us make those recommendations and set those prices to deliver the most effective, efficient care, not just to maximize profits.

Wait Till Health Care Tries Dynamic Pricing

Nice try, Wendy’s. During an earnings call last month, President and CEO Kirk Tanner outlined the company’s plan to try a new form of pricing: “Beginning as early as 2025, we will begin testing more enhanced features like dynamic pricing and day-part offerings along with AI-enabled menu changes and suggestive selling.” 

None of the analysts on the call questioned the statement, but the backlash from the public was immediate — and quite negative. As Reuters described it: “the burger chain was scorched on social media sites.”

Less than two weeks later Wendy’s backtracked – err, “clarified” – the statement. “This was misconstrued in some media reports as an intent to raise prices when demand is highest at our restaurants,” a company blog post explained. “We have no plans to do that and would not raise prices when our customers are visiting us most.”

The company was even firmer in an email to CNN: “Wendy’s will not implement surge pricing, which is the practice of raising prices when demand is highest. This was not a change in plans. It was never our plan to raise prices when customers are visiting us the most.”

OK, then. Apology accepted.

At this point it is worth explaining a distinction between dynamic pricing and the more familiar surge pricing. As Omar H. Fares writes in The Conversation: “Although surge pricing and dynamic pricing are often used interchangeably, they have slightly different definitions. Dynamic pricing refers to any pricing model that allows prices to fluctuate, while surge pricing refers to prices that are adjusted upward.”

Uber and other ride sharing services are well known for their surge pricing, whereas airlines’ pricing is more dynamic, figuring out prices by seat by when purchased by who is purchasing, among other factors.

Wendy’s wouldn’t be the first company to use dynamic pricing and it won’t be the last. Drew Patterson, co-founder of restaurant dynamic pricing provider Juicer, told The Wall Street Journal that dozens of restaurant brands used his company’s software. The company’s website doesn’t publicize those brands, of course. Still, he emphasized: “You need to make it clear that prices go up and they go down.” 

Dave & Busters is public about its pricing strategy. “We’re going to have a dynamic pricing model, so we have the right price at the right time to match the peak demand,” Dave & Buster’s CEO Chris Morris said during an investor presentation last year.  On the other hand, Dine Brands (Applebee’s/IHOP) Chief Executive John Peyton said. “We don’t think it’s an appropriate tool to use for our guests at this time.”

The potential revenue benefits are obvious, but there are risks, as Wendy’s quickly found out. Mr. Fares says: “One of the biggest risks associated with dynamic pricing is the potential negative impact on customer perception and trust. If customers feel that prices are unfair or unpredictable, they may lose trust in the brand.”

What Wendy’s tried to announce is not ground-breaking. Catherine Rampell pointed this out in a Washington Post op-ed:

In other words, things will be cheaper when demand is low to draw in more customers when there’s otherwise idle capacity. Lots of restaurants do this, including other burger chains. It’s usually called “happy hour.” Or the “early-bird special.” Non-restaurants do it, too. Think the weekday matinee deals at your local movie theater or cheaper airfares on low-traffic travel days.

Indeed, The Wall Street Journal reported: “An estimated 61% of adults support variable pricing where a restaurant lowers or raises prices based on business, with younger consumers more in favor of the approach than older ones, according to an online survey of 1,000 people by the National Restaurant Association trade group.” 

I wonder what the support would have been if the question had been about healthcare instead of restaurants. 

Like it or not, some form of dynamic pricing will come to healthcare. Want a private room instead of semi-private? Surge pricing. Willing to see a nurse practitioner instead of a physician? Dynamic pricing. Want to buy prescription drugs in the U.S. instead of in Europe? Surge pricing. Want a doctor’s appointment Monday morning instead of Tuesday? Surge pricing. Need an ER visit Saturday night instead of Sunday afternoon? Surge pricing.

Some of these healthcare has been doing for years. Others, and even more insidious ones, are coming.

We have to know that the private equity firms that have invested in healthcare have to be interested. Yashaswini Singh and Christopher Whaley wrote in The Hill: “Over the last decade, private equity firms have spent nearly $1 trillion on close to 8,000 health care deals, snapping up practices that provide care from cradle to grave: fertility clinics, neonatal care, primary care, cardiology, hospices, and everything in between.”

They go on to warn: “Although research remains mixed on how it affects quality of care, there is clear evidence that private equity ownership increases prices. These firms aim to secure high returns on their investments — upwards of 20 percent in just three to five years — which can conflict with the goal of delivering affordable, accessible, high-value health care.”

Dynamic pricing has to look good to these firms. Surge pricing would look even better.              

But one doesn’t have to be owned by private equity to be rapacious in healthcare. Everyone is looking for margins, everyone is looking to maximize revenue, and consumers – A.K.A. patients – grumble about prices but pay them anyway, especially if their health insurance company is paying most of the cost. In today’s healthcare world, if you are a CEO or CFO and you’re not considering dynamic pricing, it’s close to malfeasance.

To me, the scariest part of Wendy’s plan wasn’t the dynamic pricing but the “AI-enabled menu changes and suggestive selling.” Upcoding has been a problem in healthcare for as long as there has been coding, but when we get an AI-enabled menu of treatment options and suggested selling (aka treatments), well, we haven’t seen anything yet.

Maximize away.  

Look, I’m not going to Wendy’s even if they pay me, but I take my wife out on Valentine’s Day even though I know the restaurant has surged the hell out of its prices. Some things you pay for, and, when it comes to healthcare pricing, every day is Valentine’s Day.

I’m resigned to the fact that dynamic pricing has a toehold in healthcare already, but I’m holding out hope that we can use AI to help us make those recommendations and set those prices to deliver the most effective, efficient care, not just to maximize profits.

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

By JEFF GOLDSMITH

On Christmas Eve 2014, I received a present of some profoundly unwelcome news: a 64 slice CT scan confirming not only the presence of a malignant tumor in my neck, but also a fluid filled mass the size of a man’s finger in my chest cavity outside the lungs. Two days earlier, my ENT surgeon in Charlottesville, Paige Powers, had performed a fine needle aspiration of a suspicious almond-shaped enlarged lymph node, and the lab returned a verdict of “metastatic squamous cell carcinoma of the head and neck with an occult primary tumor”. 

I had worked in healthcare for nearly forty years when cancer struck, and considered myself an “expert” in how the health system worked. My experience fundamentally changed my view of how health care is delivered, from the patient’s point of view. Many have compared their fight against cancer as a “battle”. Mine didn’t feel like a battle so much as a chess match where the deadly opponent had begun playing many months before I was aware that he was my adversary. The remarkable image from Ingmar Bergman’s Seventh Seal sums up how this felt to me.

The CT scan was the second step in determining how many moves he had made, and in narrowing the uncertainty about my possible counter moves. The scan’s results were the darkest moment: if the mysterious fluid filled mass was the primary tumor, my options had already dangerously narrowed. Owing to holiday imaging schedules, it was not until New Years’ Eve, seven interminable days later, that a PET/CT scan dismissed the chest mass as a benign fluid-filled cyst. I would require an endoscopy to locate the still hidden primary tumor somewhere in my throat.  

I decided to seek a second opinion at my alma mater, the University of Chicago, where I did my doctoral work and subsequently worked in medical center administration.

The University of Chicago had a superb head and neck cancer team headed by Dr. Everett Vokes, Chair of Medicine, whose aggressive chemotherapy saved the life and career of Chicago’s brilliant young chef, Grant Achatz of Alinea, in 2007.

If surgery was not possible, Chicago’s cancer team had a rich and powerful repertoire of non-surgical therapies. I was very impressed both with their young team, and how collaborative their approach was to my problem. Vokes’ initial instinct that mine was a surgical case proved accurate.

The young ENT surgeon I saw there in an initial consultation, Dr. Alex Langerman performed a quick endoscopy and thought he spotted a potential primary tumor nestled up against my larynx. Alex asked me to come back for a full-blown exploration under general anaesthesia, which I did a week later. The possible threat to my voice, which could have ended my career, convinced me to return to Chicago for therapy. Alex’s endoscopy found a tumor the size of a chickpea at the base of my tongue. Surgery was scheduled a week later in the U of Chicago’s beautiful new hospital, the Center for Care and Discovery.

This surgery was performed on Feb 2, 2015, by a team of clinicians none of whom was over the age of forty. It was not minor surgery, requiring nearly six hours:  resections of both sides of my neck, including the dark almond and a host of neighboring lymph nodes. And then, there was robotic surgery that removed a nearly golf ball-sized piece of the base of my tongue and throat. The closure of this wound remodeled my throat.

I arrived in my hospital room late that day with the remarkable ability to converse in my normal voice.

Thoughtfully, I was put in a quasi-isolation unit with two doors and negative air pressure. There was a consistent, very high level of focus on infection control throughout my stay. The next day, flushed with the news that no cancer had been found in any other lymph nodes, that there were clean, ample cuts around the tumors we knew about, and, best of all, that no follow-on chemo- or radiotherapy would be needed, I chatted away happily with two visitors for almost ninety minutes. I was repaid for this premature end-zone celebration with a siege of intense throat pain that lasted over a week. I was also repaid in a different way for the optimistic removal the next morning of the nasogastric tube installed during my surgery to feed and medicate me post-op. 

My surgeon, Alex Langerman, was generous with his time. We had four visits in the hospital that I could remember and one which I couldn’t. He responded thoughtfully and substantively to my questions and concerns but delegated the day-to-day management of my care to his senior and junior residents. The senior residents, who were present in the OR,  were as impressive as Alex was.

Some of the junior residents, however, literally phoned it in. On the second night, I woke up strangling on a large blood clot that had dislodged from the wound and blocked my airway. The anxious nurse in charge of my care paged the on-call resident who . . . didn’t answer the page in 90 minutes. Paged again, the resident scolded the nurse for bothering her and instructed the nurse to inform me that “breathing and swallowing problems were normal for this type of surgery” and refused to come in to the hospital to examine me.

At this point, I asked to speak to the resident on the phone, which prompted her to appear in my room thirty minutes later. She performed a perfunctory, fifteen-second examination, pressing down on my tongue with a depressor, but failing to examine my airway where a large piece of the clot was still lodged. Then she delivered a sour little lecture on how “breathing and swallowing problems were normal. etc.” and after documenting that she had showed up, ordered a swallowing study for the next day and vanished without taking any other action, not to be seen again. I eventually coughed up the rest of the clot myself and prayed it wouldn’t happen again. 

The failure of on-call residents to respond to pages from the nurses caring for me was repeated later in my stay. Despite this inconstant clinical back up, I received thoughtful and attentive nursing care throughout my stay. Sadly, the nurses seemed to spend twice as long typing into the numerous computers in the rooms and at the nursing station as they did actually caring for us.  

However, the inadequate pain control regimen vital to my regaining my ability to swallow exacted a huge price. Originally, my pain meds were to be delivered through the nasogastric tube that bypassed my new throat. When the tube was removed the day after surgery, no thought was given to rethinking my pain control. Though I had a mild patient-controlled anaesthesia through IV, I was expected to swallow my primary pain medication delivered in liquid form roughly every four hours. 

As you might expect given the large wound in my throat, swallowing was a nightmare, particularly since the liquid pain medications seemed to be suspended in alcohol. I could not swallow them sitting up in bed, so I made a medication station out of my window sill. Even if I diluted them with water or a suspension of edible fiber, it took almost twenty minutes to down each dose of pain meds. Every tiny swallow brought a sharp stab, a hop and a yelp, followed by a spasm of painful coughing. Several days of protest brought a new idea:  bitter ground up pain pills mixed with apple sauce! Chunks of pain medication and apple hung up in my throat, lodging on the wound. 

Then the hospital entered the fugue state otherwise known as the weekend. A hospital stay expected to be seventy-two hours had stretched to six days, during which I was unable to eat and barely able to swallow even water, let alone therapeutic food. I made an angry circuit of the massive, aircraft carrier sized hospital floor every few hours, pushing my IV stand alongside of me, weakening each day from the cumulative deficit of protein. 

 I lost more than seventeen pounds during my stay in the hospital, mostly muscle, from my inability to eat. This muscle loss contributed directly to the collapse of my left hip joint later in the spring by depriving a badly eroded arthritic joint of its supporting musculature. Escalating pain in both hips required two joint replacements in the ensuing eighteen months.   

Finally, on Sunday evening, Alex called for a pain consult, which came on Monday morning, from a brilliant young anesthesiologist named David Dickerson. The result was a nearly complete victory: a combination of an anesthetic patch, local anesthetic mouthwash for the throat, a medication intended to numb the small nerves, and a strong liquid systemic painkiller to be used as needed. I was discharged within 36 hrs. able to swallow protein drinks for sustenance. 

Unfortunately, within twenty-four hours, I was back in the University of Chicago ER for bleeding. I was readmitted for minor surgery to cauterize the wound in my throat, and also to remove fluid from one side of the neck. Finally, after recovering from the anesthesia, I was sent back to my physician’s house, which was my base camp during my Chicago stay. I flew home to Virginia two days later, on February 13. 

The saga wasn’t over. Karen, my wife, stayed with me the first four days. Despite her constant presence, neither my wife nor my guardian angel hosts in Hyde Park were given discharge instructions. Karen was barely acknowledged by any member of the care team during her four days in the hospital, despite her impending role as my caregiver. I received my discharge instructions in a haze of elation and pain meds,  and immediately tucked them away in my bag. When I arrived home in Charlottesville, exhausted from my eleven-day visit to Chicago, I showered and collapsed into my welcoming bed.

I awakened fifteen hours later with no feeling in the fingers of both hands. I also found nearly two-inch blisters on my heels from lying on my back for fifteen hours. Karen, a florist, was preoccupied by Valentine’s Day, her busiest day of the year, and my son, Trevor, who came to stay, was reluctant to disturb me. Six months later, I still had no feeling in the two outer fingers of my right hand, needless collateral damage from my treatment. I basically lost my ability to type. This avoidable complication was eventually addressed with a six-hour nerve grafting surgery at Washington University in St. Louis in October, 2015.

I’d been warned by several of my policy colleagues about selecting Medicare Advantage when I turned sixty-five. “Wait ‘till you get sick”, they sagely warned me.

In fact, my carrier, Humana, did not delay my course of therapy by five minutes, and rapidly approved my personal decision based on medical advice to seek cancer care from an NCI designated Comprehensive Cancer Center five hundred miles from home and “out of network” for my Virginia-based plan. 

Unfortunately, the MA approval process placed a huge clerical/administrative burden on my Charlottesville-based primary care physician Jeff Davis, whose long-suffering office staff was required to initiate requests for authorization for every single stage of the diagnosis and treatment, a process which consumed nearly two person days of administrative time. I did get regular check-ins from a Humana nurse for several weeks after the procedure and a big shipment of frozen meals.  

But otherwise, my Medicare Advantage plan added no value to my cancer care, and grossly underpaid the University of Chicago for my surgery. The hospital was paid $15 thousand under their Humana MA contract for my total care, not counting Alex’s surgical fee, for a complex surgery, an eight day hospital stay and an emergency readmission.

The surgical care I received at the U of C was a triumph, both thorough and definitive. It saved my life.  However, the follow up pain management and the discharge process and post-surgical recovery were disasters, both from a patient experience standpoint (fed back with verve on my HCAHPS survey!) and a cost standpoint.  

The diffusion of responsibility throughout the complex care episode, and consequent lack of ownership of my recovery, was the root cause of much of this gap. An additional learning for me:  much of the risk of any clinical intervention is borne by the family after the intervention is over. The failure to prepare my family for its role had direct consequences for me in future surgical episodes that would have been unnecessary a better scripted episode. 

A recent commenter on LinkedIn compared the “consumer” of healthcare to a person gorging on Baked Alaska in a restaurant where someone else picked up the bill. Given my own frightening experience with cancer, I found this characterization insulting and demeaning. I wasn’t “consuming” anything; I was drowning! My central challenge was finding someone I could trust to save my life. Would I have chosen someone I did not know or trust, but whose services were less costly, to rid me of my cancer? Not on your life. 

Economist Kenneth Arrow wrote sixty years ago that one thing that distinguishes medicine from other things our economy does is that illness is not only unpredictable, but also an “assault on one’s personal integrity”. Responding to that lethal uncertainty is the toughest job in our economy. I was and remain deeply grateful to my clinical team for saving my life.  

I am now nine years cancer free, and sobered by how fraught and complicated my care experience was. It is hard to describe how much fear and uncertainty I felt, even in my home institution, despite forty years of working experience in and around hospitals. When I hear marketing experts prattle on about the “consumer’s care journey”, it just makes me want to throw up.

Jeff Goldsmith is a veteran health care futurist, President of Health Futures Inc and regular THCB Contributor. This post comes from his personal substack

By KIM BELLARD

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

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

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

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

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

It worked.

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

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

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

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

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

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

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

PillPack’s co-founders have recently left.   

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

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

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

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

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

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

BY KIM BELLARD

When I first read the reports about some Silicon Valley billionaires wanting to start a new city, I figured, oh, it’s just a bunch of rich white guys wanting to take their toys and go to a new, better home. After all, they’ve seen what’s been happening to downtown San Francisco (or Portland, or Chicago – pick your preferred city).  

Cities these days may be an what one expert calls an “urban doom loop” – struggling to recover after having been hollowed out by the pandemic. These so-called elites probably figured it’s easier to build something new rather than to try to fix what already exists.  And, you know, they may be right.  

Now that I think about it, the same may be true of our healthcare system.

The group, fronted by a mysterious entity called Flannery Associates, has been busy buying up land outside San Francisco for the past five years, spending a reported $1b for some 57,000 acres in Solano County. The proximity of its purchases to Travis Air Force Base had already raised concerns. Believed to be behind the group are a number of well known tech names, including LinkedIn co-founder Reid Hoffman; former Sequoia Capital partner Michael Moritz; venture capitalists Marc Andreessen and Chris Dixon; Stripe co-founders Patrick Collison and John Collison; Laurene Powell Jobs, Steve Jobs widow.

It doesn’t help that earlier this year Flannery sued dozens of local landowners for colluding to drive up prices, or that they’ve been so secretive. John Garamendi, one of the area’s Congressmen, said: “Flannery Associates has developed a very bad reputation in Solano County through their total secrecy and mistreatment of generational family farmers.” 

The group finally went public with its intentions last week. “We are proud to partner on a project that aims to deliver good-paying jobs, affordable housing, clean energy, sustainable infrastructure, open space and a healthy environment to residents of Solano County,” said spokesman Brian Brokaw. “We are excited to start working with residents and elected officials, as well as with Travis Air Force Base, on making that happen.”

Most of the land is currently zoned for agricultural use, so getting permission for residential or other business uses will take some effort, which is why Flannery Associates is planning to meet with local, state, and federal officials. 

The New York Times reported that Mr. Moritz spearheaded the effort in 2017, sending out a note: “He painted a kind of urban blank slate where everything from design to construction methods and new forms of governance could be rethought.” A poll sent out last week to Solano County residents asked if they’d be in favor of a ballot initiative that would “include a new city with tens of thousands of new homes, a large solar energy farm, orchards with over a million new trees, and over 10,000 acres of new parks and open space.”

What’s not to like? 

If this is going to be another enclave of rich people,then I hope it never gets off the ground, after burning off lots of their money (not that they’d miss it). If they’re sincere about having a diverse city, all incomes and racial/ethnic backgrounds, then I’ll be watching closely. They have a chance to build new infrastructure (hint: include robust wastewater monitoring!), ensure safe and affordable housing for all, use renewable energy, design it for walkability, and fill it with plenty of green space. They could hire the good people at Building H to help “build health into everyday life.” And if they really want to impress me, they could even replicate/expand on Stockton’s universal basic income initiative.

But what are they going to do about health care?  What’s the point of building a 21^st century city from scratch only to overlay it with our 20^th century healthcare system — the notoriously frugal Medi-Cal program, scads of employer health plans, and ACA individual plans, not to mention Medicare/Medicare Advantage for any seniors who happen to end up there. There’ll be lots of hospitals and specialists who might see the new city as a great chance to make lots of money from all those private pay patients. It will be our familiar mess.

No, if they want to do this right, they should rethink health care too. Here’s a few ideas they should consider:

Universal coverage: if you live in the community, you’re covered. No exceptions, no opt-outs, no ineligibles.  Think of it as their own group health plan.  They might need some Medicaid and Medicare waivers to do this right, but they should make this the first community where everyone is covered.

Wealth-based funding: everyone should participate in how the healthcare system is funded, but not through the inequitable premium system we’re used to but through taxes on income, wealth, and/or property.  No one should ever be priced out of coverage (or care).

Health, not medical: we always say “healthcare system” but what we mean is our medical care system. It’s built around doctors, hospitals, and other medical professionals and institutions. They’re all part of it, but they’ve become the tail that wags the dog. Nutrition, exercise, sleep, social support, and so many other factors contribute far more to our health. These shouldn’t be ancillary to the new system but integral to it, with medical care what happens only when those don’t suffice. 

Primary care emphasis: the system should focus on recruiting (and retaining) enough primary care physicians (including OB/GYNs and mental health professionals) that waits are nominal, visits aren’t rushed, and primary care is the main locus of care. Forget traditional fee schedules/salaries; make income for primary care commensurate with its value.

Tech enabled: the Silicon Valley folks should love this: the system should be designed around the latest tech – e.g., virtual care. real-time monitoring (e.g., wearables), AI support, and so on, along with proactive Big Data analysis and recommendations. And do better than Epic!

Hospitals: to be honest, I’m not sure there should be any hospitals, at least not initially. Don’t build any big buildings that become capital sinks. Maybe let the Johns Hopkins (or other) experts design a Hospital At Home program that suits the community, keeping people in their homes. Only build physical hospital(s) when the population warrants it, and even then build them as small as possible. And certainly don’t let them employ physicians.

That’s not an all-encompassing list, but it’s a start.

————–

I’m not holding my breath that Flannery Associates will build their new utopia, but, let’s admit it, they have a better chance than they do to create a 21st-century healthcare system. 

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

By MATTHEW HOLT

Humana is out with a report saying that its Medicare Advantage members who are covered by value-based care (VBC) arrangements do better and cost less than either their Medicare Advantage members who aren’t or people in regular Medicare FFS. To us wonks this is motherhood, apple pie, etc, particularly as proportionately Humana is the insurer that relies the most on Medicare Advantage for its business and has one of the larger publicity machines behind its innovation group. Not to mention Humana has decent slugs of ownership of at-home doctors group Heal and the now publicly-traded capitated medical group Oak Street Health.

Humana has 4m Medicare advantage members with ~2/3rds of those in value-based care arrangements. The report has lots of data about how Humana makes everything better for those Medicare Advantage members and how VBC shows slightly better outcomes at a lower cost. But that wasn’t really what caught my eye. What did was their chart about how they pay their physicians/medical group

What it says on the surface is that of their Medicare Advantage members, 67% are in VBC arrangements. But that covers a wide range of different payment schemes. The 67% VBC schemes include:

• Global capitation for everything 19%
• Global cap for everything but not drugs 5%
• FFS + care coordination payment + some shared savings 7%
• FFS + some share savings 36%
• FFS + some bonus 19%
• FFS only 14%

What Humana doesn’t say is how much risk the middle group is at. Those are the 7% of PCP groups being paid “FFS + care coordination payment + some shared savings” and the 36% getting “FFS + some share savings.” My guess is not much. So they could have been put in the non-VBC group. But the interesting thing is the results.

First up Humana is spending a lot more on primary care for all their VBC providers, 15% of all health care spend vs 6.6% for the FFS group, which is more than double. This is more health policy wonkdom motherhood/apple pie, etc and probably represents a lot of those trips by Oak Street Health coaches to seniors houses fixing their sinks and loose carpets. (A story often told by the Friendly Hills folk in 1994 too).

But then you get into some fuzzy math.

According to Humana their VBC Medicare Advantage members cost 19% less than if they had been in traditional FFS Medicare, and therefore those savings across their 2.4m members in VBC are $4 billion. Well, Brits of a certain age like me are wont to misquote Mandy Rice-Davis — “they would say that wouldn’t they”.

But on the very same page Humana compares the cost of their VBC Medicare Advantage members to those 33% of their Medicare Advantage members in non-VBC arrangements. Ponder this chart a tad.

Yup, that’s right. Despite the strung and dram and excitement about VBC, the cost difference between Humana’s VBC program and its non-VBC program is a rounding error of 0.4%. The $90m saved probably barely covered what they spent on the fancy website & report they wrote about it

Maybe there’s something going on in Humana’s overall approach that means that FFS PCPs in Medicare Advantage practice lower cost medicine that PCPs in regular ol’ Medicare. This might be that some of the prevention, care coordination or utilization review done by the plan has a big impact.

Or it might be that the 19% savings versus regular old Medicare is illusionary.

It’s also a little frustrating that they didn’t break out the difference between the full risk groups and the VBC “lite” who are getting FFS but also some shared savings and/or care coordination payments, but you have to assume there’s a limited difference between them if all VBC is only 0.4% cheaper than non-VBC. Presumably, if the full risk groups were way different they would have broken that data out. Hopefully they may release some of the underlying data, but I’m not holding my breath.

Finally, it’s worth remembering how many people are in these arrangements. In 2019 34% of Medicare recipients were in Medicare Advantage. Humana has been one of the most aggressive in its use of value-based care so it’s fair to assume that my estimates here are probably at the top end of how Medicare Advantage patients get paid for. So we are talking maybe 67% of 34% of all Medicare recipients in VBC, and only 25% of that 34% = 8.5% in what looks like full risk (including those not at risk for the drugs). This doesn’t count ACOs which Dan O’Neill points out are about another 11m people or about 25% of those not in Medicare Advantage. (Although as far as I can tell Medicare ACOs don’t save bupkiss unless they are run by Aledade).

I did a survey in 1997 which some may recall as the height of the (fake) managed care revolution. Those around at the time may recall that managed care was how the health insurance industry was going to save America after they killed the Clinton plan. (Ian Morrison used to call this “The market is working but managed care sucks”). At the time there was still a lot of excitement about medical groups taking full risk capitation from health plans and then like now there was a raft of newly publicly-traded medical groups that were going to accept full risk capitation, put hospitals and over-priced specialists out of business, and do it all for 30% less. The Advisory Board, bless their very expensive hearts, put out a report called The Grand Alliance which said that 95% of America would soon be under capitation. Yeah, right. Every hospital in America bought their reports for $50k a year and made David Bradley a billionaire while they spent millions on medical groups that they then sold off at a massive loss in the early 2000s. (A process they then reversed in the 2010s but with the clear desire not to accept capitation but to lock up referrals, but I digress!).

In the 1997 IFTF/Harris Health Care Outlook survey I asked doctors how they/their organization got paid. And the answer was that they were at full risk/capitation for ~3.6% of their patients. Bear in mind this is everyone, not just Medicare, so it’s not apples to apples with the Humana data. But if you look at the rest of the 36% of their patients that were “managed care” it kind of compares to the VBC break down from Humana. There’s a lot of “withholds” which was 1990s speak for shared savings and discounted fee-for-service. The other 65% of Americans were in some level of PPO-based or straight Medicare fee-for-service. Last year I heard BCBS Arizona CEO Pam Kehaly say that despite all the big talk, the industry was at about 10% VBC and the Humana data suggests this is still about right.

So this policy wonk is a bit depressed, and he’s not alone. There’s a little school of rebels (for example Kip Sullivan on THCB last year) saying that Medicare Advantage, capitated primary care and ACOs don’t really move the needle on cost and anyway no one’s really adopted them. On this evidence they’re right.

Matthew Holt is the Publisher of THCB and is still allowed to write for it occasionally.

So to celebrate 20 years, we’ll be publishing a few classics for the next week or so. This is one of my faves from the early days of THCB, back in 2006. It’s interesting to compare it with Jeff Goldsmith’s NEW piece from yesterday on vertical integration because at the time a pair of Harvard professors, Michael Porter and Elizabeth Teisberg were telling hospitals to change their operations in a way that seemed to me were going to destroy their business–cut down to one or two service lines they were best at and stop with the rest. McKinsey picked up on this and I went to town on why they were all wrong. In fact in the next decade and a half, despite all the fuss and consulting fees generated, almost no hospital system did anything other than merge horizontally with local competitors, stick up its prices, and buy feeder systems of primary care doctors or ally with/bribe specialists to keep their procedural referrals up. The result is the huge regional oligopolies that we have now. Despite all the ignoring of their advice, I don’t think Porter/Teisberg or McKinsey went broke in that same period.–Matthew Holt

McKinsey, an organization that prides itself on increasing the amount of consulting dollars it gets paid by improving the strategic direction of American business is making another foray into health care.

You may recall their last study on CDHPs was roundly criticized (see Tom Hillard for a good example including a hilarious and brutal smackdown of their research methodology in the last couple of paras), and this time they cleverly aren’t bothering with data—in fact they’re basically copying Porter and Teisberg. The piece, by Kurt Grote, Edward Levine and Paul Mango, is about hospitals and how they need to get into the 21st century.

And of course the idea is that hospitals need to change their business approach.  Well, given that I hadn’t noticed a rash of hospital closings and the the industry as a whole has been growing its revenues pretty successfully over the years, what exactly are the problems?

The rise of employer-sponsored insurance in the 1930s and 1940s, and the emergence of government-sponsored insurance in the 1960s all insulated hospitals from the need to compete for patients. Today hospitals are “price takers” for nearly 50 percent of their revenues, which is subject to the political whims of the federal and state governments. Hospitals are also required to see, evaluate, and treat virtually any patient who shows up, solvent or not. Furthermore, physicians were productive because hospitals put a great deal of capital at their disposal. Yet these hospitals didn’t enforce standardized and efficient approaches to the delivery of care. At many hospitals today, doctors still bear only limited economic
responsibility for the care decisions they make. Little wonder that it is often they who introduce expensive—and sometimes excessive—nonreimbursable technologies or that hospitals not only suffer from declining margins but are also performing less well than other players in the health care value chain 

The piece then has a pretty incomprehensible chart that compares the EBITDA (profit) of hospitals compared to drug companies and insurers. Surprisingly enough they make a whole lot less EBITDA than those businesses–although long time THCB readers will know we’ve been well down that path. And apparently their margins got worse and then better (from 25% in 1990 to 15% in 1995 to 10% in 2000 but back up to 15% in 2004).

McKinsey’s answer, basically filched from Porter/Teisberg, is for hospitals to specialize in particular service lines, stop being generalists and start trying to please the consumer who’ll be choosing among them. As a general mantra, this might be good for consultants to stick up on Powerpoint, but to be nice it’s massively oversimplified, and to be nasty it’s just plain wrong for most hospitals for the current and foreseeable medium-term future.

Their analysis ignores the fact that there are (at least) three broad categories of hospitals–inner city and rural  safety-net providers, big academic medical centers, and suburban community hospitals. Each of these has a completely different audience, completely different set of incentives, and more to McKinsey’s point, different profit margins.

Right up front they talk about the 50% of revenue that comes from the government–but for the first two categories, it’s more than that! And for everyone, as public programs grow, it’s going to be increasing.

Those hospitals relying on Medicare make most of their money but playing very careful attention to the DRG mix. The ones who play that game well and make most profit on Medicare outliers (like the for-profits McKinsey features in its metrics) don’t really want to change that by stopping their patients becoming those outliers, because if they get better at treating patients, they make less money. Brent James’ famous Intermountain story tells the truth, and until Medicare really changes the way it pays, you don’t want to be ahead of that curve. Intermountain may have spent more than 10 years leaving money on the table, but those rich Mormons can afford it.

Meanwhile, for the mainstream community hospitals, as more and more services and patients leave the building, the imperative is not to change their business model, it’s to get their hands on that revenue that’s leaving with them. That’s why most big hospitals are now-co-investing with physicians in specialty hospitals et al. But while that’s a defensive battle to build better “hotels” for the star surgeons, it’s still about building better “hotels”–not junking the model of being the nicest possible host to the big time admitting surgeons.

The McKinsey/Porter/Teisberg theory is of course that if you get good at one service line, you’ll be attractive to consumers, and that they’ll choose you. There is more truth to this notion now than there was five years ago, but not much more. Doctors choose hospitals for their patients. That’s always been the case, other for those that get admitted via the ED, and that’s a function of location. That’s why hospitals suck up to surgeons. But even when consumers make choices, they’re not very active consumers beyond the deductible, and basically all hospital spending is beyond the deductible, and even in the cash non-hospital business (the stuff like genetic testing) most consumers take their doctor’s advice.

Which leads of course to who the other real consumer for the hospital is, and that’s the third party payer. First rule of dealing with payers is to figure out how to play the Medicare system well enough that you make it very profitable, but not too “well” that you get busted, a la Columbia/HCA, Tenet & St Barnabas.

Second rule is that you need to get bargaining strength against the health plans. No one can pretend that health plans really care in a global sense about having their providers cut costs and improve care delivery. They may say they care about it, but health plans add a chunk on the top of what they pay providers and stick that to their clients (usually employers) — who basically take it in a mealy mouthed way.

There is, though, a fight in any local market about where to draw the line on hospital pricing. But this fight is not about having providers from outside (or even within) the region swooping in to capture all a payer’s business with better pricing on certain service lines, and payers moving patients to these disease-specific treatment centers.  Well, it is about that in the McKinsey/Porter/Teisberg fantasy land, but in reality the fight is about setting global pricing for all the services a payer needs for its members in that region.

Look at the big fights going on now. In Denver there’s a dust-up between United HealthGroup and HealthOne and a similar one between United (again) and HCA in Florida. HealthOne is using a rather amusing tactic that–it says United should increase what it’s paying because it gave HealthOne a good report card. But let’s be real, this is about who can create enough market power so that the other side has to hand over a bigger slice of the pie if it wants services or patients delivered. Sutter showed this well when it beat up Blue Cross in California, and that lesson has been understood by provider systems across the nation as they lined up to form oligopolies.

If hospitals decide that they are going to improve care processes, and stop offering certain services, but offer the ones they are good at at a lower rate, insurers will say two things. First, thanks for the lower price, we’ll happily pay you less, and two, can you please organize coverage for the service lines you’re dropping as our patients in that metro area need it and don’t yet want to fly to Mumbai–they don’t even want to drive across town:

Aventura resident Jean Glick, who received a letter on Aug. 4, said she was furious. ‘If they claim to be a community hospital, this not serving your community,” she said. For Aventura residents insured by UnitedHealthcare, the next closest hospitals that accept their insurance are Parkway Regional in North Miami Beach and Mount Sinai in Miami Beach. <snip> Glick said she fears that not having a nearby hospital that accepts her health insurance could be expensive and even life threatening. ”I can’t afford to pay out of network,” she said.

The interviewed resident may not exactly understand the dynamics, but she doesn’t exactly sound ready for the brave new world. And let’s not underestimate the extent of the change McKinsey’s calling for. Here’s what they say about physicians:

For many physicians—particularly clinical specialists in the service lines where hospitals hope to differentiate themselves—the traditional arm’s-length and more recent competitive relationship must give way to some sort of formal employment or to gain-sharing schemes such as joint ownership of equipment or even whole facilities. Furthermore, performance criteria for physicians must shift. In a world in which transparent quality, service, and prices help patients choose places to seek treatment, metrics such as admissions volumes will become less relevant.

That looks like a license to drop a whole bunch of money hiring doctors and dealing with all the headaches that brings–not to mention dealing with the Stark laws. And all that just after the huge successes of hiring physicians in the 1990s! It would indeed be a brave CEO who stopped caring about the admission rates of his star surgeon. I can imagine the board meeting where he says that his hospital will have a smaller but more efficient service line that one day will grow to replace the others they’re dropping, and the gruff board member asks where the money to cross-subsidize the money-losing ED will come from.

It may be the case that in some far distant future patients can really be served (and moved around) on a national or international scale, and that the local monopoly/oligopoly model gets broken. But these things change very slowly. Delta airlines tried it about a decade back (flying employees around to centers of excellence)–have you noticed the huge impact on the system? Me neither.

Furthermore, almost none of the safety net hospitals, and few AMCs, can realistically take this course, as it destroys their mission of being all things to all comers. That matters not just because of their mission but because most of their money follows their mission. (For the safety-net via local taxes/Medicaid, and for the AMCs via Federal money for training residents and research).

I’m not saying that this is a good thing one way or the other. I’m in fact all in favor of changing incentives so that more efficient and better patient care is delivered, but I am saying that with the current and near-future market realities jumping on the McKinsey bandwagon is not a great idea for the vast majority of hospitals. But don’t worry—have McKinsey come in and change your strategy, and then in a few years they can come change it back!

CODA: It’s only fair to say that  a while back (in 2001)  one of the McKinsey authors Paul Mango wrote a prefectly sensible article about how hospitals could become more profitable by doing what they do now more efficiently, and understanding capacity optimization. And that five years later is pretty much still true.

By JEFF GOLDSMITH

The concept of vertical integration has recently resurfaced in healthcare both as a solution to maturing demand for healthcare organizations’ traditional products and as a vehicle for ambitious outsiders to “disrupt” care delivery.    Vertical integration is a strategy which emerged in US in the 19th Century industrial economy.  It relied upon achieving economies of scale and co-ordination through managing the industrial value chain.    We are now in a post-industrial age, where economies of scale are in scarce supply.  Health enterprises that are pursuing vertical integration need to change course. If you look and feel like Sears or General Motors, you may well end up like them.  This essay outlines reasons for believing that vertical integration is a strategic dead end and what actions healthcare leaders need to take.

Where Did Vertical Integration Come From?

The strategy of vertical integration was a creature of the US industrial Revolution. The concept was elucidated by the late Alfred DuPont Chandler, Jr. of the Harvard Business School. Chandler found a common pattern of growth and adaptation of 70 large US industrial firms. He looked in detail at four firms that came to dominate markedly different sectors of the US economy:  DuPont, General Motors, Sears Roebuck and Standard Oil of New Jersey. They all followed a common pattern: after growing horizontally through merging with like firms, they vertically integrated by acquiring firms that supplied them raw materials or intermediate products or who distributed the finished products to final customers. Vertical integration enabled firms to own and co-ordinate the entire value chain, squeezing out middlemens’ profits.

The most famous example of vertical integration was the famed 1200 acre River Rouge complex at Ford in Detroit, where literally iron ore to make steel, copper to make wiring and sand to make windshields went in one end of the plant and finished automobiles rolled out the other end. Only the tires, made in nearby Akron Ohio, were manufactured elsewhere. Ford owned 700 thousand acres of forest, iron and limestone mines in the Mesabi range, and built a fleet of ore boats to bring the ore and other raw materials down to Detroit to be made into cars. 

Subsequent stages of industrial evolution required two cycles of re-organization to achieve greater cost discipline and control, as well as diversification into related products and geographical markets. Industrial firms that did not follow this pattern either failed or were acquired. But Chandler also showed that the benefits of each stage of evolution were fleeting; specifically, the benefits conferred by controlling the entire value chain did not last unless companies took other actions. Those interested in this process should read Chandler’s pathbreaking book: Strategy and Structure: Chapters in the History of the US Industrial Enterprise (1962).   

By the late 1960’s, the sun was setting on the firms Chandler wrote about. Chandler’s writing coincided with an historic transition in the US economy from a manufacturing dominated industrial economy to a post-industrial economy dominated by technology and services. Supply chains re-oriented around relocating and coordinating the value-added process where it could be most efficient and profitable.  Owning the entire value chain no longer made economic sense. River Rouge was designated a SuperFund site and part of it has been repurposed as a factory for Ford’s new electric F-150 Lightning truck. 

Why Vertical Integration Arose in Healthcare

I met Alfred Chandler in 1976 when I was being recruited to the Harvard Business School faculty. As a result of this meeting and reading Chandler’s writing, I wrote about the relevance to healthcare of Chandler’s framework in the Harvard Business Review in 1980 and then in a 1981 book Can Hospitals Survive: The New Competitive Healthcare Market, which was, to my knowledge, the first serious discussion of vertical integration in health services.

Can Hospitals Survive correctly predicted a significant decline in inpatient hospital use (inpatient days fell 20% in the next decade!). It also argued that Chandler’s pattern of market evolution would prevail in hospital care as the market for its core product matured. However, some of the strategic advice in this book did not age well, because it focused on defending the hospital’s inpatient franchise rather than evolving toward a more agile and less costly business model. Ambulatory services, which are today almost half of hospital revenues, were viewed as precursors to hospitalization rather than the emerging care template.

Policymakers Fell in Love with Vertical Integration:  Cost Containment by HMOs

At the time of my writing, vertical integration was a hot topic in health policy.  Federal policymakers’ attention was fixated on Kaiser Permanente, the largest vertically integrated actor in healthcare (then and now). Dr Paul Ellwood, a health reform advocate, persuaded the Nixon Administration to sponsor the HMO Act of 1973, designed to foster health plans modelled on Kaiser as a “pro-competitive” alternative to a government run national health insurance plan. 

Nixon’s 1973 HMO Act provided federal grants to foster HMOs as a vehicle for containing soaring health spending through market mechanisms. Many multi-hospital systems-Intermountain in Utah, Henry Ford in Detroit, Sentara in Virginia,  Geisinger in Pennsylvania, Humana, Lutheran Hospital Society of Southern California, Michael Reese and Rush Presbyterian Hospitals in Chicago-created their own HMOs during the 1970’s and early 80’s. As a result of these federal investments, HMOs covered 31% of the privately insured population by 1990.  

However, Kaiser-style health plans did not prosper in communities with strong traditions of independent (e.g. solo and partnership) medical practice. HMOs contracting with private physicians individually or through physician sponsored Independent Practice Associations (IPAs) dominated the space. IPAs enabled physicians to participate in HMOs without being employed by them or by hospitals, and to earn extra income through shared profits. 

The abortive Clinton health reforms during 1993-1995 provided a further push toward vertical integration. The almost inexplicably complex Clinton plan would have required the entire care system to be re-organized into competing Kaiser-like regional health enterprises that would receive a global payment for caring for all citizens in its region. The Clinton reforms foundered over concerns about restricting consumer choice of physicians and hospitals (and because no-one could understand exactly what they were trying to do). Nonetheless, hospitals launched a frenzy of physician practice acquisition and regional mergers to prepare for a ClintonCare which never came. 

Shortly thereafter, HMOs suffered an angry consumer and employer backlash (fanned by organized medicine and hospitals). Commercial insurers including Blue Cross plans, United Healthcare, Aetna, Humana and CIGNA displaced HMOs in the commercial market using broad network Preferred Provider Organizations (PPOs) that contracted with hospitals and doctors through, mainly, discounted fee-for-service payment. Today, HMOs represent only about 12% of private insurance enrollment, of which Kaiser’s members represent well more than half.  

The Obama Administration’s 2010 health reforms attempted to revive enthusiasm for vertically integrated healthcare by fostering “value based care”, a fluffy term intended to describe a raft new payment models that shifted risk onto provider organizations-hospitals, physician groups and others. The policy intent was that “value-based care” would serve as  a bridge to full risk/delegated risk capitation. Thirteen years on, “value-based” care remains largely unproven as a cost containment strategy, and the evolution to full-risk capitation has not occurred. 

Why Vertical Integration Hasn’t Worked in Healthcare:  What the Literature Shows

We now have had five full decades of broad experimentation with vertical integration strategies in healthcare. With the benefit of hindsight, Chandler’s pattern has not worked well in this field. There has been a lot of “consolidation” but no measurable efficiency gains. Costs have soared. Something about healthcare has fiercely resisted “industrialization”.

Healthcare mergers-horizontal or vertical- have not only not reduced cost, but may actually have added cost through high transaction costs and new and expensive layers of supervision. Vertical integration of physician practice into hospitals has increased costs, not reduced them. And  vertically “integrated delivery systems” that combined hospital, physicians and health plans in a single organization are neither cheaper nor of demonstrably higher quality than less integrated competitors in the same markets. As health systems diversified into non-hospital businesses, their returns on capital declined. The greater the investment, the greater the decline.  (For a comprehensive review of this literature, see my 2015 piece in integrated delivery networks).

Kaiser and Geisinger

The vertical exemplar, Kaiser, has grown to $95 billion in revenues in 2022.  However, it has remained largely a creature of the markets in which it originated (e.g the Pacific Coast) where over 80% of its members live.  It has taken nearly eighty years to grow to 12.7 million members (and about 2% of total US health spending), despite the bursts of federal enthusiasm. Kaiser suffered several years of major financial losses by attempting to become a “national brand” in the late 1990’s. Kaiser’s success was likely attributable to the market conditions in their original markets rather than its vertical strategy.

An ominous development for the vertical strategy was the recent failure of Geisinger, a 110 year old exceptionally high quality multi-specialty physician group-based health system with a significant health plan and ten hospitals in central Pennsylvania. Geisinger lost $842 million in 2022, and was losing $20 million a month on operations when it announced a complex, non-merger style affiliation with Kaiser through a new enterprise unpromisingly named Risant. At almost $7 billion revenues, it is difficult to argue that Geisinger had insufficient scale to prosper. Rather, Geisinger’s demise as a freestanding enterprise raises serious questions about the viability of the vertically integrated model.

The Heart of the Matter: The Structure of the Value Chain in Healthcare

The main problem with the vertical integration strategy in healthcare: professional judgment and the personalized care guided by it does not scale very well. People, not raw materials, energy or capital, are the vast majority of health costs. Healthcare’s value chain is fundamentally different and more complex than that in manufacturing or retailing. There is also greater variability and uncertainty at the point of service, as well as greater personal risk to the “consumer” than just about anywhere else in the economy.  Chandler’s pattern has also not held for the other professional services that dominate the American economy: education, law, accounting, consulting, etc.

Action is Needed

Vertical integration is a relic of the industrial age. It neither guarantees market dominance nor profitability in healthcare. Actors in the health system should adjust their strategies accordingly.

Keep What You Do Well or Which Would Be Missed If you Did Not Do It.  Lose the Rest.

Health care enterprises’ earnings and financial positions have been damaged by the pandemic, and restoring a positive return on the organization’s assets and people is essential. Health systems that have been adjusting to this new environment with layoffs rather than examining their portfolio of businesses. It is time to ask Peter Drucker’s famous question:  if we were starting fresh today, would we own all the assets and programs we have now? Do we do a good job of running them (e.g. generate both happy customers and black ink), and would anyone miss them if someone else did?  

Don’t just guess what you do best. Rely on empirical sources if available, whether federal HCAHPS patient survey results or Medicare STAR ratings, Leapfrog ratings, independently gathered Net Promoter Scores or internal surveys of clinicians and managers working in each service area, as well as a searching and fearless analysis of where positive cash flow is being generated.

Community needs are an important consideration. If your community would suffer if you stopped doing something, you can count the losses you incur by continuing to do it as part of your community benefit.   An important exception might be for teaching institutions, for whom the breadth of clinical experience required to train new physicians might dictate a breadth of service that does not make sense otherwise.  Those losses are covered in part by Medicare’s direct and indirect medical education supplemental payments.

Services that do not sustainably return your capital or generate a positive work experience for clinicians should be flagged for divestiture, unless you need to continue doing them for teaching purposes or are meeting a significant and demonstrable unmet community need. It makes no sense to own the tenth home care agency or the sixth chain of convenience clinics just to “feed” your clinicians referrals or to field a complete “continuum of care”.

Health Plans in Hospital Systems:  A Bridge to Nowhere?

The future of population-level risk in healthcare delivery enterprises is cloudy. It is true that some health systems saw windfall profits in their captive health plans from declining healthcare use during COVID provide a significant offset to their care delivery losses. But this was a once-in-a-century health emergency, not a “use case” for continuing to invest scarce capital (in a capital intensive business) in a business most care enterprises have struggled with.

Being a “payvider” is not vertical integration, nor is it an efficient vehicle for growing healthcare volumes. Health insurance and healthcare delivery are very different businesses, with dramatically different critical success factors. For care delivery entities, health insurance is unrelated and risky diversification with a high probability of negative investment returns. Unlike inside Kaiser, where the sole access point is enrollment in their health plan, there is “dysergy”, not synergy, between care delivery and health insurance. Success in the health plan business requires reducing both unit cost and utilization in care systems, as well as angering physicians, as Humana realized on its way to divesting its hospitals in the early 1990s.    

Overall, health plan revenues in a few health systems (UPMC, Sentara, Spectrum/CoreWell, Geisinger, InterMountain, Aultman, Providence/Oregon) are such a significant piece of overall revenues and so significant in key local markets that the plans are integral to the future of the enterprise. How many of these systems prop up their health plans’ profitability with “below market” payment rates and pay their physician groups on an RVU basis that incents them to do “more” not “less”  are interesting research questions.  

For organizations with a smaller footprint in health insurance or sputtering “risk models”, it is time for an agonizing re-appraisal of these investments. Those with successful managed care infrastructure may discover that accepting delegated risk capitation, (If, and a large if indeed, it is available in their market) is a better strategy than “owning the whole premium dollar”.

Stop Relying on Market Anomalies to Justify Physician Employment

Physicians are complex professionals, not pawns on a three-dimensional chess board. Aggrandizing the market for physician care is not a cost-effective means of leveraging other healthcare businesses, be it hospitals, health insurance or pharmacies. Subsidizing physician care as a “loss leader” is not vertical integration;  vertical integration was about capturing margins and leveraging economies of scale, not frantically grabbing market share. 

The rush to dominate the physician marketplace has created substandard working conditions for busy professionals and conveyed the impression that physicians’ services are a means to an end, not a valuable end in itself. It also fosters the toxic illusion that those physicians’ patients belong somehow to the “owner”, not the clinicians who are responsible for them. The push by major retailers like Amazon, CVS and WalMart into the physician business is likely to end in tears, both for the companies and the professionals they employ.   

Hospitals will likely lose the Medicare subsidies for employed physicians as federal budgetary conditions worsen.  It is also likely the FTC will also outlaw non-compete clauses in physicians’ contracts (though non-profit hospitals and systems may be exempt). Relying on coercive measures like non-competes clauses that compel physicians to leave your community if they resign (and laying claim to their patients as if they were your property) is a sad confession of a bankrupt corporate culture. Outlawing non-competes as FTC intends will probably damage the big retail “disrupters”, the contract physician providers like Envision and Team Health and the vast enterprise that is Optum Health more than it will damage hospitals and systems.       

Conclusion

Healthcare providers of all stripes must leave the industrial world behind. The value chains in health services are not physical, but rather comprised of human relationships, sustained by trust. Virtual care, the advent of AI in healthcare and consumer demand will require a flexible, 24/7 and care anywhere business model. Those who build the best modern clinical mousetrap will end up with a committed clinical staff and loyal patients. Healthcare isn’t about the building, or the brand, or scale. Surviving and thriving in the future will require engaged clinicians who foster trust on the part of their patients and the community.

Jeff Goldsmith is President of Health Futures, Inc. and a long time THCB Contributor. Jeff wants to thank the following individuals for comments on this writing: Tom Priselac, Andy Mueller, Stephen Jones, Steve Motew, Troy Wells, Kerry Shannon, Trevor Goldsmith, Nate Kaufman and Rebecca Harrington.

BY KIM BELLARD

I came across a phrase the other day that is so evocative, so delicious, that I had to write about it: “lazy girl job,” or, as you might know it. @#lazygirljob.

Now, before anyone gets too offended, it’s not about labeling girls as lazy; it’s not really even about lazy or even only girls.  It’s about wanting jobs with the proverbial work-life balance: jobs that pay decently, don’t require crazy hours, and give employees flexibility to manage the other parts of their lives.  Author Eliza Van Cort told Bryan Robinson, writing in Forbes: “The phrasing ‘lazy girl job’ is less than ideal—prioritizing your mental health and work-life integration is NOT lazy.”

The concept is attributed to Gabrielle Judge, who coined it on TikTok back in May (which is why I didn’t hear about it until recently).  According to her, it means not living paycheck to paycheck or having to work in unsafe conditions. She believes job flexibility doesn’t mean coming in at 10 am instead of 9 am because you have a dentist appointment; it means you have more control over your hours and when you get your work done. If Sheryl Sandberg was all about “leaning in,” Ms. Judge is about leaning out.  

Ms. Judge explained to NBC News:

Decentering your 9-to-5 from your identity is so important because if you don’t, then you’re kind of putting your eggs all in one basket that you can’t necessarily control. So it’s like, how can we stay neutral to what’s going on in our jobs, still show up and do them, but maybe it’s not 100% of who we are 24/7?

“I’m only accepting the soft life, period,” she says.

Danielle Roberts, another TikToker and who describes herself as an “anti-career” coach, told NBC News: “And rather than calling the people who are divesting from that system lazy, and telling them that they just need to work harder, we need to talk about why it’s a trend in the first place and go one level deeper.”

She went on to explain:

We’ve seen that the 40-hour work week is now outdated. We can produce the same amount of work, if not more work, in a fraction of the time. So wanting to keep those butts in seats, and not just for 40 hours, but for 40-plus hours, is just really a means of control. If you hired them, you should trust your employees to do their job and do it well.

It’s not only the work week that is outdated, but also the concept of loyalty. Ms. Judge told NBC Los Angeles: “The whole lazy girl job thing is a thing because it’s a two-way street. Like of course this is attractive to employees, but there’s a reason why this was caused and that’s because employers in general just can’t hold their weight when it comes to company loyalty like they used to be able to traditionally.”

Hailey Bouche, writing in The EveryGirl, makes an even stronger point:

Things like work-life balance and reasonable pay shouldn’t be considered luxuries. We all deserve jobs that give us access to the benefits, flexibility, and salary that we need to live a fulfilled life—and having or wanting a job that allows us all of those things does not make us lazy.

Amen.

It’s a Gen Z thing, of course, as is/was “quiet quitting.”  The cultural zeitgeist that was already bubbling up around all this got supercharged by the pandemic, when many people were forced to work from home and work suddenly seemed less important.  

But this trend is broader than Gen Z girls or even Gen Z generally. A recent Gallop poll found that 6 in 10 workers admit they aren’t putting in maximum effort, and that their biggest complaint was workplace culture. As The Wall Street Journal headlined it last week: Workers to Employers: We’re Just Not That Into You.

The WSJ article cites a number of workplace trends, such as more employers are offering the option to work remotely, more employees are taking it, employees, employees are taking more vacation and have more options for paid time off. And, perhaps as a result, the Conference Board found that worker satisfaction rose sharply in 2022 and is now at its highest point since 1987. 

Another WSJ article reported that companies that allowed at least one day or remote work per week increased staffing twice as fast as those requiring full-time office requirements.  “One of the more straightforward potential explanations is that people put a really high value on being remote and generally having flexibility, so recruitment is likely quite a bit easier,” Emma Harrington, a University of Virginia economist, told WSJ.

President Biden evidently is missing out on the #lazygirlsjobs trend too, since he’s pushing to get federal workers back in the office by this fall. Other organizations and other CEOs feel the same, wanting things to go back to “normal,” or at least more directly under their control, in the office.  But that genie may be out of the bottle.

@lazygirlsrule

———-

There are plenty of lazy girl jobs in healthcare, or, at least, ones that could be.  “Administrators” – whether they’re billing clerks, claims processors, marketing experts, or managers – far outnumber people actually delivering care in every part of the healthcare system, and there’s no reason many of those jobs couldn’t be made to qualify. 

When it comes to the people delivering our care, though, we want them to be where we want them when we need them, for as long as we need them. Physicians, in particular, are known for working long hours, being responsible for life-and-death decisions, and suffering the stress with comes from all that. Well, no wonder physician burnout is a real problem, as it is for nurses and other front-line healthcare professionals.  

Healthcare professionals haven’t fled their jobs in any great numbers yet, although the warnings are there. Healthcare doesn’t have its Gabrielle Judge yet, there’s no #lazydoctorjob meme (that I am aware of), but the societal trends that caused #lazygirljobs are going to impact healthcare too, and we better figure out what we want that to mean.

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