We Love Innovation. Don’t We?

By Kim Bellard, April 22, 2022

America loves innovation. We prize creativity. We honor inventors. We are the nation of Thomas Edison, Henry Ford, Jonas Salk, Steve Jobs, and Stephen Spielberg, to name a few luminaries. Our intellectual property protection for all that innovation is the envy of the world.

But, as it turns out, maybe not so much. If there’s any doubt, just look at our healthcare system.

Matt Richtel writes in The New York Times “We Have a Creativity Problem.” He reports on research from Katz, et. alia that analyzes not just what we say about creative people, but our implicit impressions and biases about them. Long story short, we may say people are creative but that doesn’t mean we like them or would want to hire them, and how creative we think they are depends on what they are creative about.

“People actually have strong associations between the concept of creativity and other negative associations like vomit and poison,” Jack Goncalo, a business professor at the University of Illinois at Urbana-Champaign and the lead author on the new study, told Mr. Richtel.

Vomit and poison?

Well, at least our patent system, which protects intellectual property and helps fosters innovation, works, right? Again, not so much. A New York Times editorial charges: “The United States Patent and Trademark Office is in dire need of reform.”

If there’s any doubt, just look at the price of insulin, which has been propped up by patent “innovations” that keep its price high after a hundred years. “When it comes to protecting a drug monopoly,” The Times says, not limiting those monopolies to insulin, “it seems no modification is too small.”

The U.S. is still, by far, the leader in patents granted, but not in scientific research papers or R&D spending per capita/% of GDP, which makes one wonder what all those patents are for.

Healthcare desperately needs innovation. No one can dispute that; not anyone working in it, not anyone receiving care from it, not anyone who has had any exposure to it. But healthcare also has a lot of middle managers, and middlemen, and, as Professor Mueller said, “Novel ideas have almost no upside for a middle manager.”

Even worse, healthcare is always teetering on the edge of uncertainty — where’s the funding coming from, how much, what health crisis is coming, what’s the government going to do next? The forces causing all that uncertainty should be driving innovation, but, as Professor Morrison’s 2012 research also found, “…uncertainty also makes us less able to recognize creativity.” We have blind spots about what creativity is, who creative people are, and when and how we should incorporate those into our organizations.

Right now, healthcare thinks that EHRs and digital health — whatever that might actually be — qualify as innovation. That’s enough, it believes; those are forcing change in ways and at a pace healthcare is not used to and is not comfortable with.

Too bad.

It has been said that if your company has an innovation department, it’s not innovative. If it has middle managers deciding which novel ideas get pursued, don’t expect real innovation. If it is ruling out hiring people who worked on unusual projects (think sex toys), it’s rejecting creativity.

Your biases against creativity may (not) be showing.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

ARPA-H Needs to Think Bigger

By Kim Bellard, March 25, 2022

Everyone loves DARPA, the Defense Advanced Research Projects Agency that is credited with such hits as the internet and GPS, but is also responsible for things like the Boston Dynamics back-flipping robots and even Siri.  

Healthcare is, at long last, getting its own DARPA, with ARPA-H (Advanced Research Project Agency for Health).  It’s been discussed for years, but just last week was finally funded; a billion dollars over three years.  But I fear it is already off on the wrong foot, even ignoring the fact that President Biden had requested $6.5b. 

Let’s start with the problem that it not only doesn’t have a leader yet, but it doesn’t even have a home.  More worrisome, though, is that, according to President Biden, “ARPA-H will have a singular purpose: to drive breakthroughs in biomedicine.”   The mission wasn’t originally that limited, but priorities like the “cancer moonshot” tend to focus emphasis. Biomedicine isn’t going to solve all of our health and healthcare problems.

Take, for example, the developing fiasco that is the replacement VA EHR.  Decades ago the VA developed VistA, one of the first attempts at an EHR, but during the Trump Administration it was decided to move to a commercial EHR.  Cerner won the bid.  According to three reports issued by the VA Inspector General last week about the first implementation, it is not going well, to say the least. 

Now, I’m not intending to pick on Cerner – its DoD EHR rollout seems to be doing better – or advocating for VistA. I don’t want ARPH-A to help invent a new and improved EHR.  I want them to help invent the technology that is to EHRs as EHRs are to paper records.  I want a big leap.

I want the next generation of health information technology, allowing people to store, share, exchange, and use key health information, making all that look easy – like magic.  I want technology that may not become mainstream until 2050, but which would still be useful in 2100.

I don’t know what technologies will be important to that. Maybe holograms, maybe digital twins, maybe DNA storage, maybe blockchain/Web3, maybe AI, maybe quantum computing.  Maybe all of those, and others.  The important thing is, think big enough.  About this problem, and others.

We should be looking at breakthrough technologies that get at health in our everyday lives.  How do we track it, how do we foster it, how do we improve it where we live?    Those are the kinds of thing ARPA-H needs to help develop.

DARPA’s projects can take 20-25 years to reach commercial viability – if they ever do.  We can’t afford to think too short-term (e.g., anything less than 10-15 years) or too narrowly (e.g., only biomedicine). When we think about ARPA-H projects, we should thus be thinking about what we want to our health and our healthcare system to be in 2050. 

I hope the VA EHR recovers from its stumbles.  But wishing and hoping isn’t getting us where we need to be; we need breakthroughs. 

Based on DARPA’s experience, it’s not important that the leader be a visionary.  We don’t need a Steve Jobs or Elon Musk.  We need a leader who can separate the crazy from the wild, who welcomes that wild, and who knows how to get out of the way of innovators trying to make the wild plausible.   

If what we’re debating is whether ARPA-H should be in or out of NIH, we’ve missed the point.  If we’re focusing ARPA-H on biomedicine, we’re missing the opportunities.  If we’re just trying to avoid more catastrophic failures, we’re having one.

Think bigger.  

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

Get Ready for (Healthcare) Microgrids

By Kim Bellard, February 24, 2022

We depend on it.  Indeed, our daily lives are unimaginable without it.  The trouble is, it’s become unreliable.  Lives have been lost because it wasn’t performing when it needed to be.  It’s built around large facilities that are often decades old.  Parts of it don’t communicate/coordinate well with others.  Its workforce is aging and burnt out.  There is no person or agency charged with ensuring its resiliency. It badly needs to be rethought for the 21st century. 

Oh, you thought I was talking about our nation’s power grid?  I was talking about our healthcare system. 

The parallels are striking, and concerning.  The power outages in Texas last year caught everyone’s attention.  People went for days or even weeks without power.  Oh, that’s Texas, people elsewhere might say, so the failures were not really surprising. Maybe, but it’s not just Texas.  

Large, sustained outages have occurred with increasing frequency in the U.S. over the past two decades, according to a Wall Street Journal review of federal data. In 2000, there were fewer than two dozen major disruptions, the data shows. In 2020, the number surpassed 180.

That’s where microgrids come in.

According to Microgrid Knowledge, a microgrid is a self-sufficient energy system that serves a discrete geographic footprint, such as a college campus, factory, hospital complex, business center, military installation or neighborhood. Microgrids can operate independently from the grid using power generated on-site; they can also be used for backup power. Microgrids are designed to operate consistently in both “blue sky” and emergency situations supported by a range of energy resources, such as renewable energy, energy storage, combined heat and power or generators.

Healthcare needs to literally join in.  If there’s a hospital, nursing home, pharmacy, dialysis center, or other health care facility that hasn’t already become part of a microgrid, it’s time.  Those 1960’s-era backup generators are not going to cut it.

Healthcare needs to figuratively join the microgrid movement.  Think of hospitals as the traditional power plants, the loci of the healthcare system.  Everything revolves around them, especially as they’ve bought physician practices, developed more outpatient facilities, and consolidated.  They control how healthcare is practiced and at what cost in their community/region. They power the system.

That’s worked for us, in our dysfunctional U.S. healthcare way, but the cracks are showing. We’re effectively seeing healthcare’s versions of brownouts, or even blackouts.  If there is one thing our healthcare system is not, it is resilient.

A healthcare microgrid would more effectively keep people out of hospitals.  It would rely less on physicians, especially specialists.  It would be community-based.  It would be available 24/7, and be able to flex capacity as needed.  It would be “smart,” and incorporate as many 21^st century technologies as possible, such as home monitoring.  Unlike actual microgrids (but more like most power grids) and unlike current medical practice, it would freely cross city/state/regional lines.

Telemedicine is an example of what should be included in microgrids.  Some hospitals are bold enough to impose facility fees for telehealth visits. Those are all signs that telehealth is not part of a microgrid; it’s being coopted by the power plants – er, hospitals.

Similarly, are we really taking advantage of nurse practitioners or physician assistants can do?  Why do we even think of nurse practitioners as “nurses” or PAs just as assisting physicians?  Do we give pharmacists as much authority as their training would allow for? 

And, of course, when are we going to get AI that can be our first line of medical advice, and perhaps more?

These are microgrid questions. They’re not questions we should only be considering during times of extreme crisis, like the current pandemic; they are questions we should be answering for the next crisis.   

The analogy is not perfect. I don’t know exactly what a healthcare microgrid would look like.  But, just as I know traditional power grids are not going to be enough for our energy needs, our traditional healthcare system is not going to be enough for our healthcare needs. We need something more resilient and more localized.  We need healthcare microgrids.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

The Tests Were a Test

by Kim Bellard, January 28, 2022

Raise your hand if you’ve gone out shopping for home COVID tests, only to find empty shelves and signs apologizing for the lack of availability.  Raise your hand if you’ve been able to obtain one, but were surprised at its cost.  Raise your hand if you took one and weren’t quite sure you did it right, or wondered who, if anyone, would be getting the results.

Vox says that the COVID home test reimbursement process “is a microcosm of US health care,” and I think they’ve understated the situation.  Testing has been a microcosm for the US health care system generally.  It was a test, and our healthcare system failed.

Throughout the pandemic, we’ve never had enough tests or done enough testing. We didn’t take advantage of macro-tracking approaches like wastewater monitoring.We developed “rapid” tests but questioned their accuracy.  The “gold standard” PCR tests took/takes too long to return results.  As we encountered the highly transmissible variant Omicron, we didn’t scale up the production of tests – or the labs to process them -- enough to keep up with the demand, much less with the number of acquired cases.  

In our free-for-all pricing system, it’s anyone’s guess what a test might cost.  Most PCR tests have been required to be covered “first dollar” by insurance plans, so consumers haven’t been immediately faced with how much those tests cost, but costs picked by insurance end up in premiums eventually.  Home tests have not been, and costs might vary ten-fold or more depending on the manufacturer and/or seller. 

The Biden Administration has belatedly attempted to address these problems, but in a ham-handed way that is also typical for our healthcare system.  Earlier this month, it set up a system to for each household to order 4 free home tests.

The Biden Administration also required private insurers – but not Medicare -- to pay for 8 home tests per member per month, which seems to have come as a surprise to the insurers.  In many, perhaps most, cases, individuals would have to submit claims to their insurer to get reimbursed for these tests.  Insurers only have to pay up to $12 per test; consumers must pay anything above that.  Surprise!

When I read about that process, as a former health insurance executive, I immediately thought: that is not going to work.

What documentation needs to be submitted (receipts, product codes, pictures of the test, etc.), and how, are still unclear, and will vary between health insurers.  

As bad as all that is, we now have a scenario where there are potentially hundreds of millions of tests being taken, but no system for tracking how many are used, by who, or how many positive results there are.  We thought we were doing a bad job counting how many people have received how many doses of the vaccine, but at least there was some reporting system in place.  With these tests, we’re pretty much going to be in the dark.  We’ll never know how many positive cases we’ve had.

Initially, we had no testing strategy.  Then our testing strategy was just “get tested,” with no supporting tactics to make that feasible.  Then, almost 2 years in, we get grand announcements about directly providing free tests, but not enough for everyone, plus mandates on insurers for more free tests that don’t do anything to make the tests more available, affordable, or easy to get reimbursed for.

Yeah, all that sounds like a microcosm of our healthcare system.  As Vox put it, “It’s a needlessly complicated process that provides little benefit but creates plenty of problems.”

Shame on us.  It’s not just the healthcare system that failed the test.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

Breaking Up Is Good to Do

By Kim Bellard, November 16, 2021

Last week General Electric announced it was breaking itself up. GE is an American icon, part of America’s industrial landscape for the last 129 years, but the 21st century has not been kind to it. The breakup didn’t come as a complete surprise. Then later in the week Johnson and Johnson, another longtime American icon, also announced it would split itself up, and I thought, well, that’s interesting. When on the same day Toshiba said it was splitting itself up, I thought, hmm, I may have to write about this.

Healthcare is still in the consolidation phase, but there may be some lessons here for it.

As unique as each of their stories is, the thing that each breakup has in common is that the hope is that investors will see greater value as a result. It’s not about the products or the customers; it’s about the returns.

Healthcare knows about that.

Healthcare has been a hotbed of acquisition and consolidation. Hospitals buy hospitals; health insurers buy health insurers, pharmaceutical companies buy pharmaceutical companies, digital health companies buy digital health companies, private equity firms buy physician practices. But we’re also seeing things like CVS buying Aetna or UnitedHealth Group buying DaVita Medical Group (and trying to buy Change Healthcare).

Still, though, when I see conglomerates like GE, J&J, or Toshiba breaking up, what I think about most are not those kinds of healthcare conglomerates, but, rather, hospitals.

Hospital systems are big. It probably won’t come as much surprise that a for-profit chain like HCA has annual revenues of $59b, but it might that “non-profit” UPMC has annual revenues of $23b. Mayo Clinic and Cleveland Clinic also report double digit billion dollar revenues. We’re talking about big businesses.

But are hospitals anything other than healthcare conglomerates? They fix your heart over here, they implant a new hip over there, they deliver your babies, they attack a variety of your cancers in a variety of ways, they put various kinds of scopes inside you, they take detailed images of you, and, Lord knows, they do all sorts of lab tests, all while running the meter on you to ensure they can charge you as much as they are allowed.

I can see the argument that you’ll need imaging and lab tests whether you are getting a bypass or having a baby, but it is not at all clear that doing bypasses makes a hospital a better place to deliver babies. Being the best cancer hospital, or even just a good cancer hospital, doesn’t mean it is good at doing a cholecystectomy. Service lines are businesses; it’s hard enough to ensure quality within a service line, much less across them. More isn’t necessarily better.

Michael Farr, head of Farr, Miller & Washington, told WaPo: “More effective CEOs said, ‘Wait a minute, I need to make sure this is strategically and logically integrated with everything our core business is doing.’” He was speaking of the GE divestiture, but how many hospital CEOs are having that same examination? How many of them could truly define their “core business,” other than offering a bland “patient care”? Which patients, which care, in what places using what services?

Increasingly, hospitals want to be all things to all patients in all places, just as industrial conglomerates wanted to serve all customers in all industries. That worked well for a long time, but no longer. That time is coming in healthcare too. Hospitals, and all healthcare companies, need to truly define, and focus on, their core business.

Healthcare has too many conglomerates. Time for them to break up.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)  

Not Your Father's Job Market

By Kim Bellard, September 24, 2021

If you, like me, continue to think that TikTok is mostly about dumb stunts, or, more charitably, as an unexpected platform for social activism, you probably also missed that TikTok thinks it could take on LinkedIn. 

Welcome to #TikTokresumes.  Welcome to the Gen Z workplace.  If healthcare is having a hard time adapting to Gen Z patients – and it is -- then dealing with Gen Z workers is even harder. 

TikTok actually announced the program in early July, but, as a baby boomer, I did not get the memo.  It was a pilot program, only active from July 7 to July 31, and only for a select number of employers, which included Chipotle and Target.  The announcement stated:

TikTok believes there's an opportunity to bring more value to people's experience with TikTok by enhancing the utility of the platform as a channel for recruitment. Short, creative videos, combined with TikTok's easy-to-use, built-in creation tools have organically created new ways to discover talented candidates and career opportunities.

The Wall Street Journal is also watching the trend: “Video résumés are fast becoming the new cover letter for a certain breed of young creatives…For some brands, soliciting video résumés on social media is a way to meet more young, diverse job candidates.” 

As it turns out, even Gen Zers have misgivings about the idea.  A survey by Tallo found them fairly evenly split. A bigger concern, though, was the possibility of bias: Nagaraj Nadendla, SVP of development at Oracle Cloud HCM, raised the same concerns in TechCrunch: The very element that gives video resumes their potential also presents the biggest problems. Video inescapably highlights the person behind the skills and achievements. As recruiters form their first opinions about a candidate, they will be confronted with information they do not usually see until much later in the process, including whether they belong to protected classes because of their race, disability or gender.

Lest you think this is not important to your organization, that Gen Z’s needs don’t really matter, Morten Peterson, CEO of Worksome, writing in Fast Company, calls Gen Z the “new disruptors,” pointing out: “The overwhelming majority of today’s graduate pool come from Generation Z and will do so for the next decade at least.”  

And they vote with their feet.  Research from Amdocs found they, along with Millennials, are much more likely than Baby Boomers or even Gen X to have considered leaving their job within the last year:

Every industry is having a hard time recruiting, and keeping, workers these days, and healthcare is no exception.  Between normal burnout, pandemic-related burnout, vaccine mandates, and the lure of jobs that offer more opportunity for remote work, most healthcare organizations are struggling to have enough staff.  When the current Baby Boomer doctors, nurses, technicians, and aides retire, there better be Gen Z replacements ready to step in.

Some healthcare organizations are already starting to use TikTok for marketing,  others are trying to combat misinformation, but most healthcare organizations are probably not just behind the curve when it comes to recruiting workers using TikTok; they may not have yet realized there is a curve.  If, as NYT said, one page resumes are gong the way of the fax machine, well, in healthcare those fax machines haven’t gone very far. 

RecTech Media’s Mr. Russell said it: “video is eating the world.”  Healthcare’s world too. 

TikTok resumes may not take off.  Tallo’s survey found it low on the list of sites Gen Zers felt comfortable posting a resume on (perhaps not coincidentally, Tallo’s site was rated the highest, followed by LinkedIn).  Video resumes more generally may not become the norm.  Those bias concerns with video resume are real and must be appropriately considered. 

But Gen Zers are different, and healthcare organizations, like other organizations, better be thinking about how to best recruit them.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

I Am Dr. Groot

By Kim Bellard, August 26, 2021

All I can think about is robots. Most of the recent publicity about robots has come from Elon Musk’s announcement of the Tesla Bot, or the new video of Boston Dynamic’s Atlas doing more amazing acrobatics, but I was more intrigued by Brooks Barnes’s New York Times article Are You Ready for Sentient Disney Robots?

One of the things that Disney has long included in its parks’ experience were robots. It has had robots in its parks since the early 1960’s, when it introduced “audio-animatronics,”. Disney has continued to iterate its robots, but, as Mr. Barnes points out, in a world of video games, CGI, VR/AR, and, for heaven’s sake, Atlas robots doing flips, its lineup was growing dated.

Enter Project Kiwi.

In April, Scott LaValley, the lead engineer on the project, told TechCrunch’s Matthew Panzarino: “Project KIWI started about three years ago to figure out how we can bring our smaller characters to life at their actual scale in authentic ways.” The prototype is Marvel’s character Groot, featured in comic books and the Guardians of the Galaxy movies.

By 2021, they had a functioning prototype. Mr. Barnes reported that his interactions with the would-be Groot were quite remarkable. It spoke to him, reacted to his initial non-response, and, eventually, “I wanted to hug him. And take him home.”

Groot is only the beginning. Mr. Barnes said: He is a prototype for a small-scale, free-roaming robotic actor that can take on the role of any similarly sized Disney character. In other words, Disney does not want a one-off. It wants a technology platform for a new class of animatronics.

If, as Elon Musk believes, “the economy is, at the foundation, labor,” then there may be no sector in which this is more true than in healthcare (especially long term care). Tech companies may be failing in healthcare because they think adding a tech layer will “fix” things, but our current system isn’t going anywhere until we address labor — its costs, its supply limitations, its productivity output. The pandemic almost broke our healthcare workers last year, and the recent surge is overwhelming them again.

Healthcare could use more robots.

Yes, there are robots in healthcare. People often point out to robotic surgery, which has not managed to reduce costs, improve quality, or remove the human component. There are also delivery robots (often used in hospitals), “patient simulators,” even companions, but, honestly, we need more robots like Hanson Robotics’ Grace, specifically aimed for healthcare. “I can visit with people and brighten their day with social stimulation … but can also do talk therapy, take bio readings and help healthcare providers,” Grace “told” Reuters.

It’s not there yet; it would need considerable evolution to play a significant role in our healthcare system, but, with the right investments, it will get there. And, yes, eventually there will be robot doctors, powered by AI.

Mr. Panzarino brings up the field of human-robot interaction (HRI), and asserts that, of all the companies, industries, and academic centers working on it, “the most incredibly interesting work in this space is being done in Imagineering R&D.” Again, as the Disney Institute preaches, focusing “on the details that other organizations may often undermanage — or ignore.”

I wish healthcare was leading HRI.

Healthcare needs to change its customer experience from passive to interactive. If Disney recognizes the need to stay “fresh and relevant,” that is all-the-moreso in healthcare. Healthcare thinks it is in the care business, but it must also recognize it is in the experience business — and that its experience currently is pretty woeful (often literally). It’s undermanaging and often ignoring the details that make up that experience. And when does technology in healthcare ever “disappear”?

Robots alone aren’t going to change all that in healthcare, but the level of attention — to detail, to relevancy, to customer experience — that Disney brings to its robotics efforts could go a long way.

 This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

The Most Important Thing

by Kim Bellard, July 26, 2021

Jack Dorsey has some big hopes for bitcoin.  In a webinar last week, he said: “My hope is that it creates world peace or helps create world peace.”  The previous week Mr. Dorsey announced Square was starting a decentralized financial services (DeFi) business based on bitcoin, joining the previously announced Square bitcoin wallet.  

None of this should be a surprise.  At the Bitcoin 2021 conference in June, Mr. Dorsey said: “Bitcoin changes absolutely everything.  I don’t think there is anything more important in my lifetime to work on.”

I’m impressed that someone with as many accomplishments as Jack Dorsey picks something not obviously related to those accomplishments and decides it is the most important thing he could work on.  So, of course, I had to wonder: what might accomplished people in healthcare say was the most important thing they wanted to be working on?

For many these days, of course, it is the COVID-19 pandemic.For others, perhaps, it would be to address the extreme financial hardships the U.S. healthcare system can cause.  However, both the pandemic and financial obstacles contributed to, but did not cause, the big health inequities in the U.S. healthcare system.  Digital health has never been hotter. We may be in bit of a manic phase right now, but few doubt that digital health is going to be a big part of healthcare’s future. Then there’s artificial intelligence (A.I.).  No industry in 2021 can be ignoring it.

These, and other initiatives, are all important and I sure hope people are working on them.  However, I think about some other things that Mr. Dorsey discussed in the webinar.

We have all these monopolies off balance and the individual doesn’t have power and the amount of cost and distraction that comes from our monetary system today is real and it takes away attention from the bigger problems…You fix that foundational level and everything above it improves in such a dramatic way.

So, for me, the most interesting future for healthcare has to be synthetic biology, including biohacking.

Synthetic biology, in case, you didn’t know, is “redesigning organisms for useful purposes by engineering them to have new abilities,” and biohacking is doing that to your own body, usually to optimize or improve its functioning. 

Observers seem to think that synthetic biology seems to draw an edgy, counter-cultural crowd.  It’s on the cutting edge, and it, too, is getting record funding.  Former Google CEO Eric Schmidt said, at a 2019 synthetic biology conference: “What is changing the fastest right now? Because whatever that is determining the history of next year. There’s lot of evidence that biology is in that golden period right now.” 

When we start talking about “programming biology,” well, if that isn’t “weird as hell,” I don’t know what is.  That’s fun, and that’s the future.

The theme for me is to solve health issues at the source code level.  Fix things, as Mr. Dorsey said about bitcoin, “at the foundational level.”

Mike Brock, who will head up Square’s DeFi business, tweeted: “Technology has always been a story of decentralization. From the printing press, to the internet to bitcoin – technology has the power to distribute power to the masses and unleash human potential for good, and I’m convinced this is the next step.” 

I want the same for our health – use technology to decentralize, and to distribute power to the masses.  That offers the promise of taking control from the traditional healthcare structures – not relying on hospitals, health insurance companies, or even medical professionals. 

As Mr. Dorsey thinks about bitcoin, “I don’t think there is anything more enabling for people around the world.”

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Go Ahead, A.I. — Surprise Us

By Kim Bellard, June 29, 2021

Last week I was on a fun podcast with a bunch of people who were, as usual, smarter than me, and, in particular, more knowledgeable about one of my favorite topics — artificial intelligence (A.I.), particularly for healthcare. With the WHO releasing its “first global report” on A.I. — Ethics & Governance of Artificial Intelligence for Health — and with no shortage of other experts weighing in recently, it seemed like a good time to revisit the topic.

My prediction: it’s not going to work out quite like we expect, and it probably shouldn’t.

WHO’s proposed six principles are: 

• Protecting human autonomy
• Promoting human well-being and safety and the public interest
• Ensuring transparency, explainability and intelligibility
• Fostering responsibility and accountability
• Ensuring inclusiveness and equity
• Promoting AI that is responsive and sustainable 

All valid points, but, as we’re already learning, easier to propose than to ensure. Just ask Timnit Gebru. When it comes to using new technologies, we’re not so good about thinking through their implications, much less ensuring that everyone benefits. We’re more of a “let the genie out of the bottle and see what happens” kind of species, and I hope our future AI overlords don’t laugh too much about that.

The example that I’ve been using for years is that we can’t even agree on how human physicians seeing patients in other states via telehealth should be licensed/regulated, so how are we going to decide how a cloud-based healthcare A.I. should be?

AI is going to evolve much more rapidly than other healthcare technologies, and our existing regulatory practices may not be sufficient, especially in a global market (as we’ve seen with CRISPR). Not to be facetious, but we may need AI regulators to oversee AI clinicians/clinical support, just as we may need AI lawyers to handle the inevitable AI-related malpractice suits. Only another black box may be able to understand what a black box is doing.

I worry that we’re thinking about how we can use A.I. to make our healthcare system do more of the same, just better. I think that’s the wrong approach. We should be going to ground principles. What do we want from our healthcare system? And, then, how can A.I. help get us there?

If A.I. for healthcare is a better Siri or a new decision support tool in an EHR, we’ve failed. If we’re setting the bar for A.I. to only support clinicians, or even to replicate physicians’ current functions, we’ve failed. We should be expecting much more.

E.g., how can we use A.I. to democratize health care, to get advice and even treatment in people’s hands? How can we use it to help health care be much more affordable? How can A.I. help diagnose issues sooner and deliver recommendations faster and more accurately?

In short, how can A.I. help us reorient our health care from the healthcare system that delivers it, and the people who work in it, to our health? If that means making some of those irrelevant, or at least greatly redefining their roles, so be it.

Right now, much A.I. work in healthcare seems to be focused primarily on granular problems, such as diagnosing specific diseases. That’s understandable, as data is most comparable/available around granular tools (e.g., imaging) or conditions (e.g., breast cancer). But our health is usually not confined within service lines. We need more macro A.I. approaches.

We might need A.I. to tell us how A.I. can not just improve our healthcare but also to “fix” our healthcare system. And I’m OK with that.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Healthcare’s Million Dollar Blocks

by Kim Bellard, April 28, 2021

Since I first heard about them, I have been fascinated, and dismayed, by the concept of “million dollar blocks.” For those of you unfamiliar with the term, it doesn’t refer to, say, Beverly Hills. No, it refers to city blocks for which society spends over a million dollars annually to incarcerate residents of that block.

I, of course, have to think about the healthcare parallels.

The concept dates back many years, credited to Eric Cadora, now at Justice Mapping, and Laura Kurgan, a professor of architecture at Columbia University, where she is the Director of the Center for Spatial Research (CSR). The power of the concept is to use data visualization to illustrate the problem.

But if, as they say, a picture is worth a thousand words, then perhaps data visualization is worth a million dollars. Even hardened criminal justice advocates have to blanche at how spending is so often concentrated in certain blocks, and should wonder if perhaps there are better ways to use that money for them.

CSR has a variety of projects in addition to their criminal justice work, including some focused on healthcare. Late last year their New Politics of Care project used an interactive map to highlight existing areas of health care needs. They proposed a New Deal for Public Health, with a million new community health workers deployed around the country based on the identified needs.

Somehow the Community Health Corps didn’t make it into the Biden infrastructure proposal. Perhaps no one in the Administration has seen the map.

Data visualization is nothing new for healthcare. The CDC has an Interactive Atlas of Heart Disease and Stroke, the Dartmouth Atlas has been highlighting healthcare variations for close to thirty years, and, more recently, the Johns Hopkins Coronarvirus Resource Center has been tracking what’s been happening in the pandemic.

Still, if anyone is tracking where healthcare’s “million dollar blocks” are, I’d like to hear about it.

We know — or think we know — that there are underserved communities where too many people end up in the emergency room. We know that there are communities in which maternal and infant mortality/morbidity are much worse.

But do we know where these are concentrated, or do we know how much we’re spending on the results of them? No.

I want to know in which communities the hospitals are the predominant healthcare institution. I want to know what communities are falling behind on preventive screenings and vaccinations. I want to know which communities have suspiciously low healthcare spending, and whether that is a function of better health or lack of healthcare resources.

I want to see the interactive data visualizations for these types of issues, and I want smart people acting on them.

If the pandemic has highlighted anything, it’s that our public health system is woefully inadequate. It doesn’t have the right resources and doesn’t have the right data, collected and acted upon at the right time.

Healthcare generates scads of data, but not the right data, timely, aggregated across all payors for all kinds of services, and we certainly don’t have anyone in a position to really use it to manage.

The “million dollar block” concept highlights the fact that we’re good at spending money, but we’re not very good about how we end up spending it. It emphasizes the rationale of “defund police” movement, and should be applied to healthcare as well (as I’ve discussed before).

I guess we need to see the pictures first.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard) 

Nanoparticles On My Mind

By Kim Bellard, March 24, 2021

Nanoparticles are everywhere! By that I mean, of course, that there seems to be a lot of news about them lately, particularly in regard to health and healthcare. But, of course, literally they could be anywhere and everywhere, which helps account for their potential, and their potential danger.

Let’s start with one of the more startling developments: a team at the University of Miami’s College of Engineering, led by Professor Sakhrat Khizroev, believes it has figured out a way to use nanoparticles to “talk” to the brain without wires or implants. They use “a novel class of ultrafine units called magnetoelectric nanoparticles (MENPs)” to penetrate the blood-brain barrier.

Professor Khizroev has been working on the technology for over a decade, and has received funding from Darpa as part of its Next Generation Non-surgical Neurotechnology (N3) program (also known as BrianSTORMs), the goal of which is “to develop high-performance, bi-directional brain-machine interfaces for able-bodied service members.” The team got Phase II funding last November in order to build working devices.

“Right now, we’re just scratching the surface,” Dr. Khizroev says. “We can only imagine how our everyday life will change with such technology.” Some of what he does imagine, though, is:

We will learn how to treat Parkinson’s, Alzheimer’s, and even depression. Not only could it revolutionize the field of neuroscience, but it could potentially change many other aspects of our health care system.

Lest anyone think this is either an easy or a solved problem, Darpa points out: “N3 researchers are working to develop solutions that address challenges such as the physics of scattering and weakening of signals as they pass through skin, skull, and brain tissue, as well as designing algorithms for decoding and encoding neural signals that are represented by other modalities such as light, acoustic, or electro-magnetic energy.”

But that’s not all the nanoparticle news from just this week. In no particular order:

· Researchers from Cleveland Clinic and Chungbuk National University tested a COVID-19 vaccine (on ferrets) using antigens attached to nanoparticles.

· Another research team, from Scripps and Temple, also tested using nanoparticles to deliver antigens for COVID-19, using three self-assembling protein nanoparticle (SApNP) platforms

· A research team at the University of Manchester used nanoparticles to discover previously unseen blood markers: This might allow earlier and more definitive diagnoses of Alzheimer’s.

· A research team at the University of Science and Technology China are testing “acid-responsive nanoparticles composed solely of membrane-disruptive macromolecules” to treat pancreatic cancer.

· Russian and Israeli researchers “have developed hybrid nanostructured particles that can be magnetically guided to the tumor, tracked by their fluorescence and pushed to release the drug on demand by ultrasound.

· Another Chinese research team is using nanoparticles to deliver antimicrobial peptides (AMPs) for the treatment of deep infections.

· An international team of researchers assert: “The potential of nanotechnology in fighting this deadly disease [COVID-19] has not only been realized in context of developing a nano-vaccine but by delivering the nano-based anti-viral agents.”

· Spanish researchers have been able to observe autonomous nanobots in vivo — inside the bladders of a living mouse — using Positron Emission Tomography (PET).

Again, that’s just this week, and only health-related nano news.

I’m no expert on nanoparticles, or any kind of nanotechnology. I understand that the technology has a long way to go yet. I realize that there are risks, included unintended health effects, to using nanotechnology. All that being said, too much of our health treatments are “shotgun” approaches that often cause as much collateral damage as beneficial impacts. Nanoparticles offer the promise of “rifle” approaches that offer precise targeting — like using smart bombs instead of carpet bombing.

Within my lifetime, and hopefully within the decade, we’ll have nano-delivered drugs that will greatly increase their efficacy. We’ll have nanobots swimming around in us, for a variety of therapeutic purposes. And we should have nanoparticle mediated brain-computer interfaces too.

Exciting stuff.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Need Care, Should Travel

By Kim Bellard, February 25, 2021

I find myself thinking once more about our inability to distinguish quality in our health care. I live in Cincinnati (OH).  The metro area has five hospital systems. Most Cincinnati residents go their entire lives getting all their medical care here. That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally.. 

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine. But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling. The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care? I don’t know, you don’t know, and even “experts” are likely to disagree. 

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

Of course, there would be non-trivial financial implications to such a change.  Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. All politics, as they say, is local, but all health care shouldn’t be. 

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

And You Thought Health Insurance Was Bad

By Kim Bellard, January 28, 2021

I spend most of my time thinking about health care, but a recent The New York Times article — How the American Unemployment System Failed — by Eduardo Porter, caught my attention. I mean, when the U.S. healthcare system looks fair by comparison, you know things are bad.

Long story short: unemployment doesn’t help as many people as it should, for as much as it should, or for as long as it should.

It does kind of remind you of healthcare, doesn’t it?

The pandemic, and the associated recession, has unemployment in the news more than since the “Great Recession” of 2008 and perhaps since the Great Depression. Last spring the unemployment rate skyrocketed well past Great Recession levels, before slowly starting to subside. Still, last week almost a million people filed for unemployment benefits, reminding us that unemployment is still an issue.

Mr. Porter reports:

· “In 2019, only 27 percent of unemployed workers received any benefits, a share that has been declining over the last 20 years.

· The benefits have eroded as well, to less than one-third of prior wages, on average, about eight percentage points less than in the 1940s.”

The states range from 58% of unemployed workers in New Jersey who receive benefits to 9% — 9%! — in North Carolina. Robert Moffitt, a Johns Hopkins economics professor, told Mr. Porter: “The program was set up to have tremendous cross-state variation. This makes no sense. It creates tremendous inequities.”

As with our healthcare system, “broken” isn’t really a good description. Each is working the way they’ve been designed. Unfortunately, if you’re poor or sick, and especially if you are both, they’re not designed to help you. Not until the poor and sick start making significant campaign contributions anyway, or at least vote in larger numbers.

Many unemployed workers, of course, also lose their health insurance when they lose their jobs, since ours is a predominantly employer-based health insurance system. As many as 15 million people may have lost their employment-based coverage due to the pandemic. If they work for the right kind/size of employer, they may be eligible for COBRA coverage, but paying for it may be difficult, between loss of employer contribution, low UI benefits, and delays in receiving UI.

At least under ACA they may have coverage options, including subsidies, through the Marketplace or Medicaid, — unless they live in one of the states without Medicaid expansion.

Even in the states that have expanded Medicaid, the economic crisis has hit their tax revenue severely, while increasing the number of Medicaid enrollees, creating a double whammy. The same, of course, is happening with the money to pay unemployment benefits, causing almost half the states to ask for federal loans.

In other words, when we have the worst crises — like a pandemic — both our unemployment insurance and our health insurance systems do worst. Those are the times we rely most on the government, but our federalism system of shared federal/state responsibilities is failing the latest crisis.

Mr. Porter sees hope:

Perhaps there is an upside to the current crisis: The glaring insufficiencies of the regular unemployment system may encourage states and the federal government to undertake comprehensive changes.

Perhaps. If the pandemic continues long enough — as it might — it might force deep structural changes. So far, the various relief bills have just added more patches to our patchwork quilt approach towards UI. But if in the coming months vaccines mitigate the impact, and the economy picks up, then our typical reaction will be to commission some studies and just kick the can further down the road.

ACA made our health insurance system less patchwork, with more uniform requirements, more subsidies, less discrimination against preexisting conditions, and broader Medicaid options. The Biden Administration may, and should, further improve these. Let’s hope that it takes a hard look at how it can do something similar with unemployment insurance.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Streaming, Baby Yoda, and Healthcare

by Kim Bellard, December 15, 2020

I’ve never seen The Mandalorian. I don’t have Disney+. But I know who Baby Yoda is, and I’m pretty sure Disney is counting on that. Hollywood, in case you haven’t been paying attention, is going through some radical changes. There may be some lessons for healthcare in them.

Hollywood has made some startling announcements in the past few weeks that illustrate how swiftly changes are coming to the entertainment industry:

Disney: Disney expects to have 100 new titles — TV shows or movies — each year for the next few years. Disney chairman Bob Iger noted modestly: “The pipeline of original content we’re making is much more robust than originally anticipated.” Of particular note, though, CEO Bob Chapek said, “Of the 100 new titles announced today, 80 percent of them will go to Disney Plus.”

Warner Bros: Although Disney expects some of its movies to still have theatrical runs prior to streaming, Warner Bros announced in early December that all of its 2021 releases will be available for streaming on its HBO Max service upon release, rather than after the “traditional” 90+ day wait.

If you’re worried about the original streaming service — Netflix — don’t be. Although its growth has slowed, that’s partly because it already has close to 200m subscribers worldwide. Its stock is up over 50% YTD, and even the announcements from Disney and Warner didn’t seem to shake that. Similarly, Amazon Prime has over 150m video users, more than half of them in the U.S., and continues to invest heavily in new streaming content.

It’s a new world for Hollywood. Brooks Barnes, NYT entertainment reporter, wrote: “one Warner Bros. executive told me that “the town” felt like a dismantled movie set: The gleaming false fronts had been hauled away to reveal mere mortals wandering around in a mess.” Another Hollywood insider told him: “I see this as a time of opportunity. Sometimes you have to take it down to the studs and build something new.”

Healthcare’s “false fronts” have been torn down too. If ever there was a time to take healthcare “down to the studs and build something new,” this is it.

We brag about the increases in telemedicine, but we should note the CMS rules that have expanded its use are only temporary. We haven’t addressed the inter-state licensing issues. We’re not even doing telehealth visits all that well; the Press Ganey survey concluded: “The bad news is that patients clearly feel that the process of telemedicine (logistical things like ease of scheduling and making audio/video connections) falls short.”

We’ve seen dramatic declines not just in office visits but also in use of preventive services and screenings, elective surgeries, emergency room visits, even heart attacks. We just don’t know if these declines are good or bad. Researchers Allison H. Stokes, PhD, and Jodi B. Segal, MD, suggest in Health Affairs: “We see a unique methodological opportunity to evaluate the harms of low-value care.”

But will we take advantage of that opportunity, or will we just go back to our old ways once the vaccines work their magic?

E.g., will healthcare just expect patients to go back to the theater? Or will major healthcare companies bet big on the future: “streaming” (aka telehealth) as the main consumer point-of-contact, with patient convenience as a main driver? Where digital is the norm?

Disney’s physical locations — its theme parks — are hemorrhaging money, and Warner Bros has suffered dramatic declines from theater revenues, but both are betting big on their virtual strategies — and the markets are rewarding them. Warner says its announcement is only a strategy for 2021, but, as NYT put it:

It will be almost impossible to go back, and it may force other studios to abandon the old model.

We shouldn’t expect patients to go back to the “old” healthcare system either.

I’m not expecting healthcare to have a Baby Yoda caliber idea, but it can certainly do better than its current Jar Jar Binks strategies.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Healthcare’s Bridge Fire

By Kim Bellard, November 17, 2020

We had a bridge fire here in Cincinnati last week. Two semis collided in the overnight hours. The collision ignited a blaze that burned at up to 1500 degrees Fahrenheit and took hours to quell. Fortunately, no one was killed or injured, but the bridge remains closed while investigators determine how much damage was done. It is expected to remain closed for at least another month.

Unfortunately, the bridge in question is the Brent Spence Bridge, which is the focal point for I-71 and I-75 between Ohio and Kentucky. It normally carries over 160,000 vehicles daily, and is one of the busiest trucking routes in the U.S. Over $1 billion of freight crosses each day. There are other bridges nearby, but each requires significant detouring, and none were designed for that traffic load.

What makes this all so galling is that it has been recognized for over 25 years that the bridge has been, to quote the Federal Highway Administration, “functionally obsolete” — yet no action was taken to replace it. This most recent disaster was a disaster hiding in plain sight.

Just like, as the coronavirus pandemic has illustrated, we have in health care.

Epidemiologists had long warned of a global pandemic. The Obama Administration prepared a detailed “playbook” for such a pandemic, but, nonetheless, the Trump Administration was caught flat-footed when COVID-19 hit.

Our global, just-in-time systems for supplies was found severely wanting in the case of an exponentially spreading global pandemic, leaving healthcare workers short of essential protective gear and equipment like ventilators. Similarly, our testing efforts were botched from the beginning.

As we’ve learned, COVID-19 hits people with comorbidities hardest; as we’ve long known, the U.S. leads in world in people with chronic conditions. It has also disproportionately impacted people of color — reflected, in part, their increased likelihood of being essential workers who cannot work from home, and underlying health disparities.

Just within the past week, we’ve received promising news on vaccines from Pfizer and Moderna. Unfortunately, vaccine development has become politicized.

We’ve thrown trillions of dollars at COVID-19 relief, including large amounts to the healthcare system, yet hospitals claim they are losing hundreds of billions of dollars, and our already weakened system of primary care is on the verge of collapse. Burnout among healthcare workers was already a problem, but the pandemic has caused it to reach new levels, especially when many people shun basic precautionary measures like masks or social distancing.

It’s embarrassing that in the richest country in the world, 11% of the non-elderly lack health coverage. It is disturbing that 25% of Americans report that they or a family member have put off treatment for a serious medical condition in the past year due to cost — and that was before the pandemic.

All of which is to say, the pandemic is a bridge fire, all right, but it is taking place on a healthcare bridge that we’ve long known is “functionally obsolete.”

We can’t entirely avoid bridge fires, but we can design the bridges to minimize their likelihood and can ensure they are structurally sound enough to withstand them. Similarly, we can’t preclude the possibility of a pandemic, but we can have the public heath infrastructure in place for one, and a healthcare system that is robust enough to cope with one.

What we can’t do — or, rather, what we shouldn’t do — is to wait for disasters to happen and only then try to figure out what to do.

The pandemic may be healthcare’s bridge fire, but it didn’t cause our healthcare system’s shortcomings; it only helped expose them. The question is, will it spur us to do something about them?

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Not Just Faxes

By Kim Bellard, October 21, 2020

I missed it when it was first announced in Japan, but fortunately the U.S. mainstream media has finally picked up on the story, with articles in both The Washington Post and The Wall Street Journal: Japan’s new Administrative Reform Minister Taro Kono has “declared war” on fax machines, among other paper-based traditions.

Wait, what? “Administrative Reform Minister?” The U.S., or at least the U.S. healthcare system, has to hear about this.

Mr. Kono set up a hotline for people to report government red tape, which was quickly overwhelmed with thousands of examples. It soon reopened.

It didn’t take long for Mr. Kono to start calling for significant changes. “To be honest, I don’t think there are many administrative procedures that actually need printing out paper and faxing,” he said in a press conference in late September. “

Part of the problem in Japan is the hanko, a personal stamp that is routinely used for authentication (and which thus requires paper.)

If you’ve ever envied Japan for its bullet trains, its early adoption of robots, or its broad use of consumer electronics, you may be surprised to hear that more than 95% of Japanese businesses still use faxes, and 34% of Japanese households have a fax. Mr. Kawaguchi admitted: “It may be 1970s technology, but it is extremely secure and very difficult for someone on the outside to hack…Digitisation may make things more efficient, but there is clearly a trade-off when it comes to security.”

Not surprisingly, the COVID-19 pandemic has been a big driver in the anti-fax initiative. Health care professionals were overwhelmed by the amount of reports that had to be prepared by hand and then faxed. “Come on, let’s stop this already,” one physician tweeted. “Even with corona, we’re handwriting and faxing.” Mr. Kono quickly retweeted it, even though he was still in his former position as Defense Minister — and within a week the health ministry announced a system of online filing (which, not surprisingly, has not entirely succeeded).

An independent report on Japan’s response to the pandemic found that their system “made it difficult to grasp the spread of infection in real time nationwide, and exhausted health center staff. The new coronavirus crisis was also Japan’s ‘digital defeat.’”

We don’t have hankos in the U.S., and we’re not as reliant on faxes as Japan is, even in our healthcare system. But red tape, inefficiencies, and antiquated technology? Yeah, we’ve got all that, especially in healthcare. But where’s our Secretary of Administrative Reform? Where are our Chief Administrative Reform Officers?

Heck, where are our hotlines to report red tape?

Even now, well over six months into our pandemic response, we have a slapdash, state-by-state (or even county-by-county) system of reporting, with hospitals and HHS still struggling to figure out what and how to report.

Yoshimitsu Kobayashi, chairman of Mitsubishi Chemical Holdings, sees the pandemic as an opportunity: “The very negative damage it has inflicted on Japan has in turn served as a powerful accelerator. If we miss this chance, we won’t be able to do it next time.”

Economist Paul Romer is usually credited with the quote, “A crisis is a terrible thing to waste.” Well, we certainly have a crisis, and I’m worried we’re going to waste it. Using it to just get rid of faxes would be a waste. We’re already using it to streamline development of therapeutics and vaccines, although not without problems. But will we use it to solve fundamental problems in our healthcare system, such as inequities, inefficiencies, and infrastructure?

Maybe we could recruit Mr. Kono to do the job.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

WeChat to Many, But WeDoctor to Some

By Kim Bellard, September 23, 2020

You’ve probably heard about TikTok, especially lately. But you may have paid less attention to what’s been going on with WeChat, another China-based app. WeChat was part of the original proposed ban, which a federal judge blocked this weekend, hours before it was due to go into effect (the Commerce Department plans to appeal). The ban is on “transactions,” which, in WeChat’s case, covers a lot of ground.

WeChat is owned by Tencent Holdings, one of China’s internet giants. It has been described as a “Swiss Army knife” app, able to do many tasks — not just messaging and social networking, but also games, shopping, and payments.

It is also important to users’ health. WeChat is, according to CMI Media, “fast becoming the #1 online healthcare destination in China.” It offers, among other things, health content (some in partnership with U.S. firms), health products, telehealth, a network of “trusted” doctors, a form of health insurance, and WeDoctor. The latter “provides online health enquiry service, psychological support, prevention guidelines and real-time pandemic reports,” and is free to the user. It is available “24/7 for people all over the world.”

If we’re worried about what information China might glean from the video-watching habits of teenagers, think about how worried we should be about China having access to what health information users sought, what medical advice they got, and what health products they ordered.

China is famed for its “Great Firewall,” which restricts which outside internet platforms — like Google or Facebook — can be used within its borders. Equally important, the Chinese government monitors what happens on WeChat and other internet platforms/apps, and does not allow news or opinions it finds objectionable, or subversive.

There are estimated to be 19 million U.S. users, out of WeChat’s 1.2 billion users; most are people with family or friends in China, who rely on the app to stay in touch. The U.S. may argue it is worried about what financial and personal information might be going to the Chinese government, but it should be equally worried about what “information” is being served to U.S. users.

Think, for example, what it might tell U.S. users about COVID-19 vaccines.

The U.S. moves make some worry that we’re becoming more like China, leading to the “splinternet” where, as Vox explained, “your experience of the internet increasingly depends on where you live and the whims of the ruling parties there.”

It is the opposite of the open access, no borders version of the internet that most of us have believed in for the past thirty years. Aaron Levie, CEO of cloud-computing company Box Inc, warned in The Wall Street Journal: “U.S. tech companies have far more to lose if this becomes a precedent. This creates a Balkanization of the internet and the risk of breaking the power of the internet as one platform.”

Somehow, “optimal fragmentation” isn’t how I want to think of my internet experience; I suspect that fragmentation won’t be so optimal.

In discussing the effect of potential WeChat bans with The New York Times, Fang Kecheng, a professor at the Chinese University of Hong Kong, said: “Information is like water. Water quality can be improved, but without any flow, water easily grows fetid.” He didn’t carry the analogy further, but I will: information is like water, in that, eventually, it will get to where it wants to go.

We don’t have a U.S. platform as versatile as WeChat; we don’t even have a health platform as capable as WeChat’s health capabilities. But, if we’re not careful, WeChat might become that platform.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Thriving in COVID-19 Times

by Kim Bellard, August 27, 2020

These are, no question, hard times, due to the COVID-19 pandemic. Yes, these are hard times. But not for everyone.

No one should be surprised that Amazon is doing well, as more turn to online shopping and Amazon’s quick delivery, but The Wall Street Journal reports that Bog Box stores generally are doing well.

Similarly, if you’re a streaming service like Netflix or Disney+, the pandemic has been great for business. Video conferencing services like Zoom are booming. Car dealers are struggling, but not online car sales.

In healthcare, everyone seems to agree that the big winner has been telehealth. Industry leaders TelaDoc and Livongo merged, while rival Amwell got a $100 million investment from Google. No one is quite sure how much of the flexibilities introduced during the pandemic will persist once it recedes, but no one wants to miss out on what McKinsey predicts could be a $250b opportunity.

Of course, the pharmaceutical companies are doing fine in the pandemic. They’re the cockroaches of healthcare; they’re always going to survive. Some are even getting the federal government to directly pay for their vaccine research or therapeutics.

Health insurers are also proving to be big winners despite — or because of — the pandemic. Due to all those delayed/avoided treatments, they’re racking up huge profits so far in 2020.

The big loser is employer sponsored health insurance — or rather, the people who lost it. Kaiser Family Foundation estimates that 27 million people lost their health coverage due to losing their jobs in the pandemic.

Another big loser may be primary care practices, especially those not yet owned by health systems. Financial losses are predicted to be staggering, as patients stayed away in droves. As late as July, nearly 90% of primary care practices said they were still struggling due to COVID-19, according to a survey done for the Primary Care Collaborative.

Ann Greiner, president of PCC, said the report “is a clarion call to move to a new payment system that doesn’t rely on face-to-face visits and that is prospective so practices can better manage patient care.”

Hospitals also took a big hit, with the American Hospital Association predicting that losses would top $300b in 2020 due to the pandemic’s impacts. Some of these losses will be offset by the various federal bills (CARES and PPE), others by the rebound in the stock market, but some hospitals will continue to struggle — especially the already struggling rural hospitals.

During the pandemic, it has repeatedly struck me as a particular indictment of our healthcare system is that a health crisis causes so much disruption and so many financial losses. If a sick care system — which, let’s face it, is what we have — doesn’t do well when lots of people are sick, what are we doing?

In April of this year, Microsoft CEO Satya Nadella talked about the growth of its virtual platform Teams during the pandemic and declared, “In this era of remote everything, we have seen two years’ worth of digital transformation in two months.” Healthcare has also made some significant strides, but if all we take away from the pandemic is that maybe we should keep doing more telehealth, we’ll have missed the opportunity for real change.

The pandemic has important lessons for healthcare. We shouldn’t rely on employment for health insurance. We shouldn’t rely so heavily on elective procedures for health care revenues. We need to be more flexible about where and how people get their care.

This pandemic will eventually pass, in some form and with great damage. The healthcare system will survive, at least most of it. The challenge for us is to start making the changes needed for it to thrive even in the next crisis.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Healthcare Needs Some #GoodTrouble

By Kim Bellard July 22, 2020

As hopefully most of you know, Rep. John Lewis, civil right icon and longtime member of Congress, died this past Friday. Rep. Lewis was often described the “conscience of Congress” — perhaps a low bar in today’s Congress but important nonetheless — for his unwavering commitment to social justice.

Rep. Lewis must have been heartened by the fact that, in 2020, plenty of people are, indeed, making noise and getting into good trouble, necessary trouble over issues that he cared deeply about, like Black Lives Matter and voting rights. There are others who are better able to write about those people and that trouble. So I’d like to talk about his call to action with respect to healthcare.

If you are working today in healthcare — especially in the United States — or, for that matter, someone getting healthcare or having a loved one get it, then you should be making some noise and getting into good trouble, because our healthcare system most definitely makes it necessary.

Every day, too many of us suffer in the healthcare system, ranging from waits to indignities to critical mistakes, and some face financial ruin due to the care — whether good or bad. Most of us suffer in silence, or only complain to our friends and family. We don’t see a lot of mass protests about the pitiful state of our healthcare system, and I have to wonder why.

We have to stop being so passive.

For those of you working in healthcare, here are the first two things I’d urge you to get into good trouble about:

•         Stop doing stupid stuff
•         Do simple better

The first admonition comes from a movement developed by Melinda Ashton, MD at Hawaii Pacific Health. She started asking front-line workers to identify things that were “poorly designed, unnecessary, or just plain stupid,” and — not surprisingly — there turned out to be a lot.

The second comes from advice that Dan Gingiss gives about improving customer experience. Our healthcare system is the world’s largest Rube Goldberg machine, complicated beyond understanding and with much of that complexity not achieving intended goals.

Yet we continue to add complexity, layering new technologies onto old, inserting new layers and new types of intermediaries, all of which adds costs. Even things that aren’t inherently stupid are usually more complicated than is absolutely essential.

Before we make things even more complicated, we should focusing on making the simple things better. Who is getting into good trouble about that?

If the leadership at your healthcare organization doesn’t resemble the workers in it, or, equally important, the people receiving care from it, then you should be making noise. That’s worth getting into good trouble about. That’s necessary trouble.

Or take prices. As expensive as our healthcare system is, we’ve known for a long time that our problem isn’t getting too many healthcare service as it is the prices we pay for them. If you’re working in a healthcare organization that charges the people without health insurance much more, you should be making noise. If your organization is also suing those patients to collect the resulting debts, you should be getting into good trouble to try to stop it.

And, of course, if you are working in a healthcare organization where you see patients getting services they don’t actually need, or, worse yet, delivering substandard care, then you really should be making noise and getting into good trouble. That is definitely necessary trouble.

But it’s not only those working in healthcare. If you or your loved one is receiving care, you should be making noise when you aren’t treated with respect, or when you don’t get the information you need.

We can’t be afraid to make some noise about healthcare. We must be willing to make good trouble about the many, deep, and pervasive problems in our healthcare system. If that isn’t necessary trouble, I don’t know what is.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

TikTok Teens' Time

By Kim Bellard, June 25, 2020

I knew about TikTok, but not "TikTok Teens."  I was vaguely aware of K-Pop, but I didn't know its fans had common interests beyond, you know, K-Pop.  I'd been tracking Gen X and Millennials but hadn't really focused on Gen Z.  It turns out that these overlapping groups are quite socially aware and are starting to make their influence felt. 

I can't wait for them to pay more attention to health care. This generation has a lot to protest about, and a lot of ways to do it. They were in the news this past weekend due to, of all things, President Trump's Tulsa rally.  His campaign had boasted about having a million people sign up for the rally, only to find that the arena was less than a third filled.  An outdoor rally for the expected overflow crowd was cancelled. 

It didn't take long for the TikTok Teens/K-Pop fans to boast on social media about their covert -- to us older folks -- campaign to register for the rally as a way to gum up the campaign efforts.  Most doubt that these efforts had much to do with the low attendance -- it can be more likely attributed to concerns over COVID-19 and/or the concurrent Juneteenth celebrations/Black Lives Matter protests -- but they were responsible for cluttering up the Trump campaign's efforts to collect supporter/donor information from the registration.  As a subversive guerilla marketing campaign, it was brilliant -- and effective. 

It was not their first such involvement.  One of the surprises with the BLM protests have been the number young people in attendance, of all races.   Pew Research Center recently profiled Gen Z, finding them more ethnically and racially diverse, more education, more tech savvy, and, politically, "progressive and pro-government." 

Political strategist Tim Fullerton told The Washington Post: The bigger story, long-term, is that it’s really impressive to see young people using TikTok as an organizing tool. And I do think that we're going to see a lot of that in the lead-up to November. That's a difficult audience to reach, so it could be a powerful tool.  They’re using their voice in a new and different way and engaging people.  They clearly did something that hadn’t been done before.

All that is great, but it doesn't mean Gen Z is also leading the charge on healthcare, even during the pandemic.  They're no more likely to wear masks than other age groups, and are less likely to get vaccinated for it once one is available.   In many states experiencing a resurgence of COVID-19 cases, young people are increasingly being the ones infected. 

Dr. Thomas Tsai, a professor at Harvard's School of Public Health, warns: We need to change our whole thinking about COVID-19 during this stage of the pandemic.  It's difficult to contain the virus physically because you have younger individuals, who may be pre-symptomatic or mildly symptomatic, who are going about their normal lives and reengaging with society."

Epidemiologist Dr. Judith Malmgren told NPR that reaching Gen Z is different: "They are not reading print media. You need to be on social media. You need to use short sentences. You need to use very direct messaging."  Another epidemiologist, Dr. Wafaa El-Sadr, added: "I think young people can potentially have a very, very valuable role if we can harness their energy and attention."

If.

This is the generation that is going to inherit our apathy towards climate change and huge budget deficits.  It shouldn't have to inherit our dysfunctional healthcare system as well.  If they are looking for big, important social challenges, well, Defund Health Care!

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)