My letter in response to Uwe Reinhart’s post: Purging Healthcare of Unnatural Acts

http://thehealthcareblog.com/blog/2017/01/31/purging-healthcare-of-unnatural-acts/

Uwe,
You put up a paper tiger and layer in some funny numbers without self-scouting the issues of abdicating risk management on the community rating side. Or that of forcing payments to the delivery system via commodity-assuming claims codes with prices set centrally by structures like the RVU and ICD code definitions (and randomly adjusted by payer mix and large enterprise negotiating power vs say the quality, service, or effectiveness of the actual care being provided in that particular interaction to that particular patient/ family).

In a world of big data, the ability to process insurance claims and run numbers isn’t particularly complicated or expensive…it’s not a bunch of actuaries with pieces of paper and slide rules any more. A lot of that can happen on a server not much more powerful than a laptop. And MLR %’s might go down…which would be fine if premiums have gone with them (I have no problem with a scaled back system that has 30% admin cost at $200/mo premium ($60 absolute) vs. a 15% admin cost at $1000/mo premium ($150 absolute)…I care about dollars out of my pocket that I can use for other things.). If you want to stick with relative ratios, you might want to consider working more closely with the pharma companies (and ignoring Numbers Needed to Treat (NNT)).

It’s not a joke, real absolute costs do matter. And community rating comes at a multiple bankrupting the entire country due to the flawed application of the insurance model as a cost-shifting/ obfuscating tool. Are you as shocked and awed at a bronze plan costing 3X what the pre-Obamacare version cost as I am (for a family in Alaska premiums skyrocketed from $11.6K to $34K…pocket change and rounding errors on the edges this is not): https://www.adn.com/alaska-news/health/2016/10/13/citing-consumer-pressures-premera-holds-onto-pre-obamacare-plans/

But I can’t say I’m surprised. We already knew this back in the 90’s when the young invincibles couldn’t afford plans in community guarantee states but they were cheap $75–100/mo everywhere else). https://www.nihcm.org/pdf/EV-LoSassoFINAL.pdf
But then again people not wanting to be suckers in a bad deal didn’t stop this horrible idea… someone came up with the bright idea of foisting them on their parent’s plans.

You’re right in that its hard to manage risk. Policies would likely be more like life insurance, with riders, and in the era of sensors could use things like telematics to reduce risk, ie how you’re seeing crash reduction (leading to substantial premium reduction) in young drivers in the UK https://www.theguardian.com/money/2016/mar/26/black-box-car-insurance-cuts-young-drivers-premiums

More importantly, we’d stop starving the delivery sector of margin & volume for things that work. It’s a heartbreaking thing that known programs like Arnie Milstein’s at Boeing still struggle in the wilderness despite reducing costs 20% in the sickest 20% (that drive 80% of the overall cost). http://www.commonwealthfund.org/publications/newsletters/purchasing-high-performance/2011/march-29-2011/case-study/boeings-nurse-case-managers

Or that most of what Michael Millenson described so eloquently back when I was in medical school (back in the 90’s) in terms of efficient and effective programs still have yet to scale past hospital politics. http://www.press.uchicago.edu/Misc/Chicago/525872.html

Or that programs like Dartmouth lose millions of dollars due to the poor design of the very programs that should be scaling them (instead of bankrupting them) http://www.benefitspro.com/2016/09/12/dartmouth-drops-out-of-aco-program

Or that we don’t have a quantifiable definition of health that show that programs actually accomplish something (we started to create one while I was at the X PRIZE Foundation before the ACA killed our effort with WellPoint to showcase new ideas generating 50% more bang for the health $ via a competition): https://www.dropbox.com/s/vbdrxiu6ufp9qpw/Measurement%20approach--current%20state_July%2017.pdf?dl=0

Or that clinically proven models for treatments that don’t involve surgery or drugs to solve for lifestyle driven risks still are on the periphery despite trials showing heart disease can be reversed (Ornish)
https://www.ornish.com/wp-content/uploads/Intensive-lifestyle-changes-for-reversal-of-coronary-heart-disease1.pdf

It’s startling that the core primary care system that once offered the bedrock relationship between doctor and patient and offers the most cost-effective and highest satisfaction care has been reduced to $37 Medicaid reimbursement (gotta love that Medicaid and CHIP expansion generally arbitrages the income of primary care docs trying to help) for 10 minute office visits with high rates of physician dissatisfaction and burnout due to regulatory/ paperwork burdens. Narrow networks in Obamacare plans have shredded those trusted relationships and turned physicians into data entry clerks.

We need to bring those relationships back. We’re seeing a surge in Direct Primary Care with cash-based primary care docs opting out of the insurance system (and hopefully we’ll see similar models go subscription in medical homes upstream for sicker patients/ chronic illness management). I’m rooting for them to win and for patients to scale back their insurance purchases into direct relationships with their chosen doctors, as their patients (and society with substantially lower insurance costs) will win with them.

We also need a model that rewards innovations that improve health and lower cost. I love that the Google guys are billionaires…they’ve changed life as we know it and made knowledge available to all. I love that Zuckerberg is a billionaire — he’s connected the world.

So where are the billionaires we celebrate in this space? Why can’t Dean Ornish or Rushika Fernandopulle become one for making care delivery better?

We see them in horribly clunky, interfere with talking to patients, don’t talk to each other, sometimes mix people up, want to make you poke your eyes out Health IT vendors http://www.forbes.com/forbes/2012/0507/global-2000-12-judith-faulkner-epic-system.html

Instead in a medical claims driven world still anchored in cost+ and RVUs MinuteClinic limps to a $170M exit instead of becoming a celebrated public company. The claims model has destroyed innovative business models in care delivery and will prevent our talented entrepreneurs from leveraging the great tools we see in tech.

This insanity has to end and we need to end the disintermediation of patients from caregivers that has turned us all into paper-pushing widgets.

Purging healthcare of community rating and commodity payments (or lets stop pretending pushing… was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

Beginning to calculate absolute likelihood to cause a negative health outcome would take a lot of the fear out of these potentially junky recommendations (and also counter the misleading relative effectiveness statistics we see coming out of pharma)

Really interesting! was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

It seems to me that the pendulum is swinging back to a more nimble and decentralized set of entities with more emphasis on execution relative to “big idea” rhetoric (with problematic execution, i.e. the European Union or the affordable care act). The idea and the sausage-making details of execution are often very different things.

Technological driver would be the increasing penetration of internet and social technologies that make it easier for groups to coalesce and the underlying cloud infrastructure that level the playing field for smaller organizations (and tend to make it easier for high talent members of larger institutions to want to leave and carve out their own thing)

I guess we’ll be able to tell when we look back a few cycles from now

Interesting framework. was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

Life outside the professional track in the cities looks very different…and it’s something that may be a foreign concept to those whose mental model revolves around an office with a desk job and controllable flows of work. It’s certainly not that in the ER or retail on Black Friday or uber / airport security on the week before Thanksgiving. And it’s definitely even stranger in the seasonal world of the farm or in the emergency driven world of the plumber or the Friday night spike for a chef.

Work is changing as the world and technology change reality. We left the folks in the Rust belt behind and they were understandably upset after successive administrations focused on financiers over everyday people. Smart minds need to be put to focus on helping them (and everyone in this country) see a path to a better future enabled by hard work and a bit of luck

Jason, great questions about why employment should look like and how we should measure it to focus… was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

As a M.D. who decided not to practice (I aspired to being a pediatrician but didn’t like what that meant you got paid for in the insurance era), I hope this is a positive step to affordable health in America. I previously worked on an initiative to get 50% more bang for the healthcare dollar by changing the way we conceive of health services and measure health and results…we had to stop our work on health system innovation outside the traditional boundaries of claims and insurance when Obamacare passed and made everything happen within first dollar insurance coverage within a very tight set of requirements.

Obamacare got caught up in trying to do deals with large institutions with large amounts of money at stake and there I think it failed. I don’t get much value out of health insurance if it crowds out the ability to pay rent or put healthy food on the table and it seems wasteful to pay $7000–$10,000+ in annual premiums up front (that are gone at the end of the year regardless of what I’ve used) just in case when I (and the median American) use at most a $500 of medical services a year or so (and say $1000 in allied health services out of pocket). I’d much rather pay much less and put the same money aside and build up reserves for when I actually need it.

Obviously things change for the 20% or so of people with chronic conditions and the very few % with catastrophic conditions — but why does everything applying to the other 80% get so complicated as a side effect?

Estimates say that only 10% of health is driven by medical care, so why am I being forced to spend so much on something likely to benefit me so little…especially when it crowds out things that could benefit me more…or have other priorities like education or transportation?

The Obamacare folks got so caught up in getting people to buy insurance that it forgot the point was to keep people healthy and take care of the sick…there are many other ways to get these things done than to mandate we all pay jacked up health premiums (designed with features that mapped to the most expensive insurance products in the country) via an insurance product. (note insurance products don’t actually deliver services…people and institutions do and they can do so in many different ways).

From President-Elect Trump’s 100 day plan:

Repeal and Replace Obamacare Act. Fully repeals Obamacare and replaces it with Health Savings Accounts, the ability to purchase health insurance across state lines, and lets states manage Medicaid funds. Reforms will also include cutting the red tape at the FDA: there are over 4,000 drugs awaiting approval, and we especially want to speed the approval of life-saving medications.

How might a Health Savings Account based system make health more affordable?

1. It could make for open primary care networks based on cash transactions (and inclusive of allied health alternatives)

I’ve never understood why I need to ask my insurance carrier which doctor I can go to. I want to pick one who believes in the same things I do (high levels of service, use of communications technology, use of data to prioritize issues and treatment, focus on cost-effective and time-effective solutions).

I believe in soft-tissue treatments from a myofascial therapist over drugs or advice from a doctor who has no medical training or experience in this area. I believe in spending money on good food and personal training over bariatric surgery. So why does an insurance company and outdated phone-book style physician directory(and not inclusive of physical, nutritional, exercise, etc) constrain those choices? And why can’t my doctor (or therapist or nutritionist) agree up front in the open market the price I will pay (vs I get a crazy bill after the fact)?

Today in fact a physician doesn’t set her own prices and can’t compete on service. Medicare and unelected specialist committees behind closed doors determine pricing for all health services in America, which is why we’ve made specialists rich and primary care docs poor and appointments default to 15 minutes at the office…crazy right? And they’ve made it so if you want to try alternative practice models you are completely locked out of the Medicare system for 2 years.

2. It could change the basis on how we pay for services

What if I pay my physician in cash from my HSA for a 1 hour in-depth consultation and options brainstorm and 2 followup facetime visits to set up my home equipment correctly? Or pay Sherpaa $40/ month for the majority of my primary care consultations? Or maybe its a few hundred dollars a month to manage a chronic condition with Iora Health. Or maybe I want to pay a small fee to enable secure virtual visits with OneMedical.

Do I really need to pay thousands (or tens of thousands) of dollars up front to an insurance company so they can limit my choices around treatment and stick me with massive and incomprehensible bills for everyday stuff after the fact?

3. It should change the basis of insurance in health

I do want insurance in case something bad happens. But I don’t want Big Brother insurance company to tell me what I can and can’t do. And suck up all the resources going into the system because they know better (when I having been on the inside know how little outside of billing codes they have to work with). So why can’t I buy a major medical catastrophic policy that covers very specific things and work with the government to ensure strong consumer protections on that product?

A limited product as described above should cost a fraction of the fully-loaded first dollar one that drove up premiums in Obamacare today

4. It should uncover the extent of transfer payments/ public subsidy required to the sick and the poor

I know poor people and really sick people are the most vulnerable in society. I think it’s important to help. I also think it’s important to separate out the financing of how we help the sickest and the most vulnerable rather than hiding it in the rest of the system and hoping the slosh (at $25K/family) works out. There are powerful and low cost ways to address care that are left out because we’re punting to the emergency system that’s ill-equipped to handle longer term care and more entrenched issues.

I treated a kid born mostly without a brain who had been on a ventilator the full 5 years of her life. She cost society $5M. The extent of her human capability was to roll her eyes and make a purring sound. She wouldn’t survive without human intervention to keep her attached to machines. Personally I don’t think this is appropriate or ethical care and I think it’s a waste of valuable resources that could be redirected elsewhere to people in need who would get much more benefit from them. And these cases/ stories are everywhere and happen everyday.

Do I know the right answer here? No way. Do I think what was happening was the right answer? No way…it was just kicking the can of hard decisions down the road forever…an abdication of responsibility with no path to figuring out the right decisions at a societal level.

5. It should bring down costs for everyday care

A primary care physician visit today involves a lot of wait for the patient in the waiting room of the physician (who also has to keep receptionists, medical billers, medical transcriptionist, and electronic record people on hand to meet insurance mandates for a payment that may end up being only $30–50). Imagine if, like meeting with any other professional, I could just pay on my card and get a human being who focused on addressing what I thought was important and could communicate in ways that were convenient.

The other “everyday” care circles around chronic care issues. To me that makes more sense as a subscription product with a monthly management fee than it does the piecemeal mess we see today with specialists acting in silos. But that’s how insurance wants to pay for it.

Path to Affordable Health: Making Primary Care (and the broader services marketplace) great again was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

Thankfully they were nice about my rudimentary javascript coding abilities and hopefully picked up the tips and hacks I had taken away from my few days at NG-Conf — I’d recommend checking out the YouTube videos posted and highlighted a number that I thought the community should check out below.

My key Takeaways from the conference

1. Angular 2 is here and large organizations are already in production
2. The core team and community have moved on…stuff will be back ported to 1.5 but expect Angular 1 to lose mind-share (and gain components)
3. Prepare to unlearn all the vocabulary you learned
4. Tooling makes all the difference between utter frustration and reasonable productivity

“Power-ups” — new things that add power Angular:

• Angular CLI
• Codelyzer
• Angular Universal

Entertaining and informative talks:

• The NG-Show
• Generative Art in NG2 (mind blown)
• Titanium Octopus (smoothest in-person demo I’ve seen with live coding and a minimum of snippets)

New Ways of doing things:

• Components Architecture + Lazy Loading
• Observables
• Animations in code vs CSS

Tooling:

• Intellisense (with Typescript)
• Augury
• Many others (Angular CLI, Gulp, Codelyzer, Zones, Protractor, etc, etc)

Here are the slides:

https://www.dropbox.com/s/f0j0ep6z6x1lnjk/ng-conf%202016%20redux.pdf?dl=0

NG-conf 2016 redux (slides) was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

But anyway, trying this Medium thing out. We’ll see if it sticks.

Moved to Medium (and return from 4 year hiatus) was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

English: Ruby on Rails logo (Photo credit: Wikipedia)[/caption]

I’m learning to program!

It’s taken a fair bit of work, but I’m finding that many of the concepts of strategy consulting map to the object oriented programming framework (Ruby on Rails in this case).

I was hoping that may be the case. Some initial similarities (and yes I know these stretch a bit):

• MECE (Mutually Exclusive, Collectively Exhaustive) == DRY (Do not Repeat Yourself)…everything goes somewhere but only once
• Pyramid Principle == STI (Single Table Inheritence)…make sure your taxonomies map in a logical fashion and make sure likes are at the same level
• Elegant communication means the output gets shorter, not longer

Initial resources I’ve used to explore:

• One Month Rails: Online class…was $20. Found it got me in enough to get started and then I needed to know waaaaay more…but it got me started for 20 bucks so it was a good value
• Ruby on Rails Tutorial by Michael Hartl: I’m most of the way through — I bought the screencasts. It’s really amazing to see the difference in my understanding in the video form vs. just the book. This is an amazing resource — like having a great coding teacher walking you step by step through the building of an application. I’m starting to understand why Khan Academy gets the results it does
• Ruby on Rails 3 Essentials by Kevin Scogland (Lynda.com): Great pair with Michael Hartl’s course — Michael takes you through the building of a website and shares rails concepts through applied learning — Kevin’s a great way to step back and get the higher level picture of the function and what it does/ how it works in a more holistic way
• Code School: Number of online courses to actually type in the code (e.g., Rails for Zombies). It’s good practice in applied learning — although I am a little frustrated by their engine not allowing you as much freedom as you may like…it’s kind of like when I took spanish with an ok teacher — she would mark me wrong when I answered in a less “regurgitative” way…however, it actually forces practice through regurgitation and taking the next straightforward step and that’s a good forcing mechanism to keep me from going down a rat hole
• Just signed up (still a bit advanced for me) RailsCasts — great place to see that I can do some more advanced stuff that is triggered by the current courses — helps me push a little further in exploring the approaches to solve the requirements to execute Chefalytics v1

Hope this list helps some of you learning to code in Rails — I’ve been stumbling along for a while wanting to do it and it feels great to know that I’ll be able to code soon if I keep applying myself!

Oh yeah, my other big stumbling block was that the Rails community doesn’t really support Windows, and so my initial stuff kept breaking. Bought a macbook and pace of learning has gone up substantially and frustration is receding.

Related articles

• Learning Rails in One Month

Beginning Ruby on Rails — Resources Explored was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

My initial project is to build a tool for my wife’s Los Angeles catering company to help her make it more scalable. At her volume, the app doesn’t need to scale to enable her to (lol). Essentially it’s creating an automated workflow that helps to plan the week’s work in the kitchen — to date this takes hours of cross-referencing across client jobs, recipes, staffing schedules, and inventory (largely in excel or paper) to generate:

• Staffing requirements (hours of prep work to be done)
• Order list — ingredients that need to be ordered
• Master prep list for week
• Individual prep list for each chef
• Packout list — to get the right food to each client event

Objective of the “Chefalytics” project is to utilize Ruby on Rails to streamline our kitchen ordering and production operations through more precise planning.

Next posts will focus on the journey through this project…stay tuned

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• Startup technology demystified

• From Python to Ruby: Mind Blown by Rails, the Framework

Beginning Ruby on Rails — Initial project to create chef production planning tool (Chefalytics) was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.

Back to blogging was originally published in From Medicine to McKinsey to Main St on Medium, where people are continuing the conversation by highlighting and responding to this story.