Why would health care look to startups for answers?

Several executives speaking at a recent 25th anniversary celebration for a health care informatics lab spoke hopefully about solutions that might be forthcoming from startups yet to be founded. This struck me as odd. A hospital is a huge enterprise (I learned that Children’s for example, has more than $2.3 billion/year in revenue). Health care is 18 percent of U.S. GDP (compare to 4.5 percent for Singapore where people failed to realize that they needed to take opioids 24/7 and also inhale medical marijuana).

When an industry is this big, why wouldn’t it be the biggest tech companies, e.g., IBM and Amazon, that deliver solutions? The current Epic system is clunky, but why wouldn’t the Epic research lab be the place where useful innovation happens? IBM and AT&T were slow-moving, but IBM Watson and AT&T Bell Labs were the main sources of useful innovation in their day, not a handful of engineers in a garage.

What has changed that we think it will be the startups that inherit the Earth and that fix what ails us? The availability of venture capital such that nobody capable of accomplishing anything wants to work for a straight salary anymore?

Separately, a friend who is plugged into Silicon Valley told me about the latest trend. VCs will try to fund a company around a bunch of former employees of a single big company, e.g., Xooglers (former coders on the Google plantation). This protects the VC from downside risk. No matter how lame the idea is or how poor the execution, even if the startup is a complete failure it will likely still be acquired by, e.g., Google, simply because the big company wants this set of employees back and they are known quantities. The VC fund will at least get most of its money back.

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The hospital 25 years from now: a tower of ICU

At a celebration of a health care informatics lab’s first 25 years, Boston’s most experienced hospital leaders came in to speculate on what an American hospital would look like in 25 years. The experts agreed that more procedures would be doable on an outpatient basis. So our hospitals would essentially empty out? No! They’ll be filled with people who are incredibly sick and whose cases are extremely complex: “A Tower of ICU.”

David Nathan, who graduated from Harvard Medical School in 1955 and eventually became Physician-in-Chief of Children’s and then President of Dana Farber, pointed out that it would be difficult to train young people in this kind of environment where there are no simple cases. (He also shed light on the economics: “You cannot make money doing research. And teaching is hopeless.”) John Halamka, a doc-turned-CIO, quipped “Don’t teach the Krebs cycle; teach the revenue cycle.” Sandra Fenwick, the CEO of Children’s (a $2.3 billion/year enterprise), said that hospitals like hers would see “far more complex disease,” with the simpler problems being handled at home, by primary care providers, and community hospitals.

What about information technology? Electronic health records haven’t resulted in the savings, efficiencies, or improvements that were promised by the vendors and the Obama Administration. In the rare cases when a data exchange is accomplished from one hospital to another, the treating physician is “flooded with useless data”. There is no practical way, currently, to pull just the relevant material from another institution.

Yet computers will be critical to treatment, the speakers believed. “The doctor will Google you now,” was the joke circa 2000, but machine learning will soon transform this into “The Google will doctor you now.” Diagnostic procedures are producing more data than a human can inspect. “The average number of CT slices used to be 30,” one physician said. “Now it is 300. A radiologist cannot look at 300 slices in 10 minutes.” (It was noted that Vinod Khosla predicts that 80 percent of doctors will be obsolete; perhaps we should listen to him since he was smart enough to leave Kleiner Perkins before Ellen Pao could have sex with him.)

How about payments? Atul Butte envisioned a realtime link from Epic to the payor and every order will be screened instantaneously as currently happens with credit card transactions. The doctor will order an expensive test and the insurer will immediately come back with “no.”

(You might ask how good a job hospitals and doctors are doing today. A Harvard-trained pediatrician at the conference said “Only once I had kids did I realize that all of the advice I gave to parents during my pediatrics training was bad advice.”)

What about the disastrous patchwork of private insurance, government largesse, uninsured and undocumented migrants, and self-pay surviving another 25 years? The panelists thought that we would enter the Glorious Age of Single-Payer rather than continue as an international rogue outlier. Germany was cited as a success story for single-payer (Wikipedia says that Germany has a “universal multi-payer health care system”).

Systems-oriented doctors have always loved aviation. See The Checklist Manifesto, for example. The docs at this meeting enjoyed the phrase “Care Traffic Controller” for the physician of the future, coordinating all kinds of services to benefit a patient. None of them seemed to have reflected on the fact that the primary function of an Air Traffic Controller is to separate planes, not bring anyone together.

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Business and software blueprint for a personal portable medical record

Good news: I can share with you a complete functional and business blueprint for how to make a personal portable electronic medical record.

Bad news: The plan is from 1994 and almost no progress has been made toward any of the goals set forth 25 years ago.

A slide for the Guardian Angel system appeared during a 25th anniversary celebration for a health care informatics lab that I played a small role in starting. From the big blueprint:

Current health information systems are built for the convenience of health care providers and consequently yield fragmented patient records in which medically relevant lifelong information is sometimes incomplete, incorrect, or inaccessible. We are constructing information systems centered on the individual patient instead of the provider, in which a set of “guardian angel” (GA) software agents integrates all health-related concerns, including medically-relevant legal and financial information, about an individual (its “subject”). This personal system will help track, manage, and interpret the subject’s health history, and offer advice to both patient and provider. Minimally, the system will maintain comprehensive, cumulative, correct, and coherent medical records, accessible in a timely manner as the subject moves through life, work assignments, and health care providers.

This would be awesome to have today and yet we are as far away from it, I think, as we were in 1994. Sobering!

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Why would isolated Eskimos get colds?

Welcome to cold and flu season, especially for those of you with kids in school.

The prevailing wisdom about colds is that the virus is passed from person to person, right? “Why can’t we cure the common cold?” (Guardian, 2017, about “a breakthrough”):

The only failsafe means of avoiding a cold is to live in complete isolation from the rest of humanity.

Eskimos in the pre-machine age came pretty close this “complete isolation” and yet, in The North-West Passage Roald Amundsen reported from Gjöa Haven, about as isolated as humans can be:

The return of the Eskimo again imparted a lively and variegated aspect to our little harbour. They came on board, as a rule, generally of an evening in great crowds to visit us or to introduce new friends. They were always gay and happy, and we became very good friends with them. It has always been believed that the air in the Polar regions is absolutely pure and free from bacilli; this, however, is, to say the least, doubtful, in any case as far as the regions around King William Land are concerned, for here the Eskimo nearly every winter were visited with quite an epidemic of colds. Some of them had such violent attacks that I was even afraid of inflammation of the lungs, and as nearly every one of them contracted the illness, it must in all probability have been occasioned by infection. Happily those on board the “Gjöa” escaped, but we certainly took due precautions. We had great trouble to put a stop to the spitting habit. The Eskimo are very bad in this respect, but when we had them some time under treatment they improved and paid more attention to our prohibition.

A bit later in the same book:

Summer is, one may say, rapidly succeeded by winter; the lakes freeze over, and the snow falls; but with the Eskimo there is a short period which may be described as their autumn, and as their most dismal season, just before the ice is thick enough to be used as building material. Superstition prevents them from lighting fires indoors. Their homes are, therefore, miserable in the temperature which then prevails, and they live in a raw cold, damp atmosphere, in which all, without exception, contract severe colds.

There was some travel among Eskimo communities back then, of course, but it often took so long that people would have gotten over their colds by the time they showed up at the destination settlement.

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True cost of Medicaid is 2X headline cost?

I recently attended a talk by the CEO of a hospital with $2.6 billion in annual revenue. She noted that patients on Medicaid are 40 percent of the census and that Medicaid pays only 50 percent of the cost of treatment. In order to at least break even at this not-for-profit, therefore, she has to charge privately insured patients enough extra to make the books balance.

(A doc who was formerly Physician-in-Chief of this hospital and then president of another hospital said “you can’t make money doing research” and, financially at least, “teaching is hopeless”.)

This might explain why apparently healthy people are paying such big premiums. “Employer Health Insurance Is Increasingly Unaffordable, Study Finds” (nytimes):

A relentless rise in premiums and deductibles is putting insurance out of reach for many workers, especially those with low incomes.

Instead, she quit her job last summer so her income would be low enough to enroll in Medicaid, which will cover all her medical expenses. “I’m trying to do some side jobs,” she said.

The average premium paid by the employer and the employee for a family plan now tops $20,000 a year, with the worker contributing about $6,000, according to the survey. More than a quarter of all covered workers and nearly half of those working for small businesses face an annual deductible of $2,000 or more.

Annual Medicaid spending is supposedly roughly $600 billion per year, about 3 percent of GDP. But if hospital-related charges are the majority of Medicaid costs and, in fact, the hospitals are recovering half of their expenses from unrelated privately insured patients, the true cost of Medicaid to Americans is closer to $1 trillion per year (about 5 percent of GDP, meaning that people who work 40 hours/week have to stay at work on Friday from 3-5 pm to pay for Medicaid).

Note that this off-books funding for Medicaid is done in a regressive manner since the money is extracted silently from all Americans with employer-affiliated or other private health insurance. I.e., the cost of a health insurance policy also contains a hidden tax to pay for about half of Medicaid (and also to pay for the uninsured who throw out the hospitals’ $100,000+ bills?).

[Anecdotally, we know plenty of folks in Massachusetts who are careful to refrain from earning more W-2 wages than the thresholds for public housing and MassHealth (Medicaid) eligibility.]

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Computational Health Informatics Program, 25th anniversary

It is sobering to think that I sat down and began writing a web interface to an electronic medical record system (the Oracle database at Boston Children’s Hospital) more than 25 years ago (see “Building national electronic medical record systems via the World Wide Web,” a paper from 1996).

Today is a celebration (agenda) of the 25th anniversary of the Boston Children’s Hospital Computational Health Informatics Program (CHIP). I’ll try to take some notes and write a blog post later about what I learned.

For at least 25 years we’ve had all of the tech building blocks that we’ve needed to implement almost any kind of IT support for health care. Yet in the US we have ended up with a unified database of every ad that we’ve ever clicked on and are discussing the possibility of a unified medical record.

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In 20 years, will anyone roll the dice on a naturally conceived child?

A human parent’s biggest fear is having a child with a genetic disorder (though the most commonly expressed fear on Facebook is of Donald Trump winning a second term!).

Technology is bringing us pretty close to eliminating this fear and giving us a bewildering array of options.

She Has Her Mother’s Laugh: The Powers, Perversions, and Potential of Heredity by Carl Zimmer reminds the reader of the diversity in sperm and egg cells due to meiosis:

In men, meiosis takes place within a labyrinth of tubes coiled within the testicles. The tube walls are lined with sperm precursor cells, each carrying two copies of each chromosome—one from the man’s mother, the other from his father. When these cells divide, they copy all their DNA, so that now they have four copies of each chromosome. Rather than drawing apart from each other, however, the chromosomes stay together. A maternal and paternal copy of each chromosome line up alongside each other. Proteins descend on them and slice the chromosomes, making cuts at precisely the same spots. As the cell repairs these self-inflicted wounds, a remarkable exchange can take place. A piece of DNA from one chromosome may get moved to the same position in the other, its own place taken by its counterpart. This molecular surgery cannot be rushed. All told, a cell may need three weeks to finish meiosis. Once it’s done, its chromosomes pull away from each other. The cell then divides twice, to make four new sperm cells. Each of the four cells inherits a single copy of all twenty-three chromosomes. But each sperm cell contains a different assembly of DNA. One source of this difference comes from how the pairs of chromosomes get separated. A sperm might contain the version of chromosome 1 that a man inherited from his father, chromosome 2 from his mother, and so on. Another sperm might have a different combination. At the same time, some chromosomes in a sperm are hybrids. Thanks to meiosis, a sperm cell’s copy of chromosome 1 might be a combination of DNA from both his mother and father.

A particular child of two parents, therefore, is just one choice from a near-infinite array of genetic possibilities assembled from the four grandparents. That’s what comes out when a baby is conceived naturally. What if parents were given the opportunity to choose from hundreds of possible outcomes?

In 2012, the Japanese biologist Katsuhiko Hayashi managed to coax induced pluripotent stem cells to develop into the progenitors of eggs. If he implanted them in the ovaries of female mice, they could finish maturing. Over the next few years, Hayashi perfected the procedure, transforming mouse skin cells into eggs entirely in a dish. When he fertilized the eggs, some of them developed into healthy mouse pups. Other researchers have figured out how to make sperm from skin cells taken from adult mice.

Nevertheless, the success that Yamanaka and other researchers have had with animals is grounds for optimism—or worry, depending on what you think about how we might make use of this technology. It’s entirely possible that, before long, scientists will learn how to swab the inside of people’s cheeks and transform their cells into sperm or eggs, ready for in vitro fertilization. If scientists can perfect this process—called in vitro gametogenesis—it will probably be snapped up by fertility doctors. Harvesting mature eggs from women remains a difficult, painful undertaking. It would be far easier for women to reprogram one of their skin cells into an egg. It would also mean that both women and men who can’t make any sex cells at all wouldn’t need a donor to have a child.

Today, parents who use in vitro fertilization can choose from about half a dozen embryos. In vitro gametogenesis might offer them a hundred or more. Shuffling combinations of genes together so many times could produce a much bigger range of possibilities.

But the implications of in vitro gametogenesis go far beyond these familiar scenarios—to ones that Hermann Muller never would have thought of. Induced pluripotent stem cells have depths of possibilities that scientists have just started to investigate. Men, for instance, might be able to produce eggs. A homosexual couple might someday be able to combine gametes, producing children who inherited DNA from both of them. One man might produce both eggs and sperm, combining them to produce a family—not a family of clones, but one in which each child draws a different combination of alleles. It would give the term single-parent family a whole new meaning.

Here’s a yet more science fiction-y possibility… The highest fertility among Americans is in the lowest income mothers, i.e., those who are on welfare. The government will be paying for 100 percent of the costs of any children produced by these mothers: housing, health care, food, education, etc. Once grown up, these children are likely to be low earners and therefore on welfare themselves (see The Son Also Rises). What if the government begins to run out of borrowing capacity and decides that it needs to fund future taxpayers, not future welfare recipients? The tendency to work and pay taxes is as heritable as anything else. So the government offers financial inducements to mothers who agree to abort children conceived with low-income men and instead incubate embryos provided by the government. Said embryos to be carefully screened such that the moms are almost guaranteed to have a physically and mentally healthy child and the government is almost guaranteed to get an adult that enjoys working and paying taxes.

Readers: What do you think? In 2040 or 2050 will there be anyone willing to roll the genetic dice by having sex and seeing what kind of baby comes out?

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Adventures in the U.S. health care system

In case of crazy weather on our Greenland-to-Alaska cruise (through what used to be called the “Northwest Passage” and is now the “Trump Global Warming (TM) Passage”), I decided to fortify myself with some scopolamine patches. A physician friend wrote me a prescription for 8 patches, each of which can last for three days, but sometimes they come off in the shower, etc.

Wikipedia dates the medication to 1881. The brand name patches were about $340. Thanks to the patent (presumably on the delivery mechanism) having expired, the generics are available for only… $275.

We pay the big $$ for Blue Cross/Blue Shield coverage, so I had the pharmacy run my card. Coverage was denied due to a mismatch in name/gender/relationship that could not be further explained. It was a Saturday, so calling Member Services was unsuccessful.

On Monday, I invested some time in calling Blue Cross, which invested some money in paying a woman to deal with me. She explained that the pharmacy had “rung me in” with two Ls in my first name and with a gender of “female” (of course I asked how many additional gender options there were and she was familiar with only “male” and “female”; where is the LGBTQIA enthusiasm?) It should be a $10 co-pay for a 30-day supply.

After visiting four different pharmacies, I found one that had two packages of the patches in stock. They said that the insurance company would pay them $154, which means that the total price would be $165 (a 40% discount off the $275 that would have been charged to the struggling uninsured person!).

To me this is a great example of how the 18 percent of GDP that is purportedly for “health care” is illusory in terms of benefits to Americans. Absent FDA regulation, the generic patches would have cost $20-40 (8 cost about $60 in the Canadian regulatory environment). It took a week and the efforts of multiple people to get this organized. As soon as the doc wrote the prescription, why didn’t the patches show up a few days later via a standard ecommerce retail process?

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Knee replacement in Mexico

It has long amazed me that the typical non-emergency medical intervention for an American does not start with a plane flight to a country in which medicine can be done efficiently.

“A Mexican Hospital, an American Surgeon, and a $5,000 Check (Yes, a Check)” (nytimes) is a story about a knee replacement that happens in the way that Econ 101 would suggest:

The hospital costs of the American medical system are so high that it made financial sense for both a highly trained orthopedist from Milwaukee and a patient from Mississippi to leave the country and meet at an upscale private Mexican hospital for the surgery.

Ms. Ferguson gets her health coverage through her husband’s employer, Ashley Furniture Industries. The cost to Ashley was less than half of what a knee replacement in the United States would have been. That’s why its employees and dependents who use this option have no out-of-pocket co-pays or deductibles for the procedure; in fact, they receive a $5,000 payment from the company, and all their travel costs are covered.

Dr. Parisi, who spent less than 24 hours in Cancún, was paid $2,700, or three times what he would have received from Medicare, the largest single payer of hospital costs in the United States. Private insurers often base their reimbursement rates on what Medicare pays.

Interesting, but it raises more questions than it answers, e.g., why aren’t all knee replacements done in a country where knee replacements can be done efficiently?

[Separately, note that the NYT informs us that Mexico is too dangerous for a caravan of Hondurans to dwell, which is why they need to continue across the southern border of the U.S. and claim asylum. But, on the other hand, the same newspaper tells us that Mexico is sufficiently safe and organized to serve as a meeting place for American surgeons and privately insured patients.]

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Another reason to abandon the suburbs in favor of the city?

If you’ve been on the fence regarding whether to give up the car-dependent lifestyle and move back to the city… “Lyme Disease Cases Are Exploding. And It’s Only Going to Get Worse.”:

Since 1992, the Cary Institute [Millbrook, NY] has been compiling a record of tick ecology that they believe to be the longest continuous study of this kind in the U.S. and possibly the world. … The process for counting ticks not affixed to hosts is called a drag — the researchers pull a one-square-meter sheet of fabric along the ground for 30 meters then tally the number of ticks affixed to it. Oggenfuss holds the Cary Institute record for ticks collected in a single drag: 1,700. As horrifying as that haul was — and it would, by extrapolation, put the tick population on the Cary Institute’s 2,000-acre campus at 2 billion — Oggenfuss is quick to note it was exceptional, and tick density is irregular. Her more conservative calculations of average tick populations, based on drags done during the same time of year (August, the larval peak), are only reassuring by comparison: upward of 20,000 ticks per acre, more than 100,000 on the Henry Control grid, and more than 40 million on the Cary Institute grounds.

Here’s the bottom line for American humans: “It’s estimated that 300,000 people contract Lyme every year in the U.S., with victims found not just in traditionally tick-heavy areas like upstate New York and Maine, but also in all 50 states and Washington, D.C.”

We dug our own Lyme-infested graves by burning fossil fuels:

Human-driven climate change is making tick season longer and tick country larger. As winters get warmer and shorter, ticks become dormant later in the year (if at all should it fail to fall below freezing) and active earlier.

But the disease started in Connecticut, which is much cooler than the southern U.S. Climate change is so powerful that it is spreading ticks and Lyme disease both north and south:

When Aucott joined Johns Hopkins in 1996, Lyme disease had been a mounting concern for a number of years, but conventional wisdom held that the illness would not spread south of the Potomac River. However, he soon began seeing case referrals from first northern then southern Virginia. Lyme is now endemic in North Carolina and has moved westward to Tennessee, Kentucky, and Ohio.

How about escaping both state income tax and Lyme disease by moving to Las Vegas (check Nevada family law first; the state takes a completely different approach to custody and child support compared to the typical winner-take-all U.S. state)?

That very scenario is playing out on the U.S.-Mexico border in Mexicali, where a particular clade of brown dog tick has caused a massive outbreak of Rocky Mountain spotted fever, which can be fatal in up to 30% of cases and causes more deaths than any other tick-borne disease in North America. … While ticks need moisture to survive, the common brown dog tick requires far less than most. This particular clade takes that to the extreme, suggesting its spread could be hastened by climate change. “This tick needs it hot and it needs it dry. This tick is rooting for global warming and drought,” Foley says. As places like California and Arizona become hotter and drier, the tick’s reach will expand, she says. To compound matters, research has shown that the hotter the temperature, the more aggressive this tick becomes. “You can actually do experiments and bring the temperature up and increase the bite rate of that tick,” Foley says.

How about simply live in the city? It would be tough to get bitten by a tick in Midtown Manhattan.

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