Nature vs Nurture

 

By, SAURABH JHA MD

My wife chooses sides in the nature-versus-nurture war expeditiously. When our children are polite, she credits her nurture. When they’re rowdy, she blames my genes. But the nature-nurture war won’t be resolved anytime soon.

The gene played a significant role in the great Indian epic, the Mahabharata. Karna, abandoned by his mother, Kunti, and raised by a charioteer, was taught warfare by Parashurama, a gifted teacher with a fiery temperament, who despised warriors and only taught Brahmins.

One day, Parashurama was asleep with his head on Karna’s lap. Karna was bitten by a scorpion but did not move, because he did not want to disturb his guru’s nap. Parashurama, who believed that Karna was a Brahmin, seeing Karna’s blood on the ground realized that he had withstood pain which only a warrior could abide. Parashurama cursed Karna that he would forget his knowledge of warfare when he most needed it. Karna later fought for the Kauravas in the Battle of Kurukshetra. Parashurama’s malediction helped Arjuna beat Karna, which sealed the victory for the Pandavas. Neither Karna nor Parashurama knew about the double helix. The gene is an abstraction which has stood the test of time.

The battle between nature and nurture was never resolved in Hindu mythology. Lord Krishna said that it was “karma”, not birth, which made one a warrior. Yet, Hindus believe in destiny. The Hindu caste system is an example of genomic segregation. As a child, I was counselled that it was unlikely, based on my track record and those of others from my caste, that I would excel in sprinting, throwing javelins, or competitive football. In fact, I received granular advice. My caste (allegedly, I’m a Brahmin) was not adept at entrepreneurship, either. We’re supposedly competent at only one activity – sitting examinations. I became a doctor, and I’m still sitting examinations. I’m unsure if my DNA determined my fate, or if nature locked nurture, that is nature became a self-fulfilling prophesy.

Generalizations hold statistical truths, although it is unclear if nature or nurture, or both, explains these truths. Siddhartha Mukherjee, the author of The Gene: An Intimate History, is a Bengali, known for their literary talents. Perhaps there’s something in the air of Calcutta, in its wild, unpredictable traffic, which draws Bengalis to writing. This is hard to countenance because, superficially, Calcutta looks like any Indian city; polluted, anarchic, yet with a certain order.

If so much is determined by the gene, is anything left to chance? Chance, it seems, favors the genomically prepared. What if chance, if the dice we cast, is also predetermined? Is will only as free as deemed by our nucleic acid overlords? The prospect is at once redeeming and condemning. The gene’s paradox, or genius, is that it belongs to no ideology. If the gene condemns man to certain actions, it also exculpates man from those actions. The gene is loyal to neither conservatives nor liberals. If destiny is encoded, if talent is predetermined, if I could never have become a sprinter no matter how hard I tried, the implications are profound. Perhaps society should, like the sorting hat in Hogwarts, sort me away from the talents that I will never realize. The conservative may rejoice that society is indeed hierarchical. The progressive may feel justified that criminal inclination, for instance, is not the fault of the criminal. Even the egalitarian can take solace in the gene, for is not equality before destiny the ultimate equality?

The gene has a sordid past. Crystallizing twentieth century totalitarianisms, Mukherjee talks about two regimes that took genetic determination to a reductio ad absurdum. The Nazis believed genetic determination was everything; the Bolsheviks believed genetic determination was nothing. The Soviets and Nazis fought over genetic destiny in a war, ostensibly about control, but really between two competing ideologies of what made man, man, what made utopia, utopia. Stalingrad hosted the bloodiest war between nature and nurture.

The gene inspired not just tyranny, but social justice in its most perverse sense – the eugenic movement. Eugenicists, such as Francis Galton, Ronald Fisher, H.G. Wells, dreamt of making society more efficient by genetic centrifuging, or selective breeding. It was actually the dismal economist, Thomas Malthus, who sowed the seeds of eugenics, by prophesizing a doomsday when food would be in shortage because the species would multiply logarithmically. Malthus realized that the first casualty of famine would be the destitute. The eugenicists wanted to spare the poor from their destiny, by removing them. In an ironic twist, the gene thwarted Malthus’s prophesy by allowing itself to be modified in crops, leading to abundance of food and saving Malthus’s hungry generations from starvation and civil war.

Racial hygiene was taken to an uncompromising level by the Nazis. Though unable to stem the tide of the Nazi massacres, the gene threw Nazi ambitions to the wind because the characteristics which the Nazis wanted to propagate – intelligence, physical strength and cunning – are polygenic. This means that more than one gene is responsible for any characteristic, and any gene is responsible for more than one characteristic. The gene may be selfish but it is also fickle, frivolous and temperamental. To distil the gene to perfection is to render it ineffective. Nature, it seems, has a bias towards nurture.

In Aldous Huxley’s Brave New World, the Director of Hatcheries, the only person who self-evidently retained insight in the dystopia, boasted about mass production of embryos by the Bokanovsky’s Process, which yielded the right number of alphas, betas and epsilons, to carry out the labour in the country. Even in Huxley’s dystopia the gene, though necessary, was not sufficient. The babies had to be conditioned. Those destined to manual labor were conditioned to loathe reading books. The conditioning was nuanced because the laborers had to love the outdoors but not the countryside. The director achieved this by making them repelled by flowers but attracted to sports.

Huxley was a realistic dystopian. He once said that modern medicine was so advanced that scarcely a healthy person would be left behind. This was before genetic testing became cheaper than health insurance. Mukherjee reframes Huxley’s statement into a primal question: what does health and disease even mean? As the gene continues to spurn information, we will be given our chances of developing certain diseases, such as cancer and Alzheimer’s disease. This will shift disease from a certainty in the present to a possibility in the future. If our genes roll the dice, will disease be a roll of the dice? Will statistics maketh illness?

H.G. Wells was a more visceral dystopian than Huxley. In Time Machine, he imagined a society which bifurcated into Elois and Morlocks. The Elois were effeminate, emotionally restricted, and in permanent ennui. The Morlocks were not particularly endowed, feared light, but ate Elois. Wells extrapolated 19th century class distinctions took the nature-nurture duo to its logical conclusion. The gene alone did not produce the light-phobia in Morlocks, it was the deprivation of light over several generations. Wells might have been alluding to the most interesting and controversial part of Mukherjee’s tome – epigenetics.

Epigenetics is a plot twister in the nature versus nurture war. Researchers found that starvation changed the genome of Dutch survivors in the Second World War. Children of the survivors produced proteins which protected the body from acute starvation. The environment can leave an indelible mark on the gene. Nurture refuses to be forgotten. The gene is here to stay. The greatest challenge is in accepting the benefits of genetic knowledge, such as gene therapy for inheritable diseases like Huntington’s Chorea, while assuaging fears of parents using gene editing to produce “designer babies.” Mukherjee goes to great lengths to show that our fears, though understandable, are exaggerated.

The battle between nature and nurture cannot be won by any side because, as Mukherjee puts it in an elegant equation: Phenotype (what we are) = genotype (gene) + environment + triggers + chance. That chance still has a role means that choice, the harbinger of chance, is not dead.

Charles Murray, in Coming Apart, warns that American society may irreconcilably be transforming from a class to a caste system. Murray notes an emerging phenomenon in American society: educated professionals marry educated professionals. American society is being garrisoned in much the same way as the Indian society once was. Murray’s premise lies in the highly controversial inheritability of intelligence – intelligent couples have intelligent children. Murray fears that if intelligence becomes segregated, so does society. Even if the inheritability of intelligence is exaggerated, nurture can produce the same effects as nature. If the habits of the Boston Brahmins are systematically different from the folks in America’s Rust Belt, so that their children are more likely to become doctors and lawyers, nurture will ossify society as surely as nature can.

I’ve dissuaded my children from throwing javelins and playing American football, and forced them to focus on chess, spelling, mathematics and literature. The apple doesn’t fall far from the tree. I blame their gene. But their gene may be incidental, an innocent scapegoat, in nurture’s perennial conformity with nature.

 

This piece originally appeared in The Telegraph.

Saurabh Jha is a contributing editor to THCB. He can be reached on Twitter @RogueRad

 

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Would Repealing the ACA Violate International Law?

By DAVID INTROCASO and JASON CHUNG

Barely one month after a stinging and stunning legislative defeat, President Donald Trump has committed to revising the AHCA and potentially resubmitting it for Congressional approval.

In addition to Democrats and widespread popular opinion against ACA repeal, the AHCA may face another obstacle – international law.

This week the Washington Post’s Dana Milbank reported that the United Nations Office of the High Commission on Human Rights forwarded a four-page letter to the Acting Secretary of State, Thomas A. Shannon, to express the Commission’s “serious concern” that the US was in danger of violating its obligations under international law if the U.S. ratified legislation repealing the ACA.

The letter authored by Dainius Puras, a Lithuanian with somewhat remarkable title of UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, argues that repealing core elements of the ACA would negatively impact almost 30 million Americans’ right to the “highest attainable standards of physical and mental health”, particularly those in moderate and low income brackets and those suffering from poverty or social exclusion.

While we in the United States debate whether health care is a right or a privilege, Puras cites U.S. international treaty obligations as authorities for why health care is a right. In particular, he argues that Article 25 of the Universal Declaration of Human Rights (UDHR), a Declaration which the US voted for and had a key role in developing, clearly “establishes everyone’s right to a standard of living adequate for the health and well-being, including food, medical care and necessary social services”

He further cites other similar provisions in international treaties, conventions and UN Committee comments including Article 12 of the International Covenant on Economic, Social and Cultural Rights (ICESCR) (signed but not ratified by the U.S.), article 5(e) the International Convention on the Elimination of All Forms of Racial Discrimination and General Comment No. 14 of the Committee on Economic, Social and Cultural Rights as proof of states’ obligation for a “progressive realization of the right to health” for all.

The letter concludes by asking the Trump administration to respond to four questions:

Not surprisingly, the Trump  administration has failed to respond.  According to Milbank, the letter was leaked to Congressional Democrats by a DHHS employee.

Does this mean that President Trump, or members of his administration, will be dragged before international courts?  No.  The UDHR is declaration by the UN General Assembly and doesn’t legally bind member-states, the U.S. never ratified and acceded to the ICESCR and while the U.S. has ratified the ICEAFRD, it does not recognize article 22 which provides that disputes be referred to the International Court of Justice.  President Trump can therefore probably rest easy in knowing that the long arm of the law is actually relatively short – at least in an international context.

But while public international law suffers from problems of applicability and enforceability, it still holds considerable political and moral authority in the international realm and helps provide a common aspirational foundation for UN member-states.  In the past, the U.S. has been a champion of key international legal instruments advanced by the UN and, in fact, the U.S. Department of State , still states that two of its key human rights goals are to:

•    Hold governments accountable to their obligations under universal human rights norms and international human rights instruments; and
•    Assist efforts to reform and strengthen the institutional capacity of the Office of the UN High Commissioner for Human Rights and the UN Commission on Human Rights.

Although the President may not be a fan of the UN, even he recently expressed that it has “huge potential. ”  Part of that potential is realized when the UN can compel states in meeting treaty obligations for the purposes of working towards a common goal of peace, security and prosperity.

For this reason, the U.S. should bolster the UN by addressing its concerns about possible contravention of international law.  This relatively simple approach may ensure that the U.S. can leverage the UN in securing its long-term interests in other areas.

Footnote:
This is not the first time the US has been in conflict with UN efforts to safeguard human health.  Readers of THCB will recall from my the February 7 post, “Hell Is A Very Small Place: Voices From Solitary Confinement,” the UN Special Rapporteur on Torture, Juan E. Mendez, noted in 2011 that solitary confinement, that in the US isolates prisoners for decades, be limited to no more than 15 days and be absolutely prohibited for those with mental disabilities and juveniles.

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Can Interactive Group Therapy Boost Productivity in Medicine?

By DEVON HERRICK

Imagine attending private lectures and taking all your college exams in your professors’ offices individually, one-on-one. Your instructors lecture you, then pepper you with questions, grading your answers and recording your scores. This is not unlike traditional physician visits. Contrast this to attending classroom lectures and taking online multiple choice exams where a computer algorithm or Scantron tallies your answers and calculates your grade. Classroom instruction with standardized testing is much more efficient that private tutoring. Hundreds of students can learn and take their online exams simultaneously. What if medical productivity could be similarly improved?

Inefficient Physician Communication. When you visit your doctor you are engaging in what’s known as synchronous communication. You queue up in a waiting room and later both you and your doctor meet one-on-one in an exam room (at the same time). You may spend five minutes talking to a nurse and then 10 minutes talking to a doctor. A survey found with waiting and travel time, the whole process takes patients about three hours, on average. Furthermore, many doctors see only about 20 to 25 patients a day. The amount of information conveyed during an office visit is limited — as is the amount of information patients retain. Doctors also must take notes and update medical records during the exam. Fiddling with electronic health records further reduces the amount of useful information exchanged during a 10-minute encounter while your doctor hunts for pull-down menus. The way medicine is practiced is inherently labor intensive, not to mention inconvenient for patients.

Synchronous telemedicine is where you call your doctor or he/she calls back and you talk one-on-one. That may be a little more convenient for patients, but it’s still labor intensive. Asynchronous telemedicine is like email (or snail mail for that matter). You email your doctor or call your doctor and leave a message. Your doctor replies via email or by leaving voicemail. Asynchronous communication doesn’t require both parties to be present at the same time to communicate, but the information flow back and forth can be slow and inhibited compared to talking.

Medical Automation. Mercatus scholar, Robert Graboyes, writes about Lemonaid Health, a type of asynchronous telemedicine on steroids. (Lemonaid Health charges a flat $15 for a prescription for handful of common ailments.) He explains some medical services require one-on-one time (think an initial visit for a diagnosis), while others can be quickly performed through a series of interactive processes. The latter are scalable; aided by a computer algorithm, one doctor could oversee the care of many times more patients than possible if limited to one-on-one office visits.

Now for a thought experiment: imagine logging-in on your doctor’s office website, then being examined by answering questions from an interactive menu. The website algorithm then generates a treatment plan based on your responses for a chronic disease like, say, diabetes. Your doctor could review the results and approve your treatment plan, order prescriptions and maybe insert some specific advice much more quickly than using the traditional synchronous communication (office visit) model. At least in theory, a doctor performing the cursory evaluation of the automated treatment plan could be located anywhere in the world.

Computer-aided diagnostic tools for physicians already exists. Most mammograms are initially read by computer algorithms, highlighting areas where there may be problems or uncertain indications for a radiologist to interpret. An alternative method requires two different radiologists to validate individual interpretations. One radiologist using one computer is more efficient than two redundant radiologists using no computer.

Strength in Numbers. Now let me expand on Bob Graboyes’ discussion. Numerous diseases have support groups, where people suffering with the same disease or condition shares stories and exchange information on symptoms, treatments, doctors and so on. Nowadays most support groups are online. Members may never actually meet in person, yet benefit tremendously from interacting with others. Not only can people exchange ideas, the discussion thread is archived online for others to read and learn from long after the initial exchange occurred.

Group therapy is therapy sessions provided to educate a group of patients rather than each individually. It is most common in environments where sharing the experience of others with similar conditions is beneficial or peer pressure is needed to improve outcomes. Overweight people have group therapy: it’s called Weight Watchers. Addicts have group therapy: it’s called Alcoholics Anonymous or Narcotics Anonymous. People with mental health conditions used to have group therapy (simply called, group therapy). Think back to the old Bob Newhart Show in the 1970s. Half a dozen comically-neurotic characters, with a garden variety of mental health issues like depression, anxiety or phobias, would all arrive for a group session at a scheduled time. They would sit around for an hour and each take turns sharing their neuroses while validating each other’s feelings.

I actually attended a group therapy session of sorts the other day. My dog’s veterinary behaviorist charges $150 an hour to evaluate canine behavior problems. Initial evaluations take about two hours. The veterinarian periodically sponsors group sessions where dog owners can come as a group and listen to a presentation on some aspect of dog behavior. The events last about two hours and admission is only $15. Dog owners can learn more from these $15 seminars than most could afford to pay the vet one-on-one.

Interactive Group Therapy. Now imagine rather than a diabetes online support group open to the public, members are enrolled in an exclusive telemedicine group therapy program. Members could share a name or nickname and discuss or message other members privately. However, most interactions would be shared among the entire group. Doctors would monitor the group’s interactions and correct bad information. A physician or nurse practitioner could check metrics that are entered on a periodic basis (weight, blood glucose, activity levels, medications taken, etc.). Based on the inputs and interactions, physicians would review the automated treatment plans, update the medical record and prescribe medications electronically. People who don’t participate might be contacted by others in the group, a nurse or the computer system. Such a system could upload some metrics (e.g. weight and blood glucose levels) using Bluetooth. Members could share recipes, eating habits, exercise regimens and generally support each other’s efforts — all while under medical supervision.

Interactive group therapy could easily work in a Direct Primary Care practice to replace in-person routine physicals and wellness visits. I could sign up with my doctor alongside a thousand other guys. We could watch our doctor’s YouTube videos on wellness, the importance of maintaining proper weight, blood pressure, cholesterol and so on. We could routinely upload information on weight, blood pressure and any concerns we have. Our physician could follow up if needed for a nominal fee. Perhaps once or twice a year we could have blood drawn to check cholesterol, hormones, liver kidney, etc. Any readings out of the normal range would alert the doctor, who could call in a prescription or call us in for a one-on-one evaluation.

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GuideWell Wants Your Opinion: Deadline Tomorrow!

By CHELSEA POLANIECKI

It goes without saying that a cancer diagnosis is daunting, terrifying and can be completely life-altering. With approximately 40 percent of men and women being diagnosed at some pointduring their lifetimes. cancer changes a survivor’s life from one-minute daily activities to grand life decisions. GuideWell Innovation is committed to bringing great minds together to facilitate and transform new ideas into solutions, helping to jumpstart the path to better health. With the launch of the GuideWell Cancer Challenge this past February, GuideWell is harnessing the strength of collaboration to help support cancer patients and survivors with concierge services to support the wide range of needs of living with cancer.

The challenge deadline is nearly here, but it’s not too late to make your mark. We want to hear from you! Simply register or log in to the challenge website to submit an idea for a service, share insights about living with cancer, or view ideas submitted by others. You can then VOTE or COMMENT on any submitted idea. And get this—you don’t even have to submit an idea to be eligible for a prize! Just by providing your thoughts and insight on a submission you can enter the competition for cash prizes ranging from $1,000 to $5,000.

The challenge has received unique ideas addressing various cancer patient needs and promoting vital support for people living with cancer. On March 30, we hosted a webinar answering key questions about how to get involved (view it here). Submissions thus far include a wide range of services and insights including app and web-based platforms designed to monitor and identify cancer diagnoses and support for finding treatment and nutrition information.

The deadline to participate in the challenge is TOMORROW, Friday, April 28, 2017. The GuideWell Innovation steering committee will then begin to review and evaluate all submissions and comments. If we bring our minds together we can work to mitigate the issues and improve the experience of living with cancer. With just one click, you can help make a difference in the lives of those who live, and will live with cancer.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

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The Return of the Angry Granny State

By CHARLES SILVER

Texas should call itself The Granny State. That’s because it’s a nanny state in which the public officials who run the place have the values of a tea-totaling, Bible-thumping biddy who knows how God wants everyone to live and can’t resist telling them. No buying liquor on Sundays when people are supposed to be at church. No gambling ever. No whacky-weed for medicinal uses or recreation, even in the privacy of one’s home. No gay marriage, preferably no gays, and no transgender folk deciding which restrooms to use. And, of course, no sex, sex education, birth control, or abortions. Women should have sex only in marriage and then only to reproduce, and those who get pregnant must carry their babies to term, regardless of the consequences for themselves or anyone else.

These religion-inspired policies have served Texans poorly. The state’s maternal mortality rate nearly doubled in just two years after Texas cut its budget for family planning by two-thirds and eliminated funding for Planned Parenthood clinics. It’s now the worst in the developed world, not just in the US. Texas ranks 8^th from the bottom in the frequency of STDs and has the 5^th highest teen pregnancy rate too. Its 35 births per 1,000 girls aged 15-19 are nearly double the national average. Meanwhile, Colorado and other states have achieved miraculous reductions in teen pregnancy rates and abortion rates by providing young women with long-acting contraceptives, like implants and IUDs. If Texas is following God’s plan, then God’s plan is a bust.

Now Granny is once again sticking her nose where it doesn’t belong. Currently before the Texas legislature is Senate Bill 25, which would eliminate the wrongful birth cause of action that the Texas Supreme Court recognized four decades ago in Jacobs v. Theimer. The facts were as follows. While traveling, Dortha Jacobs became ill. Upon returning home, she consulted a physician, Dr. Louis Theimer, who discovered that she was newly pregnant. Fearing that the illness was rubella—also known as the German measles—Jacobs asked Dr. Theimer if there was reason for concern. Rubella can injure a gestating fetus severely. Dr. Theimer told her not to worry, but he did so without performing an available diagnostic test. In fact, the disease was rubella and the child “was born with defects of brain, speech, sight, hearing, kidneys, and urinary tract,” among others. The medical expenses were extraordinary.

The Jacobs sued for medical malpractice. In defense, Dr. Theimer argued that his mistake could not have harmed them. When Mrs. Jacobs became pregnant, the US Supreme Court hadn’t yet decided Roe v. Wade and abortion was illegal in Texas for all purposes except to save the life of the mother. Because the baby’s defects did not endanger Mrs. Jacobs, Dr. Theimer contended that abortion wasn’t an option for her. She’d have had to deliver the baby even if he had identified her illness correctly. Therefore, she and her husband would also have had to bear the infant’s medical costs.

The Texas Supreme Court disagreed. Abortion was illegal in Texas, it reasoned, but the procedure was lawful elsewhere. Consequently, Dr. Theimer had to give the Jacobs the information they needed to choose among their available options, including the option of having an abortion performed in another state. By misdiagnosing the illness, he therefore caused their loss and was on the hook for the extraordinary medical costs. (To be clear, Dr. Theimer was not responsible for costs the couple would have borne in the course of raising a healthy child. A healthy child is regarded as a gain, not a loss, even when a pregnancy is unwanted.)

SB 25 would eliminate the wrongful birth cause of action by making it impermissible for anyone to recover damages by claiming that they would have terminated a pregnancy instead of carrying a baby to term. The bill provides that “[a] cause of action may not arise, and damages may not be awarded, on behalf of any person, based on the claim that but for the act or omission of another, a person would not have been permitted to have been born alive but would have been aborted.” Had the bill been law in 1975, the Jacobs would not have been able to argue that, but for Dr. Theimer’s negligence, they would have aborted the baby. They’d have had to pay for all the surgeries and other treatments the child needed, expenses that, today, would into the millions.

SB 25, which offers parents in the Jacobs’ position no financial help at all, has already passed the Texas Senate and seems bound to pass the House. Its success is assured because, politically, it is a two-fer. Texas’ Republican lawmakers are eager to free doctors from financial responsibility for medical errors and to advance the Christian right’s anti-abortion agenda. SB 25 does both.

The bill will cause problems, though, first and foremost because it allows medical providers to make errors with impunity. Given the frequency with which mistakes occur, Texas’ leaders should be strengthening the incentives providers have to exercise reasonable care, not emasculating the state’s already-weakened malpractice liability system.

 

The wording of SB 25 is also too broad. Suppose that a woman with a defective uterus becomes pregnant, that her ob-gyn negligently fails to identify the defect, that late in the pregnancy her uterus ruptures, and that the woman dies or is severely injured. If SB 25 becomes law, neither the mother nor her survivors will be able to recover from the ob-gyn. Their claim would be that, but for the doctor’s mistake, the mother would have protected herself by aborting the fetus instead of carrying the baby to term—precisely the claim that SB 25 would forbid. The bill would thus eliminate civil liability for negligence committed in the one context where abortion has always been lawful in Texas—to protect the life of the mother.

 

There’s no need for the bill either. In 2003, Texas eliminated the possibility of excessive damage awards in medical malpractice cases by capping patients’ damages. Both the number of malpractice claims and physicians’ insurance premiums are at historic lows. Wrongful birth cases are rare too. Although the available data do not quantify them precisely, a study by The Doctors Company finds that most malpractice claims against obstetricians involve delays in treatment of fetal distress or improper performance of vaginal delivery. Wrongful birth claims are brought too infrequently to have their own category.

 

SB 25’s supporters are offering two types of argument in support of the proposal. One is the worn-out assertion that the bill will attract doctors by making Texas a safer place for them to practice. Texas is already one of the most doctor-friendly states in the US—Emergency Physicians Monthly ranks it among the top four—and the assertion that tort reform brings doctors into the state has been thoroughly disproven. Texas’ leaders should be ashamed of themselves for repeating this falsehood.

Another argument is that wrongful birth lawsuits insult disabled persons by telling them that they would have been aborted had their parents known of their impairments. This is an example of good intentions gone astray. In all lawsuits, parties say unpleasant things about others. Plaintiffs accuse defendants of neglecting duties, committing frauds, breaking agreements, and being dishonest. Defendants accuse plaintiffs of spouting falsehoods, exaggerating injuries, and being responsible for their own losses. One wishes that civil justice could be delivered with fewer insults, but it is a blood sport and always will be. The main point, though, is that parents of children borne with serious defects need resources. Only with those in hand can they love their children and provide for them too. When the choice is between a dignitary loss and the money with which to pay for life’s necessities, the decision is easy, even if it is also made with regret.

 

Charles Silver is a professor at the University of Texas School of Law and a co-author of After Obamacare: Making American Health Care Better and Cheaper (forthcoming 2018).

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The Fairy Tale of a Non-Profit Hospital

By NIRAN AL-AGBA, MD

Nonprofit hospitals have higher profit margins than most for-profit hospitals after accounting for their tax obligations.  3900 (62%) of U.S. Hospitals are non-profit and therefore tax-exempt: they pay no property tax, no federal or state income tax, and no sales tax.  An article published in Health Affairs found seven of the nation’s 10 most profitable hospitals were of the non-profit variety, each earning more than $163 million from patient care services. Revoking their property tax-exempt status for not functioning as a charitable entity could return billions in healthcare dollars to local government, communities, and citizens, struggling to afford quality health care.

The idea of exempting nonprofits from paying taxes in the first place is based on the belief these entities provide charity for the underserved and underinsured who would otherwise require the government to lend a helping hand.  As the percentage of uninsured declines as a result of the ACA, the justification for tax exempt status is being called into question.

Many nonprofit hospitals calculate their charitable care by using something known as “charge master” pricing; exorbitant, non-negotiated prices which are inflated many times higher than what private insurance or Medicare would pay.  This allows facilities to overstate their provision of “charity care,” calculated as revenue loss by the hospital in exchange for their lucrative tax exemptions. In a patient evaluated with chest pain, the allowable for Medicare is $3600; however, in an uninsured patient, the hospital may “write-off” an inflated $25,600 in uncompensated costs, which is 8 times higher than actual cost of care provided.  Nonprofit hospitals should be required to meet a higher standard by providing true (non-inflated) charity care.

A study, conducted by Zack Cooper (Yale), Stuart Craig (University of Pennsylvania), Martin Gaynor (Carnegie Mellon), and John Van Reenen (London School of Economics), evaluated the way nonprofit hospitals charge.  “Not-for-profit hospitals don’t price any less aggressively than for-profits. We subsidize not-for-profits to the tune of $30 billion annually, in the form of tax exemptions, and we have to ask what that money is getting us,” says Cooper, co-author of the study.

So what is the tax exemption getting us if not to “real” charity care for those in need?  A significant amount of nonprofit hospital revenue is being spent on executive salaries and benefit packages, reinvestment in new state-of-the-art facilities, and expanded healthcare services for those who can afford it.

According to Becker’s Hospital Review in 2012, the combined compensation of the top executives at the 25 most profitable non-profit hospitals totaled almost $58 million. The highest paid nonprofit hospital CEO in the nation is Jeffrey Romoff, at the University of Pittsburgh Medical Center (UPMC.)  An article in The Pittsburgh Post Gazette found his 2015 compensation was $6.43 million dollars; he has topped $6 million for the last four years, plus notable perks, such as access to a private chef, chauffeur, and a jet.  Additionally, the Gazette found 31 UPMC executives and physicians earned at least $1 million in 2015, six of whom received more than $2 million each.

In 2013, Pittsburgh Mayor Luke Ravenstahl unsuccessfully sued UPMC to collect more taxes on the grounds his city was losing $20 million annually as a result of the tax exemptions.  CBS News aired a segment after investigating the financial details.  UPMC brought in $948 million in profit over the 2 year period 2011-2012, while providing a mere 2% of its budget in charity care, and yet was saving $200 million after tax exemption. Imagine what that could pay for in the way of healthcare for the poor, disabled, and elderly, not to mention the funding for teachers, police officers, and firefighters?

The idea nonprofit hospitals should be paying property taxes has been gaining traction ever since.  In 2015, a New Jersey judge ruled that Morristown Medical Center should be responsible for paying property taxes because it acted more like a for-profit organization than one devoted to the provision of charity care.  He said, “modern nonprofit hospitals are essentially legal fictions;” kind of like a modern day fairy tale.  Ultimately, Morristown Medical Center reached an amicable agreement with the city to pay $1 million in the way of taxes, but multiple cities have followed suit, challenging the tax exempt status of nonprofit hospitals in the state.

Illinois is the latest battleground for the property tax exemption controversy.  A 2009 report by the Center for Tax and Budget Accountability found the property tax exemptions for 47 Chicago-area nonprofit hospitals were worth $279 million. In Illinois, a charity was originally defined as an organization generating revenue from donations and providing services to those in need.   In 2010, the Illinois Supreme Court ruled Provena Covenant Medical Center was not entitled to a property tax exemption because they were not a charity, as most of their revenue was generated from fees for service.

In 2012, the Illinois Hospital Association lobbied hard to expand the definition of charity in state law.  The state legislature passed a provision—buried in the Medicaid Reform Bill 2194– allowing property tax exemptions for hospitals providing charity care in the equivalent amount to their tax liability.  Medicaid reimbursements, considerably lower than private insurance payments, were allowed to count toward the “charity care” tabulation.

The Carle Foundation Hospital is the 10th most profitable hospital in the nation, according to the May 2013 article in Health Affairs.  They filed a request to have a property tax exemption after the controversial 2012 law was enacted.  The City of Urbana argued Carle had revenues approaching $2 billion annually, functioned more as a for-profit organization than nonprofit, and caused the city to lose $6.3 million in property taxes, necessitating a rate increase for other city properties as a result.  Last year, the 4th District Appellate Court ruled the 2012 state law unconstitutional.

Dissatisfied with the outcome, Carle Foundation Hospital appealed to the Illinois Supreme Court.  On March 23, 2017 the Supreme Court of Illinois vacated the ruling of the Appellate Court, but would not consider constitutionality of the 2012 law; Carle will be entitled to the property tax exemption for now.  The Supreme Court recommended reconsideration in the lower courts as to the question of constitutionality, so the debate remains ongoing.

The days of charitable establishments singularly devoted to comforting and caring for the poor and suffering are long gone.  Most nonprofit hospitals are vast profit machines bearing little resemblance to the charitable organizations of the past.  By reinvesting in state-of-the-art facilities with unnecessary “bells and whistles,” nonprofits are currently dominating city landscapes, becoming the largest local employers, and bringing in more revenue than the cities in which they are located.
By sidestepping property tax payments to the county or city in which nonprofit hospitals reside, they are shifting the financial burden for essential services and infrastructure onto the backs of individual citizens and small business owners, who should not bear the costs alone.  Stricter criteria should be applied to determine whether a hospital meets a “charity care threshold” in order to retain the lucrative nonprofit designation.  This is a vital step toward ensuring cities and counties collect adequate revenue for developed land, while ensuring vulnerable populations have somewhere to go when in need of healthcare, which is rapidly becoming unaffordable for us all.

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BTG buys Oncoverse–Amanda Goltz explains all

Amanda Goltz is a massive ball of energy in the world of digital health. For the past 2 years she’s been working for English pharma company BTG. But how does a pharma company get involved in health tech without wasting everyone’s time, and what exactly are they trying to do? Amanda certainly has both opinions and a plan. Today part of that plan became official with the purchase of Oncoverse, a cancer management program BTG has been working on with Wanda and Dignity Health. I spoke to her Monday morning my time to find out more (and yes, if you wait to the end, there is both a job “offer” and I have my own BBC Live home office moment!)

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The Sad Myth of the Direct to Consumer Startup

By LISA SUENNEN

Last week I had a startup entrepreneur come to me with an idea about how to “pivot” his company strategy. The company, which had begun as a medical device company but couldn’t quite find it’s market, was considering re-emerging as a consumer-focused digital medical device company in an adjacent market. The idea was to create a device to measure a serious medical condition and market it to consumers directly. Their plan was to target mothers who would be paranoid enough to spend money on medical devices to diagnose an issue in their children.

Imagine my heavy sigh.

Ever the heart-breaker, I had to tell this person that this strategy did not make any sense to me. As his target market representative du jour, I mentioned that there is no world in which I would trust myself to diagnose a major medical problem. Rather, if I even suspected a hangnail I would rush my precious princess straight to the doctor, do not pass Go, do not pay iTunes fees.

In fact, as I sat there explaining this psychology, I could not think of one single digital health company addressing a major medical condition that had successfully created a company by selling directly to consumers. If I am missing one, please do let me know in the comments section below. Please remember I am talking about companies that sell directly to consumers, not to physicians. And I am also talking about companies that address real, hardcore medical conditions, not fitness and not beauty. People will spend all kinds of money on fitness and beauty products even knowing full well they will make them neither fit nor beautiful. But medical products? Not so much. Insurance is supposed to pay for that. Or at least that’s what most consumers think.

Yes, there are some consumer-direct digital health companies that have had minor successes in the market, but none that have been able to achieve any size at all and certainly none that were able to deliver on venture capital return goals, even reasonable ones. And here’s why: if someone has a major medical problem they sure as hell don’t trust themselves to diagnose and treat it; they want their doctor involved, and appropriately so. Consumers might use a digital health medical device type product if their physician recommends it, but buy it off the shelf on their own without physician prescription or recommendation? Nope.

I have written about this issue before (consumer willingness to purchase medical products) and have seen my Digital Health, Destiny and Doritos article literally circle the globe. I think it’s because I talk about guacamole in the article. Everyone loves guacamole. If you don’t like guacamole, I have a digital diagnostic product to sell you that will determine your mental fitness to visit California, where guacamole consumption is mandatory.

So this is a cautionary tale for entrepreneurs, whose passion for their work is always so admirable but who don’t always think through this consumer issue to its logical conclusion (doom). And all too often, when I break their hearts by telling them what I know is the truth, they get even more committed to proving me wrong. I have broken more hearts than George Thorogood. I am pretty sure I’m not through yet.

I love this quote from George Santayana and even have it hanging on the wall of my office decorating a Road Runner & Wile E. Coyote animation piece, “Fanaticism consists of redoubling your effort when you have forgotten your aim.” Way too many entrepreneurs are way too committed to their vision of minting rational and engaged healthcare consumers when they should be thinking about how to influence those who influence consumers instead. And in case you needed further amplification on this issue: the cost of direct to consumer marketing is beyond the realm of nearly every healthcare-focused venture fund’s checkbook limit.

If I had a dollar for every entrepreneur to whom I said, “Dear God, please don’t rely on a direct to consumer strategy or you are doomed” and who later came back to me and said, “you were right.” I wouldn’t have to work anymore. In fact, this may be my new business model. Download my new app and receive a small electric shock whenever you think about going direct to consumer. I know you will thank me. That will be $1.

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Finding Care Can Be Easy; Check Out The RWJF Choosing Care Challenge Finalists

By CHELSEA POLANIECKI                    PARTNER CONTENT

How would you get to an unfamiliar destination without Google Maps, Waze, a GPS or even an old school map? Now how about your health care– how do you determine which road to take when you need local, reliable and affordable services? It can be tough to find the right care, but the RWJF Choosing Care Challenge is changing the game. In Phase I of the challenge, over 60 teams submitted seamless solutions to help patients find the care and services that fit their needs. Each team’s solution simplifies the journey to address the crucial need for personalized and accessible health care.

The challenge judges were particularly impressed with the solutions of: Stroll Health, Project Helix, A Moment Team, Luma Health and Transcendent Endeavors. Named the Phase I Finalists, each of these teams will receive $5,000 to further their tech development for Phase II of the challenge. These solutions include:

Stroll Health (@StrollHealth) helps health providers send patients directly to a local imaging center that fits their needs. Stroll delivers a convenient easy-to-use platform providing automatic referrals, prior authorization and real-time scheduling.

Project Helix (@kcdigitaldrive) utilizes a chatbot within a mobile application to walk patients through the steps of a doctor’s care recommendations. Transparency and accessibility are key in Project Helix’s technology, as the team connects with the patient each step of the way with text notifications and API data tailoring results to the patient’s needs.

A Moment Team (@momentdesign) created “Orderly,” which has three key features: 1) patients receive up-to-date lists of preferred specialists, imaging labs and pharmacies, 2) patients can view data such as cost, coverage and location, and 3) patients can schedule next steps through provided contact information and online booking tools.

Luma Health (@Lumahealthhq) uses text message updates to connect patients with a pharmacy, imaging center or specialist as soon as they step out of an appointment. Luma’s secure chatbot collects basic information to fully understand health care needs. Once the information is collected, a phone call from a specified provider will then be initiated directing them to their choice of preferred care.

Transcendent Endeavors (@TransEndeavor) introduces “Pooled,” a web-based platform designed to collect patient demographics to be used in a patient pool. Healthcare providers can then compete, or bid, to offer the lowest price for their services. With this solution, patients can follow a bidding process to compare price and location of services to get the most out of their care experience.

Amongst the many innovative and comprehensive submissions, the judges also recognized the following five teams as honorable mentions:

• Emrify’s (@emrify) mobile app empowers patients to document their care and discover follow-up resources to improve outcomes.
• Markit Medical (@MarkitMedical) pinpoints a patient’s needs and identifies follow-up care at the moment when it’s most actionable for the patient.
• Team Anakalypsi uses a Facebook chatbot to communicate with patients on a more personal level.
• Doctible (@doctible) leverages a patient referral systems to deliver an easy-to-use experience for patients and providers.
• HonestHealth’s (@honestHealth) consumer-focused portal on health.ny.gov acts as a baseline to locate and acquire imaging lab services and specialists, affordable coverage options and in-network referrals.

In Phase II, three of the five finalists will be selected as winners and granted prize funding to continue to develop their tech-enabled solutions. The third place winner will receive $10,000, followed by the second place winner with $15,000, and first place will be awarded the grand prize of $50,000.  For further updates on the Phase II winners of the RWJF Choosing Care Challenge and other programs, subscribe to the Catalyst @ Health 2.0 Newsletter, and follow @catalyst_h20 on Twitter.

Chelsea Polaniecki is a Program Manager at Catalyst @ Health 2.0.

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If I Had More Time, I Would Have Written a Shorter Blog Post

By ROBERT MCNUTT

I don’t know why, but even as a young person I never could make sense of the saying, “seeing is believing”. Seeing, vision, is nothing more than a data collection instrument, not an arbiter of insight. I saw my wife frown at me the other day, for example, after I claimed to have washed the dishes so thoroughly that no spot of grease could be left behind. I have made this claim before and been incorrect, so the frown, the data, triggered an anticipation of being rebuffed. However, nothing of that sort followed. I asked, Why the frown?” She responded, “I just cut my finger”. The frown was obvious, the cause unclear. I believed I was about to be reprimanded and missed the chance to notice her accident.  This story suggests that a truer aphorism might be, instead, then, that “believing is seeing”.

These comments about bias in interpretation of data are not new. Consider the condition of “hindsight bias”; once we know, we change our minds to show how correct we now can be. How about, “confirmation bias”; since we believe we know the diagnosis we find information to justify that diagnosis, eschewing contrary data. Counselors tell us all that if you change your mind, you change your life.

But changing our minds is not that easy, and, in medical care, it is extremely difficult because of deeply held beliefs that shape the ideas, which shape the actions, which produce the consequences of costly, wasteful care.  So, let’s examine some beliefs:

If we believe that the young and well must pay through the nose to assure care for the sick, we will continue to design profitable margins into plans, and make sure inequality in those plans fulfill our beliefs. Right (sarcasm), my son and daughters should pay to make sure my 82 year old relative gets 2 CT scans, 2 MRIs, 1 PET scan, and 3 months of chemotherapy for an metastatic non treatable cancer; the treatment that finally contributes to her end from an infection during a nadir in counts.

If we believe that economics and profit matter in medicine and that medical care is a good employment system, we will continue to let economists and governments intrude in medical care. We will keep adding people to the mix of delivering wasteful care. Specialists will proliferate, physicians and nurses will proliferate, and integrative medicine groups will proliferate to bill the unsuspecting.

If we believe we can determine what is best for patients with averaged out, small-randomized trials conducted with patients who we have no idea where they came from, we will continue to produce inferior trials and not advance the science of letting individuals have information to make informed choices.

If we believe in population health we will continue to disparage the lives of individuals who are not at the mean. We will continue to aggregate into groups rather than take full advantage of the singular, cottage industry needed to provide time and space for a doc and patient to become informed about care.

If we believe that physicians know best about decisions we will continue to let physicians drive costly care to even newer highs. (See my aunts care above, and then multiply by thousands of daily decisions).

If we believe that malpractice insurance somehow protects more than harms, we will see decisions promulgated by physicians in specious attempts to protect themselves.

If we believe we need “guidelines” to bulldoze care decisions over unsuspecting physicians and patients, we will unduly continue to underwrite the economic interests of suppliers of medicines, tests, and procedures.

If we believe that money matters, as much or more than best care for people who are ill, we will see TV and radio adds targeted to unsuspecting people proliferate.

If we believe only physicians can judge the veracity of medical information we will continue to see cults of organ based physicians continue to grow. Biomedical journals will sprout to produce the weakest of seeds, as good and bad information will carry the same fermentation weights. Since patients cannot presently sift the wheat from the chaff, contrary data will destroy confidence and trust.

If we believe physicians are more important than patients, we will see the development of guilds and gilded unions to advocate for physicians and the system rather than patients.

The title of this piece is based on a well-known saying. I did not put the title in quotes, as we really don’t know who wrote it, but, who we think wrote it, did not say it this way (Blaise Pascal, according to a superficial, non-expertise based search for the quote). Its value, in my view, is that it embodies a contrary notion; we expect the end of the sentence to be 180 degrees opposite. This sort of twist is used in comedy, sarcasm and irony. But, it also suggests that sometimes what we believe is just the opposite of what is true. This is why what we believe is param

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