Goodbye, 2020. Hello, 2030

By KIM BELLARD

2020 is almost over; thank goodness.  It has been one of the strangest, and longest, years most of us have ever endured.  We’ve all probably known someone who contracted COVID-19; many of us have had lost loved ones from it.  Most of us have had to make drastic changes to our lives – masks, social distancing, limits on family visits, eating out, concerts, or trips among them.  No, 2020 can’t get over fast enough.

I was struck, though, by a quote I recently read.  Loren Padelford, a vice-president at Shopify, told The Wall Street Journal: “Covid has acted like a time machine: it brought 2030 to 2020.” 

Gosh, I hope not.

Mr. Padelford went on to explain: “All those trends, where organizations thought they had more time, got rapidly accelerated.” These trends include the shift from physical to online, further decline of cash, and work from home/remote learning.  Individuals/families without broadband are being left behind; companies not investing in IT and logistics may not be here in 2030.  Healthcare has not been exempt from these trends.

The pandemic has illustrated both the great strengths and the great weaknesses of the U.S. healthcare system.  Among the strengths are the courage and professionalism of our health care workers, the innovation that has delivered several vaccines within a matter of months, and the ability to adapt to an existing but underutilized mode of care in telemedicine. 

Among the weaknesses, of course, are the lack of planning and coordination that has doomed testing, contact testing, and supply of personal protective equipment; the patchwork quilt of insurance coverage that has left even more without coverage (e.g., due to loss of job based coverage and/or lack of Medicaid expansion); the refusal of many to act in their own best health interests, such as not wearing masks or taking vaccines. 

Legislators/regulators may be taking bold actions like throwing money at healthcare organizations, vowing that the COVID testing and vaccines are “free,” and loosening restrictions on telemedicine, but the underlying disfunction in our healthcare system has never been more visible.  We don’t test enough or fast enough.  We have sick people on gurneys in gift shops, we have dead people in refrigerator trucks, and we still have people crushed by their healthcare bills.

Please, don’t let this be a picture of 2030.

2030 is a decade, three Presidential administrations, six Congresses, and hundreds of state/local governments away, so it’s hard to predict what healthcare might look like then.  Some think our current crisis is the perfect opportunity to take big, bold political action on healthcare, and it should be, but I must admit I’m dubious we’ll take it.

Instead, I’ll offer a few more measured – but important — hopes for 2030:

Ensure a floor of coverage: ACA was supposed to achieve this, but a Supreme Court ruling and a number of ideological states kept it from happening.  I don’t know if we’ll ever get to true universal coverage, be that “Medicare For All or something else, but we should at least be able to ensure that cost is not a barrier to coverage for anyone, especially for the poorest among us.  Maybe we should shoot for “Medicaid For All” and let those who choose “buy up.”

Ensure a ceiling for spending: Again, ACA addressed this, with out-of-pocket maximums and cost-sharing reductions, but too many people still end up spending too much of their money on healthcare (think about surprise bills or non-covered services).  A healthcare system that drives people into bankruptcy and/or takes them to court for services they cannot afford is just indefensible.  We should stop defending it.

Oriented around virtual care: Telehealth/telemedicine/virtual care has been around for at least two decades, but barely was a ripple in the healthcare system until COVID-19 sparked it into prominence.  However, right now it still is being bolted on to our system, rather than being truly integrated, and those bolts aren’t even all that strong.  By 2030, virtual care – in whatever form it may take by then (think AI/holograms/etc.) should be part and parcel of all health care, the first point-of-contact for most needs. 

Quality first: We talk about quality in healthcare, but we don’t really know what it is, much less measure it.  Our various attempts at payment reform have failed either to improve quality or to control costs, and will continue to do so as long as there is not agreement on the quality that is delivered for those payments.  In a world of continuous monitoring, there’s no reason for us not to know which patients got how much better through what interventions from which health care professionals.  That information would allow us to tie reimbursement appropriately to quality of care/outcomes.

Big picture: In the big picture, health is not just connected to medical care but also to vision and dental care.  In the big picture, health is not just connected to care but also to lifestyle and environment (SDoH).  In the big picture, our microbiome is integral to “us” and to our health.  But most of our healthcare system and our solutions to improving it focus mainly on the smaller, medical picture.  That it so 19^th century of us, yet 2030 brings us almost a third into the 21st century.  We need to think much, much bigger – starting now.

————

December has been the worst month of the pandemic in the U.S.  Many experts think that the worst is yet to come, despite vaccinations beginning.  2020 may be ending but what has happened in 2020 is going to have a long and very unpleasant tail. 

2020 is a decade after ACA passed, and, let’s be clear, our healthcare is much better for it.  But if 2030 doesn’t find us with significantly more improvements than the 2010’s brought us, well, expect many more bad years like 2020. 

We can muddle through another decade of incremental improvements in our healthcare system.  We can lurch from crisis to crisis, addressing each without tacking the underlying weaknesses that allow them to become crises.  We can continue to astonish the world with our profligate spending and very mediocre outcomes. 

Me, I’m hoping 2030 will astonish us by how far we’ll have come.

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

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Need to Choose a Doctor? What Does AI Think About the Choices?

By ZEESHAN SYED

Tens of millions of Americans rely on consumer experience apps to help them find the best new restaurant or the right hairdresser. But while relying on customer opinion might make sense for figuring out where to get dinner tonight, when it comes to picking which doctor is best for you, AI might be more trustworthy than the wisdom of the crowd.

Consumer apps provide us with rich data categories that often take into account preferences, from location to free wi-fi, to help users narrow down choices. Navigating your health insurer’s network of physicians is a different proposition, and some of the popular ranking systems reportedly have significant limitations. Doctors are often categorized by specialty, insurance, hospital, or location, which may be effective for logistics, but fail to take into account a patient’s unique health conditions and say very little about what an individual patient can expect in terms of health outcomes. Research from my company Health at Scale shows that 83 percent of Medicare patients seeking cardiology care and 88 percent of cases seeking orthopedic care may not be choosing providers that are highly rated for best predicted outcomes based on each patient’s individual health conditions. 

Deep personalization is exactly what physicians, health systems, and insurers need to offer patients to improve outcomes and lower costs across the board. A study using our data recently published in the Journal of Medical Internet Research sought to quantify how consumer, quality and volume metrics may be associated with outcomes. Researchers analyzed data from 4,192 Medicare fee-for-service beneficiaries undergoing elective hip replacements between 2013-2018 in the greater Chicago area, comparing post-procedure hospitalization rate, emergency department visits, and total costs of care at hospitals ranked highly by popular consumer ratings systems and CMS star ratings as well as those ranked highly by a machine intelligence algorithm for personalized provider navigation.

The results showed that patients treated by hospitals ranked highly by the machine intelligence-based algorithm experienced better health outcomes and lower total costs of care than those treated in hospitals rated highly by the other approaches. Not only did machine intelligence outperform the field on all three metrics, but in some cases the hospitals ranked highly by other approaches had worse outcomes.

The machine intelligence algorithm employed here solves a problem long believed to be intractable: modeling how physician outcomes vary from patient to patient across a broad set of health factors. Using anonymized health record data from over a hundred million lives in the U.S., the machine intelligence algorithm constructs a detailed profile for each provider in a health insurance network and their history of optimal outcomes with specific patient profiles relative to one another. The model uses this information and a richly detailed profile of a patient to create a personalized ranking of providers for the patient. Using a nationwide dataset enables rigorous evaluation of the model across specialties and geographies, ensuring that the model is as accurate for assisting a heart patient in Houston as it is for the hip patient in Chicago. In short, by developing highly detailed profiles of both provider and patient, machine intelligence can apply big data solutions to a small data problem.

So what does all of this mean? The results show that relying on general, sometimes arbitrary metrics may be of limited utility when considering provider options relative to a personalized and outcomes-based approach. If insurers or care managers employ more precise machine intelligence tools to inform these patient decisions, they may take a step closer to care that is highly personalized and highly effective, based on selecting the right physicians based on each patient’s unique medical needs. Yet there is still room to grow: just 26% of patients in the study attended the hospital that machine intelligence determined was top rated for them.

To improve the health care system for patients, care managers and insurers need to use the best decision-making tools to guide their search for care, focusing on technologies that account for the health variables that make each patient unique and providing suggestions that prioritize measurable health outcomes. Machine intelligence is proving its ability to make care navigation simple and precise, demonstrating that we can make selecting a doctor both less like a drudge through the phonebook and more reliable than advice from strangers on an app.

Zeeshan Syed, CEO of Health at Scale, was a Clinical Associate Professor at Stanford Medicine and an Associate Professor with Tenure in Computer Science at the University of Michigan.

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Evaluating President-Elect Biden’s Healthcare Plan | Part 2

By TAYLOR J. CHRISTENSEN

In Part 1 of this series, I reviewed the relevant context of our post-ACA healthcare system to show why President-Elect Joe Biden’s healthcare plan is perfectly reasonable. In this part, I will critically evaluate that plan to show what he got right and what he got wrong or missed altogether.

Joe Biden plans to get rid of the current limit (400% of the federal poverty level) on who qualifies for health insurance premium subsidies and instead convert it to a flat percentage of income (8.5%), which means anyone whose health insurance is going to cost more than 8.5% of their annual income would qualify for a subsidy. And those subsidies would be more generous, being based on a gold-level insurance plan’s price rather than a silver-level insurance plan. He also plans to create a new government-run health insurance company to offer an insurance plan—a “public option”—on the private market, which would be available to private market health insurance shoppers and some other groups as well.

Ok, now for some evaluation of all that.

First, let me frame how I am going to evaluate Joe Biden’s plan.

There are three problems healthcare reformers are usually trying to solve. They want to (1) increase access to care, (2) decrease healthcare prices, and (3) improve the quality of care.

But if we merge the last two goals into one, we can say they want to (1) increase access, and (2) improve the value of care (Value = Quality / Price). We will take these one by one.

Goal 1: Increase Access

How will Joe Biden’s plan do at increasing access?

There are three things to consider when evaluating access-increasing policies. The first is how many people will be covered. The second is how much it will cost. And the third, almost universally forgotten, is how much it will interfere with efforts to accomplish the second goal to improve the value of care.

That third consideration is important because if we increase access but coincidently impair our efforts to improve the value of care, we have taken one step forward and one step backward all at the same time.

Regarding how many people will be covered, remember from Part 1 of this series that there are about 30 million uninsured people in the U.S. Joe Biden’s website quotes that this plan will get 97% of Americans insured, which means he projects there to be about 10 million uninsured people when all this is implemented. Whether that is too many or not is purely a judgment call based on your own personal moral and political beliefs, so I will not give any comment on that here.

Regarding how much it will cost, we will skip that discussion and instead let the CBO weigh in when they actually have a bill to evaluate. Suffice it to say that it will not be as expensive as Medicare for All. Again, whether it is too expensive or not is a judgment call.

And regarding the plan’s impact on efforts to improve the value of care, this takes a little more analysis.

If you have read any of my other writings, you will already know that I believe the key to improving value in healthcare is to get more patients to choose higher-value insurers and providers, which comes from giving them price and quality information about their options and then making sure nothing interferes with their incentives to choose the highest-value one for them. When that is happening properly, market share and profit flows to the higher-value providers and, therefore, it stimulates competition over who can offer the highest value to patients.

In contrast to recent Medicare for All proposals, improving the Affordable Care Act in the way Joe Biden has proposed is possibly the most value-improvement friendly way to increase access. It will not interfere with patients having multiple insurer and provider options, it will not create new barriers to them being able to know their price and quality beforehand, and it will not ruin whatever incentives they have to choose the highest-value one. In short, Joe Biden’s plan does not create any major new barriers to the changes that need to be made to improve healthcare value.

Goal 2: Improve Value

How will Joe Biden’s plan do at improving value?

. . . Crickets.

In spite of choosing an access-increasing plan that should not create any new barriers to our efforts to improve value, I do not see much in his plan that will take advantage of that. Nothing about payment reform, price transparency, publicly available quality metrics, insurance plan design changes, anti-trust enforcement, insurance plan shoppability, etc.

I do not think this is an oversight; I just think this is an acknowledgement that he and his team do not yet know what needs to happen to make transformative changes in healthcare value.

He has at least proposed what he can to try to lower drug costs, which would improve value in that narrow but significant segment of the market.

But what about the private option? Would this somehow improve value by forcing private insurers to price more fairly?

Maybe.

Creating a public option is a workaround. It is trying to solve a problem without getting at the root of the problem, which severely hampers its effectiveness at solving that problem plus risks causing collateral damage.

The primary problem that a public option is trying to solve is the issue of supposedly non-competitive insurance markets. The idea is that if a new insurer joins the competitive landscape and offers great quality at a fair price, it will force the others to do the same or else they will lose their market share.

But no other market in society needs a government-produced option to keep the market’s competition and pricing honest, so why does healthcare insurance?

The answer is that it doesn’t.

What the healthcare insurance market needs is what other markets already have, and it’s the same thing I mentioned above: It needs shoppers to be able to readily identify the highest-value insurance plan and then choose it. Eliminating barriers to this will do more to stimulate competition over value than a public option will, and it risks no collateral damage.

But if the long-term goal is a gradual shift toward 100% of people being on a publicly run insurance plan, a public option is a great way to do this by slowly phasing out private insurance. You could call it Medicare-and-Medicaid-and-Public-Option for All. Whether that is his goal or not, it does not matter, because a public option opens up an avenue for that to eventually take place, which could work out fine where improving healthcare value is concerned, but only if it is implemented correctly.

Conclusion

I am impressed with Joe Biden’s approach to fixing the ACA. It’s a very rational approach to increasing access to healthcare, which is why it is very similar to what I described in my KevinMD post in 2019 about a possible optimal future U.S. healthcare system.

Importantly, it also avoids the moral dilemmas of (1) having people priced out of the insurance market on the one hand and (2) forcing people to buy something they do not want on the other. In a system like the one he is proposing, if there are people who do not have health insurance, it will be because they simply chose to spend their money on other things.

But I am very concerned about his addition of a public option, which I think will distract from the real changes that need to be made in the health insurance market and also risk creating, sooner or later, new barriers to improving the healthcare system’s value.

And as for his plan to improve healthcare value, he does not really have one. I guess that means it is only half a plan, with some positive aspects and some negative aspects. But if he drops the public option and instead proposes some things to improve the value of care (here are some suggestions), we would have a bright future for our healthcare system.

Taylor J. Christensen is an internal medicine physician and health policy researcher who blogs about how to fix the healthcare system at clearthinkingonhealthcare.com.

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Evaluating President-Elect Biden’s Healthcare Plan | Part 1

By TAYLOR J. CHRISTENSEN

Without the full support of congress behind him, President-Elect Joe Biden will probably not have an opportunity to sign any major system-altering healthcare legislation. But, if Democrats can gain a majority in the senate–either this election cycle or next—healthcare reform will be high on the agenda. Let’s take a critical look at what Joe Biden would push to accomplish.

For this evaluation, I am relying solely on information that Joe Biden has committed to on his official campaign website. He has many pages talking about a variety healthcare issues, such as the pandemic, gun violence, and the opioid epidemic. But the main page that reviews his plans for the healthcare system as a whole is here. Consider giving it a read through first, because what follows will only be summarizing and evaluating the key big-picture components of his plan.

Joe Biden is not pushing for Medicare for All. He instead wants to keep the Affordable Care Act (i.e., the ACA, or “Obamacare”) and fix the parts of it that are not working so well. To understand the rationale of his proposed changes, we first need to review where we are at now with the ACA.

There are many parts to the ACA, but its main thrust was to increase insurance coverage. What kind of numbers are we working with? Below are some 2019 data, rounded for simplicity. And note that I am excluding the 60,000,000 people who are over age 65 and therefore on Medicare.

The under-age-65 people fall into one of four insurance groups . . .

Employer-sponsored insurance (160,000,000 people) if they are lucky enough to work for an employer that provides benefits.

Medicaid (70,000,000 people) if their income is low enough to qualify.

Private insurance from the “private market” (10,000,000 people) if they make too much money to qualify for Medicaid and do not have an employer that provides benefits.

Uninsured (30,000,000 people) if they do not get insurance from their employer, their income is too high to qualify for Medicaid, and they do not want to pay for insurance from the private market.

Remember, those are from 2019, so they are post-ACA numbers. Prior to the implementation of the ACA, the uninsured number hovered around 45,000,000 people. What did it do to reduce the number of uninsured people? There were many ways, but here are the two biggest ways:

First, it allowed states to liberalize their eligibility criteria for Medicaid. This is known as a “Medicaid expansion,” and it offered federal funds to pay for most of the costs associated with all the new Medicaid enrollees. That accounts for about 12,000,000 of the 70,000,000 people who are currently on Medicaid, some of whom were previously uninsured, and others of whom were previously on private insurance. But Medicaid expansion was ruled optional by the supreme court, so not all states chose to expand their Medicaid programs.

Second, it created a tax (also called a “health insurance mandate”) for anyone who did not have health insurance. This was to push the uninsured who did not qualify for Medicaid to buy insurance. And because everyone was going to be required to buy insurance, the government had to make sure it would be affordable for everyone, so they promised to help cover the cost of insurance premiums for anyone under 400% of the poverty level. Additionally, to prevent insurance companies from taking advantage of the government’s willingness to help pay for people’s insurance premiums, they made a rule that insurers have to charge everyone the same premium without respect to pre-existing conditions (although that premium can be adjusted up or down to a limited extent depending on a person’s age and smoking status).

So, an easy way to summarize the ACA’s second way it was trying to increase insurance coverage is by saying it was attempting to shift uninsured people into that private market. The ACA even created a nice website (healthcare.gov) to make it extra easy for people to shop for insurance plans on the private market by listing them all there side by side in a standardized fashion, and the website went so far as to pull in people’s tax information to calculate their premium subsidy right up front as well.

While Medicaid expansions were predictably effective at lowering the number of uninsured people in the states that chose to do that, the mandate did not work so well–most of the healthy uninsured who did not newly qualify for Medicaid still did not buy insurance.

This was for a variety of reasons. Some people who were not on health insurance when the ACA’s mandate took effect did not even realize they were choosing, by default, to pay that tax, so it had no motivating impact on their insurance status. Other people wanted to buy insurance to avoid paying the tax, but unless they qualified for premium subsidies, they found that private market premiums were unaffordable, so it made more sense for them to just risk continuing to be uninsured and pay the tax.

The summary of the ACA’s effects on the private market, then, is that it created a perfect storm of sick people getting insurance and healthy people not getting insurance, which drove premiums higher and priced out even more people. Then, in 2017, the mandate was eliminated, which further aggravated these issues.

All these factors help explain why we continue to have 30,000,000 people uninsured in spite of the ACA’s efforts.

With all this in mind, the natural solution becomes fairly obvious: To shift the uninsured into the private market, restore and strengthen the mandate and get rid of the 400% poverty level limit on premium subsidies and make them more generous.

And that’s exactly what Joe Biden would do. Except for the reinstating the mandate part, which would probably not be popular nor even possible. I guess he hopes that if his subsidies are generous enough, he will get the healthy people into the market even without a mandate.

How generous is he making the subsidies? Healthcare premiums will be limited to no more than 8.5% of any individual or family’s income, regardless of income. Currently subsidies kick in at around 10%. And not only that, but he is also planning on benchmarking these subsidies based on gold level plans rather than silver (meaning out-of-pocket costs, especially deductibles, will be a lot lower). This will certainly entice at least some of those 30,000,000 people into buying health insurance.

But he has gone further than that. I suspect he feels that insurance companies do not truly competitively price their plans, because he also intends to create a new government-run insurance company that would offer its own plan (known as the “public option”) in the private market alongside all the other private insurers’ plans on healthcare.gov. As the thinking goes, if the public option ends up being way cheaper than all the private plans, private insurers will lose much of their market share and will be forced to offer lower prices.

This private option would also be made available to other groups, such as employees whose employer does not provide health insurance, and it would even be offered for free to low-income uninsured people in states that have not expanded Medicaid.

Now you know the major points of Joe Biden’s healthcare plan, plus the relevant context to show why he chose them. Part 2 of this series will critically evaluate that plan to show what he got right and what he got wrong or missed altogether.

Taylor J. Christensen is an internal medicine physician and health policy researcher who blogs about how to fix the healthcare system at clearthinkingonhealthcare.com.

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Evaluating President-Elect Biden’s Healthcare Plan | Part 1

By TAYLOR J. CHRISTENSEN

Without the full support of congress behind him, President-Elect Joe Biden will probably not have an opportunity to sign any major system-altering healthcare legislation. But, if Democrats can gain a majority in the senate–either this election cycle or next—healthcare reform will be high on the agenda. Let’s take a critical look at what Joe Biden would push to accomplish.

For this evaluation, I am relying solely on information that Joe Biden has committed to on his official campaign website. He has many pages talking about a variety healthcare issues, such as the pandemic, gun violence, and the opioid epidemic. But the main page that reviews his plans for the healthcare system as a whole is here. Consider giving it a read through first, because what follows will only be summarizing and evaluating the key big-picture components of his plan.

Joe Biden is not pushing for Medicare for All. He instead wants to keep the Affordable Care Act (i.e., the ACA, or “Obamacare”) and fix the parts of it that are not working so well. To understand the rationale of his proposed changes, we first need to review where we are at now with the ACA.

There are many parts to the ACA, but its main thrust was to increase insurance coverage. What kind of numbers are we working with? Below are some 2019 data, rounded for simplicity. And note that I am excluding the 60,000,000 people who are over age 65 and therefore on Medicare.

The under-age-65 people fall into one of four insurance groups . . .

Employer-sponsored insurance (160,000,000 people) if they are lucky enough to work for an employer that provides benefits.

Medicaid (70,000,000 people) if their income is low enough to qualify.

Private insurance from the “private market” (10,000,000 people) if they make too much money to qualify for Medicaid and do not have an employer that provides benefits.

Uninsured (30,000,000 people) if they do not get insurance from their employer, their income is too high to qualify for Medicaid, and they do not want to pay for insurance from the private market.

Remember, those are from 2019, so they are post-ACA numbers. Prior to the implementation of the ACA, the uninsured number hovered around 45,000,000 people. What did it do to reduce the number of uninsured people? There were many ways, but here are the two biggest ways:

First, it allowed states to liberalize their eligibility criteria for Medicaid. This is known as a “Medicaid expansion,” and it offered federal funds to pay for most of the costs associated with all the new Medicaid enrollees. That accounts for about 12,000,000 of the 70,000,000 people who are currently on Medicaid, some of whom were previously uninsured, and others of whom were previously on private insurance. But Medicaid expansion was ruled optional by the supreme court, so not all states chose to expand their Medicaid programs.

Second, it created a tax (also called a “health insurance mandate”) for anyone who did not have health insurance. This was to push the uninsured who did not qualify for Medicaid to buy insurance. And because everyone was going to be required to buy insurance, the government had to make sure it would be affordable for everyone, so they promised to help cover the cost of insurance premiums for anyone under 400% of the poverty level. Additionally, to prevent insurance companies from taking advantage of the government’s willingness to help pay for people’s insurance premiums, they made a rule that insurers have to charge everyone the same premium without respect to pre-existing conditions (although that premium can be adjusted up or down to a limited extent depending on a person’s age and smoking status).

So, an easy way to summarize the ACA’s second way it was trying to increase insurance coverage is by saying it was attempting to shift uninsured people into that private market. The ACA even created a nice website (healthcare.gov) to make it extra easy for people to shop for insurance plans on the private market by listing them all there side by side in a standardized fashion, and the website went so far as to pull in people’s tax information to calculate their premium subsidy right up front as well.

While Medicaid expansions were predictably effective at lowering the number of uninsured people in the states that chose to do that, the mandate did not work so well–most of the healthy uninsured who did not newly qualify for Medicaid still did not buy insurance.

This was for a variety of reasons. Some people who were not on health insurance when the ACA’s mandate took effect did not even realize they were choosing, by default, to pay that tax, so it had no motivating impact on their insurance status. Other people wanted to buy insurance to avoid paying the tax, but unless they qualified for premium subsidies, they found that private market premiums were unaffordable, so it made more sense for them to just risk continuing to be uninsured and pay the tax.

The summary of the ACA’s effects on the private market, then, is that it created a perfect storm of sick people getting insurance and healthy people not getting insurance, which drove premiums higher and priced out even more people. Then, in 2017, the mandate was eliminated, which further aggravated these issues.

All these factors help explain why we continue to have 30,000,000 people uninsured in spite of the ACA’s efforts.

With all this in mind, the natural solution becomes fairly obvious: To shift the uninsured into the private market, restore and strengthen the mandate and get rid of the 400% poverty level limit on premium subsidies and make them more generous.

And that’s exactly what Joe Biden would do. Except for the reinstating the mandate part, which would probably not be popular nor even possible. I guess he hopes that if his subsidies are generous enough, he will get the healthy people into the market even without a mandate.

How generous is he making the subsidies? Healthcare premiums will be limited to no more than 8.5% of any individual or family’s income, regardless of income. Currently subsidies kick in at around 10%. And not only that, but he is also planning on benchmarking these subsidies based on gold level plans rather than silver (meaning out-of-pocket costs, especially deductibles, will be a lot lower). This will certainly entice at least some of those 30,000,000 people into buying health insurance.

But he has gone further than that. I suspect he feels that insurance companies do not truly competitively price their plans, because he also intends to create a new government-run insurance company that would offer its own plan (known as the “public option”) in the private market alongside all the other private insurers’ plans on healthcare.gov. As the thinking goes, if the public option ends up being way cheaper than all the private plans, private insurers will lose much of their market share and will be forced to offer lower prices.

This private option would also be made available to other groups, such as employees whose employer does not provide health insurance, and it would even be offered for free to low-income uninsured people in states that have not expanded Medicaid.

Now you know the major points of Joe Biden’s healthcare plan, plus the relevant context to show why he chose them. Part 2 of this series will critically evaluate that plan to show what he got right and what he got wrong or missed altogether.

Taylor J. Christensen is an internal medicine physician and health policy researcher who blogs about how to fix the healthcare system at clearthinkingonhealthcare.com.

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Health in 2 Point 00 — with no video!

By MATTHEW HOLT (without JESS DAMASSA!)

Due to @jessdamassa being lost in America and my totally crap internet in the Sierras, there is no #HealthIn2Point00 this week.

So I’m going to write out a few things we would have said:

1. @OscarHealth raises another $140m and files to IPO. SPAC or no SPAC, a bunch of these startup health plans are going to try to get out the door while the window is open! 420,000 members ain’t a lot–I mean there are 5-6 Medicaid plans bigger than that in CA alone! I still predict someone big buys them but whether pre- or post crash I don’t know.

2. @LyraHealth is raising another $175m (apparently). That’s the 3rd trip to the well THIS YEAR! Mental health is sexy these days. Just how many online mental health cos can make it? I think Lyra needs to use these $$ for automated self-service tech, cos psychiatrists don’t scale, and they currently sell themselves as having a better network than anyone else.

3. @kyruus buys @HealthSparq (from @Cambia). No $$ announced. Unclear why a company that makes $$ routing patients to doctors within systems (& prevents “leakage”) needs a transparency tool that explains who’s charging what. But maybe an overall pivot to serving health plans?

4. @h1insights raises $58m (total is over $70m). It’s a database of doctors sold to drug companies to help them better target their marketing. Good to know that in the new world of health tech, helping big pharma push pills is a reliable way to make bank.

OK, so that’s what I would normally have covered in 2 mins on #HealthIn2Point00 yes, it’s much better with @jessdamassa on video and running the show while poking fun at me. Hopefully the internet works next week! #MerryChristmas2020

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No Names, Please

By KIM BELLARD

Feeling good about your holiday spending?  You’ve made it through most of this mostly horrible 2020, maybe lost a job or even a loved one, but still probably found a way to buy presents for your loved ones and maybe even to give some money to charity.  Indeed, charitable giving was up 7.5% for the first half of 2020, despite the economic headwinds.

Then there’s MacKenzie Scott.

Ms. Scott, as you may recall, is the former wife of Amazon founder/CEO Jeff Bezos.  She got Amazon stock worth some $38b in their 2019 divorce, which is now estimated to be worth around $62b.  She just gave away $4.2b – and that’s on top of $1.7b she gave away in July. 

In case your math skills are impaired, that’s $6b in six months, which Melissa Berman, chief executive officer of Rockefeller Philanthropy Advisors told Bloomberg: “has to be one of the biggest annual distributions by a living individual.”   Ms. Scott has vowed: “I will keep at it until the safe is empty.”

Kenzie Bryant, writing in Vanity Fair, marveled: “It gives a whole new meaning to “fuck-you money.” 

Private foundations are required to distribute at least 5% of their endowments each year; Ms. Scott not only has given away 10% of her net worth this year alone, but she hasn’t even used a foundation to do so.  As The New York Times reported: “Ms. Scott’s operation has no known address — or even website. She refers to a “team of advisers” rather than a large dedicated staff.”

She doesn’t make recipients plead for money through grant applications.  She doesn’t specify how the money is to be used, or require reports on how it is spent.  She doesn’t expect her name on anything.  She doesn’t even make public how much she is giving each recipient (although some choose to do so).

NYT says:

Ms. Scott has turned traditional philanthropy on its head…By disbursing her money quickly and without much hoopla, Ms. Scott has pushed the focus away from the giver and onto the nonprofits she is trying to help.

Ms. Scott’s Medium post outlined her goals for the giving: “special attention to those operating in communities facing high projected food insecurity, high measures of racial inequity, high local  poverty rates, and low access to philanthropic capital.”  Easterseals, food banks, Goodwill, Meals-on-Wheels, United Way, and YMCAs accounted for a large number of recipients.  She’s guided by “a conviction that people who have experience with inequities are the ones best equipped to design solutions.”

In all, Ms. Scott and her team analyzed nearly 6,500 organizations and made grants to 384, in all 50 states, Washington D.C., and Puerto Rico. 

The Washington Post did its own calculation and estimate that at least $800 million of her donations went to higher education institutions, especially those serving people of color: “$147 million went to Hispanic-serving institutions, $5 million to tribal colleges and $560 million to historically Black colleges and universities. In addition, a total of $130 million went to five other public colleges in Florida, Washington state, Nebraska and Kentucky.” 

Rob Reich, co-director of the Center on Philanthropy and Civil Society at Stanford, told NYT: “She’s moved extraordinary sums out the door, quickly, in an anti-paternalistic way.”  Debra Mesch, a professor at the Women’s Philanthropy Institute at Indiana University added:

If you look at the motivations for the way women engage in philanthropy versus the ways that men engage in philanthropy, there’s much more ego involved in the man, it’s much more transactional, it’s much more status driven.  Women don’t like to splash their names on buildings, in general.

Take that, Mark Zuckerberg (or, rather, take this).   

The New York Post put the difference with typical bluntness:

While all the tech bros fight over colonizing space and California tax codes, banding together for the only thing they really care about — fending off anti-trust legislators — Scott makes them all look like stingy, greedy incels without a shred of compassion for those ruined by COVID-19. 

Healthcare likes to splash donors’ names on buildings.  Healthcare organization, especially hospitals, like to get big donors on their boards as a reward for, or incentive to get, donations.  Look at the nearest big hospital.  Chances are there are wings, departments, even buildings with big donors’ names on them.  Maybe there’s a brick or a plaque with your name on it to commemorate a smaller donation too.  Medical schools have followed suit. 

Lately, hospitals have made targeted efforts to solicit patients for donations.  In 2019, NYT reported:

Many hospitals conduct nightly wealth screenings — using software that culls public data such as property records, contributions to political campaigns and other charities — to gauge which patients are most likely to be the source of large donations.

“Nightly wealthy screenings.”  That should make us all shudder.  Hospitals do this despite the fact that patients generally look down upon the practice, with most fearing it might interfere with the patient-physician relationship.  They’re probably right.

It’s easy to do those kinds of donations: we sympathize with the hard-working hospital staff, we can tell if the buildings look modern or run-down, and chances are we or someone we know has used that hospital.  Making a donation is an easy way to seem like we’re making a difference; the bigger the donation, the bigger the difference.

And maybe we’ll get our name on something.

That’s not a way to run a healthcare system – or a society.  Ideally, our taxes would help assure that we all have access to enough food, safe housing, good education, clean air and water, reliable infrastructure, decent paying jobs, and quality healthcare – all at affordable levels.  To the extent that our taxes don’t prove sufficient, those of us with some extra left over can help fund organizations that try to make things better for those who are less well off.

Ms. Scott pleaded:

If you’re craving a way to use your time, voice, or money to help others at the end of this difficult year, I highly recommend a gift to one of the thousands of organizations doing remarkable work all across the country. Every one of them could benefit from more resources to share with the communities they’re serving. And the hope you feed with your gift is likely to feed your own.

There are a lot of unmet needs in our society, especially during this pandemic.  Ms. Scott is showing us that we can do something about them.  We shouldn’t just admire her; we should try to emulate her, especially (but not only) anyone with a few billion dollars.

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

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Olive CEO Sean Lane on 2020’s Big Numbers: 3 Funding Rounds, $450M, & a 5-Point Plan for the Future

By JESSICA DaMASSA, WTF HEALTH

Arguably 2020’s hottest health tech startup, Olive (olive.ai) closed THREE funding rounds this year, totaling $450M and valuing the company at $1.5B. Backed by a “who’s who” of technology, healthcare, and health tech venture capital, Sean Lane, CEO, clues us in about just what makes Olive so damn fund-able. The company boasts a “healthcare AI workforce” that tackles all the back-office processes hospitals use to run their organizations. This is not sexy stuff — filing and tracking insurance claims, ordering inventory, managing suppliers, etc. What’s hot, though, is how Olive is able to automate these tasks (according to Sean, currently many of these processes are handled by spreadsheets and faxes), “learn” as she’s doing it, and create efficiencies and cost savings across all of Olive’s 600+ hospital client-base as she does. Could this be the end of “admin expense” in healthcare? If what Olive is currently doing isn’t enough, we dive deep into Olive’s strategic plan — ALL FIVE POINTS OF IT (!) — to learn what’s next. My favorite? Number 3. The one where Olive starts to INSTANT PAY CLAIMS to completely disrupt hospital cash flow.

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3 Patient Lessons: What Cancer Patients Teach Me

By YASMIN ASVAT

An estimated 1.8 million people in this country may face a cancer diagnosis this year, in what has already been a bleak year of isolation and loss.  

While news of the COVID-19 vaccine rolling out across the U.S. offers hope in a year of 311,000 deaths,  11 million  people face the financial pressure of unemployment, and, approximately 43 percent of the nation reports some symptoms of anxiety or depression.  

It is understandable that a cancer diagnosis now may be too much to bear. And yet, somehow, many patients cope with the diagnosis and the associated uncertainty, fragility, and the threat of mortality with remarkable resilience.  

As a clinical psychologist in the Supportive Oncology program at a major Midwestern cancer center, I witness these quiet heroics every day. 

Since the beginning of the pandemic earlier this year, I have been striving to listen, empathize, support, and help cancer patients cope as their lives have been disrupted by both a cancer diagnosis and COVID-19. These are lessons these patients have taught me. 

Courage is being faced with doing something that utterly terrifies you, and you do it anyway. One of my patients described that leading up to the day of chemotherapy treatment, she is highly anxious, has racing thoughts and worries, and has trouble concentrating and sleeping. The morning of treatment, she vents to her partner about how she doesn’t want to go to the clinic. During the drive, she braces herself repeating, “I don’t want to do this” over and over again. 

Once in the clinic, she tells some of her nurses that she doesn’t want to be there because she worries about COVID-19 exposure, despite all the precautions the clinics have in place. She tells another set of nurses that she is scared of the side-effects of treatment – the disabling fatigue, the nausea, the suppressed immune system. 

And yet, despite her fears and her protests, she stays. The nurses hook her up to the needle, attached to a tube, attached to a bag, attached to an infusion pump that delivers the toxic and cancer-fighting chemotherapy. 

She stays for her children and grandchildren and the desire to see them grow, for her partner, for the hope of a cancer-free future, for her eagerness to live.  She goes home relieved that one more treatment is completed and anxiously anticipates the next round. From this remarkable woman I have learned what it means to live the adage credited to Nelson Mandela, that “courage is not the absence of fear, but the triumph over it.” You may be terrified – and yet you do what needs to be done, anyway.

When you have clarity about what matters, even impossible, heart-breaking decisions are clear. Few decisions in life are more poignant, heartbreaking, and difficult than deciding how to die. Many spend most of their lives conveniently shoving the reality of mortality to the back of their minds, necessarily so, in order to continue persevering through the expected and unexpected challenges of living. Many patients make decisions about their deaths with certainty and acceptance. 

One of these patients was a Latina in her early 50s, Spanish-speaking who battled a particularly aggressive form of metastatic colorectal cancer for two years, with extensive surgery and multiple rounds of chemotherapy. All the while, her priorities were beautifully simple – to spend time with her husband of three decades, enjoy the company of her three children, dance to her favorite music, play with her beloved dog, and find comfort in her faith. 

For as long as her body was able to sustain itself, she did exactly that – she lived, laughed, danced and tolerated all the side-effects of treatment with dignity. And when the day came that saw herself spending her time lying in bed because moving was too painful, sleeping because without medication the pain was so unbearable it would make her scream, she knew what she had to do because she knew what mattered. She said she was living a half-life where she was a shell of herself, breathing but not really living, seeing her family but not really participating in their lives, listening to music but not being able to dance.  

Her doctor suggested yet another round of chemo, with no assurances that it would help, and she declined. She resolved to speak with her family about hospice care. There was sadness, naturally, but no despair. There was wishing she had more time, and there was gratitude for the time she did have. She said there were no regrets, and there was comfort in knowing her family would lean on each other to heal. Knowing what mattered made her choice crystal clear – in the words of German philosopher Nietzsche, she chose to “die proudly when it is no longer possible to live proudly.” 

Being flexible is mandatory for our survival. One of my patients said she was crushed to realize that she would likely be spending the Christmas holiday without her grandchildren. She faced a particularly grueling treatment that knocked her down for eight days, unable to eat, severely fatigued, and spending most of her days sleeping. 

By the ninth day, she started feeling a little better and was able to do a few things around the house and in her beloved garden, and another two weeks later she was back in clinic for the next round of chemotherapy.  She handled this ordeal with the utmost grace and willingness to sacrifice six months of her life for the hope of the rest of her life. 

But faced with the prospect of sacrificing her cherished Christmas season, she almost broke. We talked about safe options to celebrate the holidays, and we philosophized about her values and what brings meaning to her life. In the midst of circumstances that are unprecedented, uncertain, and threating to her physical health and emotional wellbeing, she chose to adapt to survive. 

So she rallied, creatively and flexibly, and planned a virtual baking session — she would make the dough, her husband would drop it off to the grandchildren, and they would Facetime while the grandkids baked and decorated the cookies. She also planned to have gifts and a holiday meal delivered to her daughter’s home. And her daughter adapted by planning a holiday drive-by so her mother could see her family briefly and from a safe distance. 

In true Darwinian fashion, “it is not the strongest of the species that survives, nor the most intelligent; it is the one most adaptable to change.” 

Cancer patients adapt so that they may yet hold on to a slice of what brings their lives joy and meaning. It is a lesson everyone can learn. 

Yasmin Asvat, PhD is a licensed clinical psychologist at Rush University Medical Center with eight years of experience providing mental health services to chronically ill patients, primarily cancer patients. She is a Public Voices Fellow through The OpEd Project.

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A Christmas Message to All Physicians From a Swedish-American Country Doctor in Maine

By HANS DUVEFELT, MD

Growing up in Sweden without a Thanksgiving holiday, Christmas has been a time for me to reflect on where I am and where I have been and New Year’s is when I look forward.

I have written different kinds of Christmas reflections before: sometimes in jest, asking Santa for a better EMR; sometimes filled with compassion for physicians or patients who struggle during the holidays. I have also borrowed original sentences from Osler’s writings to imagine how he would address physicians in the present time.

This year, with the pandemic changing both medicine and so many aspects of life in general, and with a gut wrenching political battle that threatens to erupt in anarchy or civil war within the next few weeks or months, my thoughts run deep toward the soul of medicine, the purpose of being a good doctor, even being a good human being.

We live in ideological silos, protected from dissenting opinions. News is not news if it is unpopular. Fake news and fake science are concepts that seemed marginal before but have now entered the mainstream.

As a physician, I serve whoever comes to see me to the best of my ability. But this year I have had to pay extra attention to the fact that so many people have already made up their minds about the nature and severity of the pandemic we are living with. If they don’t believe the country’s top experts, they are not likely to believe in me. Still, I try to gently state that we are still trying to figure this thing out and until we do, it’s better to be cautious.

I am starting to read about what some are now calling the Fourth Wave of the pandemic, the mental health crisis this winter may see in the wake of the physical illness we are surrounded by.

With this raging pandemic and the pandemonium it has created in our personal lives and the lives of those around us, we as doctors need to keep our priorities straight:

• A physician’s mission is to ease suffering.
• We save lives when we can.
• But sometimes, all we can do is help inevitable death happen with dignity and without unnecessary suffering.
• Because we have seen suffering and death in our work, our words of experience and our empathy can help others.
• We are all mental health workers in the eyes of our patients.
• We must work hard to the best of our abilities.
• But we cannot sacrifice our own health in the process.
• We must put our own oxygen mask on first, as during in-flight emergencies.
• We must accept that bad things happen in spite of our efforts.
• We must accept that in life, there is no light without darkness, no joy without sorrow, and no good without evil.
• We must recognize that we need to make every day count, because time, and life itself, is a finite resource.

Life is certainly messy, confusing and unpredictable. And while scientists and politicians may be using their brains for thinking of ways out of the situation the world is now in, the rest of us, doctors on the frontlines, are hunkering down in our shrunken worlds – reconnecting with the soulful, inconsistent underpinnings of who we really are but were perhaps too busy to really think about, recommitting to easing suffering, one patient at a time.

Remember Hippocrates: “Ars longa, vita brevis, occasio praeceps, experimentum periculosum, iudicium difficile” — “Life is short, the art is long, opportunity fleeting, experiment treacherous, judgment difficult.”

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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