If there is a silver lining to the Trump assault on decency and civility, it is our majority response to this “stress test” of our Democracy, and the sturdiness (thus far) of our Founders’ vision.
It was, after all, a long shot when Alexander Hamilton, under the pen name Publius, published Federalist No. 1 on October 27, 1787, writing: “It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force.”
Two weeks before the Iowa caucus in 2016, Trump himself sided with “force” and signaled a rocky road ahead when he stated in Sioux City, Iowa, that “I could stand in the middle of Fifth Avenue and shoot somebody, and I wouldn’t lose any voters, OK? It’s, like, incredible.”
Of course, Trump, while representing our Executive branch, was not acting alone. He was supported by members of our Legislative branch as they successfully stacked the Judicial branch with religious conservatives. The net impact was this past year’s overturning of Roe v. Wade, and a Christian Evangelical legislative windfall (and subsequent political backlash) in multiple Red States across the union.
This too was foreseen by our Founders. In 1799, Thomas Jefferson, in a letter to James Madison, warned that “The tyranny of the legislatures is the most formidable dread at present, and will be for long years. That of the executive will come in its turn, but it will be a remote period.”
Without the law, there is no society. President Teddy Roosevelt made this clear in his 1903 State of the Union address when he said. “No man is above the law and no man is below it; nor do we ask any man’s permission when we require him to obey it. Obedience to the law is demanded as a right; not asked as a favor.”
In the current assault on Roe v. Wade lies buried an assault not only on Democracy, but also on women’s rights, their autonomy, and on the integrity of the patient-physician relationship. In pushing patriarchy, and MAGA Republican dominance, a fringe minority is willing to bend the law to their favor, and undermine the health of our nation.
On June 24, 2022, Roe v. Wade was overturned. Only 5 months later, Indianapolis physician Dr. Caitlin Bernard was hauled into court to face a judge in response to a complaint filed by Indiana Attorney General Todd Rokita that the doctor had violated state law requiring notification of police and child welfare officials in cases of child abuse.
The 10-year old child involved had been raped by a 27-year old Ohio man who was under arrest. Ohio’s 6-week “fetal heart beat” abortion ban (which took affect after Roe v. Wade was eliminated) resulted in the child’s parents being forced to cross state lines and seek help in nearby Indiana. After the 3-day required waiting period, Dr. Bernard provided care necessary for a medical abortion. As her attorney stated, “Dr. Bernard is a skilled and competent doctor, and I would submit that she is exactly the doctor that people would want their children to see under these circumstances.”
She, and her fellow doctors across the nation, provide compassion, understanding, and partnership to Americans from “sea to shining sea.” But less well recognized is their function in providing health to our Democracy in three ways. First, they process the nation’s fear and worry on a daily basis, which might otherwise rise to destabilizing effect. Second, they reinforce linkages between individuals, families, and their communities, pointing those in need to resources that might help. Third, they reinforce a sense of hopefulness. If not a cure today, perhaps one just around the corner.
Extreme MAGA Republicans have inadvertently awakened deeply buried and historic fears and resentment. As historian Lawrence Friedman put it, “The American Revolution, whatever else was at issue, fed on resentment against English oppression….Criminal laws are one of the levers the government uses to exercise its power over the individual, over the ordinary citizen…the British had abused criminal justice, and were impairing the rights of the colonists….The leaders of the Revolutionary generation felt strongly that there had to be safeguards against abuse of criminal justice, or the use of criminal process to crush political dissent – the offenses King George was blamed for.”
Trump, no doubt, remains anxious to test out his theory with a last stand “in the middle of Fifth Avenue.” But in the process, he has fast-walked his followers into a position of state government over-reach, which places low-level bureaucrats at the patient’s bedside, criminalizes doctors and nurses, and leads the former “Sons of Liberty” into King George’s (or Donald’s) waiting arms.
Mike Magee MD is a Medical Historian and the author of CODE BLUE: Inside the Medical-Industrial Complex.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday June 29 at 1PM PT 4PM ET are futurist Jeff Goldsmith: medical historian Mike Magee (@drmikemagee); patient safety expert and all around wit Michael Millenson (@mlmillenson) and Suntra Modern Recovery CEO JL Neptune (@JeanLucNeptune).
You can see the video below & if you’d rather listen than watch, the audio is preserved as a weekly podcast available on our iTunes & Spotify channels.
After a 3 decade career in a solo private practice the healthcare environment shifted
As an employed physician, my institution’s policies hindered my ability to care for my patients
The consequent moral injury left me unwilling to re-engage with the healthcare industry
I retired early from the profession that I loved because the devolution of the healthcare system had made it impossible for me to provide care to my patients in a manner which met my own standards. The resultant “moral injury” left me leary of again becoming involved with our healthcare system in the near future.
My Early Career
Although I had originally planned a career as a physician-scientist, it became apparent toward the end of my training that this was not the best career path for me and I choose to pursue a career in private practice.
My first post-training job was as a physician working in a clinic owned by Blue Cross and Blue Shield (1989-1991.) After two years in this relatively low stress environment it became clear that taking care of young, healthy patients was not much fun nor interesting.
I then joined Dr. LP’s private medical practice where I learned how to run a private practice. It was in this setting that I began to create an electronic medical record program for my practice, ComChart EMR. ComChart evolved into a minor commercial endeavor, it was a hobby that earned me some money, and it connected me to many interesting physicians around the US, some of whom I continue to hear from to this day.
After a couple of years practicing alongside Dr. LP I decided it was time to strike out on my own. I built out a new office and soon thereafter added a nurse practitioner.
Improving Healthcare with Health Information Technology
At that time, early-mid 1990s, I was somewhat of a rarity in the medical community; a practicing physician who created and was using his own electronic health record program. Thus, I began writing articles about health information technology for the throw-away journals, blogging, giving lectures locally and nationally, and I became involved with the Massachusetts Medical Society. My intent was to improve our healthcare system though the implement of appropriate health information technology.
Because I was able to tailor ComChart EMR to my practices’ every need, my practice became extremely efficient and this was documented by innumerable patient comments I received over the years. Subsequently my local hospital put a newly employed and recently trained endocrinologist (Dr. MA) into my practice.
The Medical Practice Environment Changes
In 2017 it became clear that my healthcare environment had changed and if I wanted to continue to see patients, I would need to become an employed physician in the hospital’s newly created diabetes and endocrine center. As part of my contract negotiations, my local hospital agreed to allow me and Dr. MA to continue to use ComChart EMR even though they intended to have the other two physicians and two nurse practitioners in the diabetes and endocrine center use Cerner.
While working side by side with the other healthcare providers it rapidly became apparent that ComChart EMR allowed me to deliver healthcare far more efficiently and effectively than would have been possible using Cerner. Nevertheless the institutional bureaucrats eventually insisted that Dr. MA switch from ComChart to Cerner.
During my contract negotiations, the institution had promised me that the physicians that we would be allowed to run the newly created diabetes and endocrine center as they saw fit because “Its your office.” But that is not what happened. The hospital hired an office manager who answered to the hospital bureaucrats, and despite repeated complaints from the practicing physicians, the hospital bureaucrats continued to enforce their mandates because “we know what we’re doing.” They didn’t and we, the physicians, were not happy.
When my institution replaced Cerner with Epic I chose to switch from ComChart to Epic because, as an IT geek, I was interested to learn Epic and I knew it would make it easier for the physician who would eventually replace me.
Epic was a very well designed and comprehensive electronic health record (EHR) program but it had a steep learning curve. While Epic had many of ComChart’s features that were absent from Cerner, Epic lacked some of features that should have been present. I attempted to convey this information to Epic IT people, without much success. I was also pleased to discover that Epic shared the same design philosophy as I used in designing ComChart, which was to bring the relevant information to the physician at the point of care.
Roadblocks by Institutional Bureaucrats
Unfortunately, the transition to Epic was not well thought-out by the institutional bureaucrats. For example, when I called Epic technical support, I got a non-technical person who took my information and would pass it on to the Epic support team. There was no realtime technical support. Imagine a pilot has a problem, he/she calls the control tower who calls Boeing tech support, who then says “we will get back to you in a day or two.”
Having run an EHR company and practiced medicine, I know what is needed for EHR technical support. Epic’s technical support system was seriously deficient, interfered with my ability to deliver care to my patients, and needlessly made the practice environment more stressful.
Despite many meetings in which we discuss ways to improve the practice, the institutional bureaucrats remained intransigent; nothing significant ever changed. With time the physicians became increasingly unhappy, stressed, and hopeless.
By the time I decided to retire from the career I loved, three of five physicians had resigned from my clinic. I believe they left because they realized that the institution would never allow them to fix the daily deficiencies which made it difficult for them to provide care to their patients.
In my last few months as an employed physician I sent innumerable emails to the hospital president and other senior hospital bureaucrats explaining that they had built a medical practice in which it was impossible for me to take care of my patients. I pointed out that 60% of their professional staff had already resigned. Their response was, again, “we’ve got this under control” or “we’ll talk about this in the future.”
When I complained to one of the hospital bureaucrats about the dire nature of the clinic, they responded “Are you accusing me of being incompetent?” I replied that they were as competent as I would be if I were the institution’s senior attorney or CFO.
Toward the end of my medical career, my wife made it clear that she thought I was under too much stress and was very unhappy. I attributed this to “physician burnout” (practice environment, Covid, new EHR, abysmally designed healthcare system) but felt it was just part of my job.
It is Time to Make a Change
Ultimately, my frustration culminated in a regrettably loud and angry encounter with my associate, Dr. MA, who was technically the physician who ran the clinic. In reality, he did not run the practice; the office was run buy the bureaucrats who made all the decisions. It was most unprofessional on my part but I was at my wit’s end. I subsequently apologized to Dr. MA. This encounter was probably the precipitating event that ultimately pushed me into considering that it was time for me to make a change.
Soon thereafter, while standing at the top of a spectacularly beautiful mountain pass in Alaska I had a moment of cognitive clarity. When I returned to my tent that night I wrote an email to the hospital president which included the following:
I am retiring 2 years prematurely because institutional constraints at [the facility] has made it impossible for me to provide care to my patients in a manner that meets my professional standards while simultaneously inducing an unacceptable level of stress which occurs when I am unable to meet my own standards. I believe it is for similar reasons that 3 other physicians and one NP have already resigned from [the facility].
It has been five months since I saw my last patient and I now believe I can look back on the events with a bit more objectivity.
The Hurt and Consequences of Moral Injury
Recently two physicians told me about “moral injury.”
Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs. In the health care context, that deeply held moral belief is the oath each of us took when embarking on our paths as health care providers: Put the needs of patients first. That oath is the lynchpin of our working lives and our guiding principle when searching for the right course of action. But as clinicians, we are increasingly forced to consider the demands of other stakeholders—the electronic medical record (EMR), the insurers, the hospital, the health care system, even our own financial security—before the needs of our patients. Every time we are forced to make a decision that contravenes our patients’ best interests, we feel a sting of moral injustice. Over time, these repetitive insults amass into moral injury… The difference between burnout and moral injury is important because using different terminology reframes the problem and the solutions. Burnout suggests that the problem resides within the individual, who is in some way deficient… Moral injury locates the source of distress in a broken system, not a broken individual, and allows us to direct solutions at the causes of distress.
I now understand that the reason I retired two years prematurely was an attempt to protect myself from additional moral injury.
To this day I have not regretted my decision to retire from medicine even though I still believe that being a physician is among the greatest privileges in the world.
I remain furious that our healthcare system is not what it should be. I am mad at the CHIPHIT complex, (the Consolidated Healthcare institutions, the Insurance companies, the Pharmaceutical companies, the Health Information Technology companies) and the Federal Government, who were all complicit in creating the current version of the US healthcare system.
I am also furious at the Massachusetts Medical Society and the American Medical Association for having allowed this to happen. I tried to warn both organizations of what was happening to our healthcare system – but to no avail. Long ago they should have taken a stand against corporate medicine and rallied US physicians against meaningful use, formularies, prior authorizations, insurance company mandates, and all the other daily insults which slowly whittled away the authority and hindered a physician’s ability to take care of their patients.
We now have a healthcare system in which the physicians are vendors; a healthcare system run by corporations whose primary responsibility is to their shareholders and to the bottomline. Quality healthcare is no longer the primary objective. And the situation is about to get much worse as venture capital firms are buying up lucrative medical practices.
The vast majority of physicians, PAs, NPs, nurses, pharmacists and patients would agree that the US healthcare system is not working the way it should. I could cite innumerable academic studies showing objectively that the US healthcare system’s quality is inferior, our costs are much higher, and patient satisfaction is lower than comparable industrialized countries – but that is beyond the scope of this essay.
A few years ago I was talking to the CMO of one of the big, three health insurance companies in Massachusetts. He candidly said to me: “Our healthcare system is not working. We need single payer even though that would put me out of a job.”
I am so tired of listening to the apologist for our healthcare system. I do not want to again hear that “capitalism” will solve our healthcare problems. Capitalism IS the cause of our healthcare problems. It as been the cause for the last five decades and it will continue to progressively convert more of our healthcare system from providing healthcare to enriching corporate America. If we continue to bang our head against this same wall then we assuredly will continue to complain about the same pains. Other countries have demonstrated how to implement a better healthcare system – none of them use a predominately capitalistic model. (Try asking ChatGPT, Bard, or Google: Which 10 healthcare systems provide the best quality and lowest cost. The US will not be on any list.)
Now that I am retired, my wife has commented many times that I am less stressed and happier.
And I am glad I retired when I did.
A few weeks ago I attended my second MIT Grand Medical Hackathon. I reluctantly left the conference early because I did not feel that the problems discussed were going to fix our dysfunctional healthcare system. In hindsight, I wonder if my decision to leave the conference prematurely (I was/am very ambivalent about my decision to leave) was partly a result of my recent experiences with the US healthcare system and my need to protect myself from incurring additional “moral injury.”
I have accumulated a wealth of experience and knowledge which would be helpful to those who are trying to fix our healthcare system. I hope my wounds heal quickly so I can return to assist them in our fight to build the healthcare system Americans need and deserve.
Hayward Zwerling
26 May 2023
Addendum: For physicians who want to learn more about moral injury, I refer you to FixMoralInjury.org.
I’m seeing two conflicting yet connected visions about the future. One is when journalist David Wallace-Wells says we might be in for “golden age for medicine,” with CRISPR and mRNA revolutionizing drug development. The second is the dystopian HBO hit “The Last of Us,” in which a fungal infection has turned much of the world’s population into zombie-like creatures.
The conflict is clear but the connection not so much. Mr. Wallace-Wells never mentions fungi in his article, but if we’re going to have a golden age of medicine, or if we want to avoid a global fungal outbreak, we better be paying more attention to mycology – that is, the study of fungi.
We don’t need “The Last of Us” to be worried about fungal outbreaks. The Wall Street Journalreports:
Severe fungal disease used to be a freak occurrence. Now it is a threat to millions of vulnerable Americans, and treatments have been losing efficacy as fungal pathogens develop resistance to standard drugs.
“It’s going to get worse,” Dr. Tom Chiller, head of the fungal-disease branch of the Centers for Disease Control and Prevention, warns WSJ.
A new study found that a common yet extremely drug resistant type of fungus — Aspergillus fumigatus – has been found even in a very remote, sparsely populated part of China. Professor Jianping Xu, one of the authors, points out: “This fungus is highly ubiquitous — it’s around us all the time. We all inhale hundreds of spores of this species every day.”
We shouldn’t be surprised, because fungi tend to spread by spores In fact, according to Merlin Sheldrake’s fascinating Entangled Life: How Fungi Make Our Worlds, Change Our Minds, and Shape Our Futures,fungi spores are the largest source of living particles in the air. They’re also in the ground, in the water, and in us. They’re everywhere.
That sounds scary, but without fungi, we not only wouldn’t be alive, we never would have evolved. Fungi allowed sea-based plants to colonize land, which led to sea creatures moving ashore, which eventually led to us, among other species. Dr. Sheldrake notes that every plant growing under natural conditions has fungi living with it. They help break down minerals in the soil for plants, among other things.
Without them, we’re nothing.
And that part about taking over animal’s brains, as in The Last of Us, is, in fact, true. For example, they are known to invade ants’ and mice’s brains, causing them to exhibit unusual behavior that gets the animal killed but cause the fungi to spread, which is their goal. As for influencing human’s behavior, the answer seems to be somewhere between “maybe” and “probably.” If you are a fan of hallucinogenic mushrooms, then the answer is “yes.”
In an interview with The New York Times, Dr. Sheldrake argues: “Mycelium [networks of fungal threads] is ecological connective tissue and reminds us that all life-forms, humans included, are bound up within seething networks of relationships, some visible and some less so.” We can ignore them, we can try to fight them, but failing to recognize how we fit into those networks comes at our own risk.
“Fungi aren’t being given enough thought,” Dr. Peter Pappas, an infectious-disease specialist at the University of Alabama at Birmingham, told WSJ. Dr. Andrej Spec, an infectious-disease specialist at Washington University, agreed, adding: “In medicine, fungi are an afterthought. We need a paradigm shift.”
Indeed. As WSJ went on to say:
Many medical schools aren’t adequately training aspiring doctors to identify and treat fungal disease, infectious-disease experts said. Some schools dedicate a couple of hours to the topic, those experts said. “Most fungal diseases are taught in medical school as being rare or unusual or some even regional, but we see these on a daily basis,” said Dr. George R. Thompson, an infectious-disease specialist at the UC Davis Medical Center in Sacramento.
I’m glad that we’re at least realizing the issues that fungi can cause for our health, but I fear we’ll go down the same road we’ve gone down with bacteria. We discovered they could harm us, then found we could kill them, developing an array of antibacterials that could wipe them out at scale, then proceeded to blithely overuse them. To late, we eventually realized that, duh, bacteria become resistant to them over time, and, even worse, we need some bacteria.
We’re starting – barely – to recognize the importance that our microbiome plays in our health, but we haven’t significantly changed our medical education or our practice of medicine to recognize that role. We’re even further behind when it comes to the mycobiome. If we’re barely teaching how to identify and treat fungal diseases in medical school, imagine how much further behind we are in how to use our fungal companions to bolster our health.
Immunologist Barney Graham, a central figure in the development of mRNA vaccines, told Mr. Wallace-Wells: “It’s stunning. You cannot imagine what you’re going to see over the next 30 years. The pace of advancement is in an exponential phase right now.” But, I would argue, if all we do is to build a new array of vaccines and weapons against various microbes, I don’t expect a golden age for our health.
Mr. Sheldrake and others are looking at using, not killing, fungi. They can be used, for example, to create antivirals, to break down pollutants, to create food, to build materials (mycofabrication), and even, as Mr. Sheldrake describes in a new paper, to help us combat climate change through carbon sequestration. They are not our enemy. They were here before us, and they’ll be here long after us.
As Dr. Pappas said, we need a paradigm shift.
It’s amazing that we’ve cracked our genetic code, and even more than we’re now able to edit it. It’s astonishing how we can use imaging to watch our bodies – and even our brains – function in real time, and can use those results to identify problems. It’s exciting that we can use DNA fragments to detect cancers and other illnesses at early stages. But we’re still stymied as to what a “healthy” microbiome is and how that matters to us, much less how our mycobiome interacts with it, and with “us.”
The fact of the matter is that our concept of “us” is an illusion. We are a network, of our own DNA, cells and processes, and of all the other organisms that coexist with us. Our health is a network effect; we’re only healthy when that network is in balance.
We’re not getting to a golden age of medicine and biomedical innovation without fungi.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor
I’m seeing two conflicting yet connected visions about the future. One is when journalist David Wallace-Wells says we might be in for “golden age for medicine,” with CRISPR and mRNA revolutionizing drug development. The second is the dystopian HBO hit “The Last of Us,” in which a fungal infection has turned much of the world’s population into zombie-like creatures.
The conflict is clear but the connection not so much. Mr. Wallace-Wells never mentions fungi in his article, but if we’re going to have a golden age of medicine, or if we want to avoid a global fungal outbreak, we better be paying more attention to mycology – that is, the study of fungi.
We don’t need “The Last of Us” to be worried about fungal outbreaks. The Wall Street Journalreports:
Severe fungal disease used to be a freak occurrence. Now it is a threat to millions of vulnerable Americans, and treatments have been losing efficacy as fungal pathogens develop resistance to standard drugs.
“It’s going to get worse,” Dr. Tom Chiller, head of the fungal-disease branch of the Centers for Disease Control and Prevention, warns WSJ.
A new study found that a common yet extremely drug resistant type of fungus — Aspergillus fumigatus – has been found even in a very remote, sparsely populated part of China. Professor Jianping Xu, one of the authors, points out: “This fungus is highly ubiquitous — it’s around us all the time. We all inhale hundreds of spores of this species every day.”
We shouldn’t be surprised, because fungi tend to spread by spores In fact, according to Merlin Sheldrake’s fascinating Entangled Life: How Fungi Make Our Worlds, Change Our Minds, and Shape Our Futures,fungi spores are the largest source of living particles in the air. They’re also in the ground, in the water, and in us. They’re everywhere.
That sounds scary, but without fungi, we not only wouldn’t be alive, we never would have evolved.
Fungi allowed sea-based plants to colonize land, which led to sea creatures moving ashore, which eventually led to us, among other species. Dr. Sheldrake notes that every plant growing under natural conditions has fungi living with it. They help break down minerals in the soil for plants, among other things.
Without them, we’re nothing.
And that part about taking over animal’s brains, as in The Last of Us, is, in fact, true. For example, they are known to invade ants’ and mice’s brains, causing them to exhibit unusual behavior that gets the animal killed but cause the fungi to spread, which is their goal. As for influencing human’s behavior, the answer seems to be somewhere between “maybe” and “probably.” If you are a fan of hallucinogenic mushrooms, then the answer is “yes.”
In an interview with The New York Times, Dr. Sheldrake argues: “Mycelium [networks of fungal threads] is ecological connective tissue and reminds us that all life-forms, humans included, are bound up within seething networks of relationships, some visible and some less so.” We can ignore them, we can try to fight them, but failing to recognize how we fit into those networks comes at our own risk.
“Fungi aren’t being given enough thought,” Dr. Peter Pappas, an infectious-disease specialist at the University of Alabama at Birmingham, told WSJ. Dr. Andrej Spec, an infectious-disease specialist at Washington University, agreed, adding: “In medicine, fungi are an afterthought. We need a paradigm shift.”
Indeed. As WSJ went on to say:
Many medical schools aren’t adequately training aspiring doctors to identify and treat fungal disease, infectious-disease experts said. Some schools dedicate a couple of hours to the topic, those experts said. “Most fungal diseases are taught in medical school as being rare or unusual or some even regional, but we see these on a daily basis,” said Dr. George R. Thompson, an infectious-disease specialist at the UC Davis Medical Center in Sacramento.
I’m glad that we’re at least realizing the issues that fungi can cause for our health, but I fear we’ll go down the same road we’ve gone down with bacteria. We discovered they could harm us, then found we could kill them, developing an array of antibacterials that could wipe them out at scale, then proceeded to blithely overuse them. To late, we eventually realized that, duh, bacteria become resistant to them over time, and, even worse, we need some bacteria.
We’re starting – barely – to recognize the importance that our microbiome plays in our health, but we haven’t significantly changed our medical education or our practice of medicine to recognize that role. We’re even further behind when it comes to the mycobiome. If we’re barely teaching how to identify and treat fungal diseases in medical school, imagine how much further behind we are in how to use our fungal companions to bolster our health.
Immunologist Barney Graham, a central figure in the development of mRNA vaccines, told Mr. Wallace-Wells: “It’s stunning. You cannot imagine what you’re going to see over the next 30 years. The pace of advancement is in an exponential phase right now.” But, I would argue, if all we do is to build a new array of vaccines and weapons against various microbes, I don’t expect a golden age for our health.
Mr. Sheldrake and others are looking at using, not killing, fungi. They can be used, for example, to create antivirals, to break down pollutants, to create food, to build materials (mycofabrication), and even, as Mr. Sheldrake describes in a new paper, to help us combat climate change through carbon sequestration. They are not our enemy. They were here before us, and they’ll be here long after us.
As Dr. Pappas said, we need a paradigm shift.
It’s amazing that we’ve cracked our genetic code, and even more than we’re now able to edit it. It’s astonishing how we can use imaging to watch our bodies – and even our brains – function in real time, and can use those results to identify problems. It’s exciting that we can use DNA fragments to detect cancers and other illnesses at early stages. But we’re still stymied as to what a “healthy” microbiome is and how that matters to us, much less how our mycobiome interacts with it, and with “us.”
The fact of the matter is that our concept of “us” is an illusion. We are a network, of our own DNA, cells and processes, and of all the other organisms that coexist with us. Our health is a network effect; we’re only healthy when that network is in balance.
We’re not getting to a golden age of medicine and biomedical innovation without fungi.
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt
On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.
I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.
Joining Matthew Holt (@boltyboy) on #THCBGang on Thursday June 22 at 1PM PT 4PM ET are delivery & platform expert Vince Kuraitis (@VinceKuraitis); privacy expert and entrepreneur Deven McGraw (@HealthPrivacy); and back after way too long of an absence, health economist Jane Sarasohn-Kahn (@healthythinker).
The video is below. If you’d rather listen to the episode, the audio is preserved from Friday as a weekly podcast available on our iTunes & Spotify channels
We know from the current annual report from the Medicare trustees that Medicare Advantage is saving Medicare, and that Medicare will be a much stronger program as Medicare Advantage continues to grow.
When we look at actual numbers from that report, we see that Medicare Advantage cost Medicare $403.3bn last year.
The report shows that Medicare is growing 6.7% each year in total revenue. We see that Medicare Parts A and B have expense growth that slightly exceeds 8%, and that Medicare Advantage is projected to have expense growth of 4.2% for the year.
That means we’re losing money from the fee-for-service part of the Medicaid program — and that is eating into the Medicare trust fund. We also can see that Medicare Advantage is making a surplus for Medicare, and is increasing the size of the fund.
We know that Medicare Advantage bids against the average cost of Medicare in every county to create the capitation levels for each year. Those bids are typically discounted by 15% (or more) from the average Medicare cost.
Those discounted bids cost Medicare less in actual dollars each month. The Medicare Advantage critics speculate about coding levels for the plans, but the Medicare trust fund doesn’t care about codes.
They only care about actual dollars. When you look at actual dollars, we see that Medicare spent $403.3bn to pay for the coverage with Medicare Advantage plans.
Medicare Advantage costs less than Medicare because the plans deliver much better care in many key areas. Fee-for-service Medicare for low-income people has some of the highest blindness rates in the world.
Medicare Advantage plans have quality goals and processes that are anchored on the medical reality that you can reduce the blindness rate by 60% when blood sugar is controlled for diabetic patients. So the plans all have blood sugar management goals and their performance in those areas improved under Covid.
Low-income Medicare patients for fee-for-service Medicare have some of the highest amputation rates in the world. Medicare spends billions on amputations. The Medicare Advantage plans all know that 90% of the amputations are caused by foot ulcers.
They know that we can reduce foot ulcers by more than 40% with dry feet and clean socks. They have much lower costs for amputations, because over 90% of the Medicare Advantage special-needs plan patients have clean socks.
The Medicare Advantage capitation levels and benchmarks are based on using the average cost of fee-for-service Medicare in every county as the starting point for the process. The plans have much better care in a number of areas, so the plans bid at discounts that exceed 15% from those Medicare average cost levels.
The plans still make a profit from those lower bids, because care is so much better. The program was designed as part of the Affordable Care Act to take the possible profits for the plans and turn them into higher benefits for the members.
That worked extremely well.
The plans offer dental, vision, and hearing benefits along with other community support benefits from the profits they make with better care. Fee-for-service Medicare is an extremely poor and expensive care purchasing and delivery process. The average cost of care that sets up the bidding benchmarks in every county for the plans creates a cashflow that is a much better and more competent use of the Medicare dollar than traditional Medicare.
Some of the plans use their profits from those bids to buy Medicare Part D drug coverage for their members. Medicare Part D is an extremely good and solid program for getting prescription drugs to Medicare members. The plans both work with that program to provide the right drugs, and they sometimes even pay the Part D premiums for their members from the profits.
That payment of that premium does not increase the overall cost of Medicare. The profits that were needed to buy that Part D coverage were actually included in the $403.3bn total cost of Medicare Advantage that we saw in the trustee report.
Medicare broke even overall this year on the reserve levels. We know from the fact that Medicare Advantage capitation costs will increase by 4% this year, in the face of the overall program receiving 6.7% in additional revenue, that every member of Medicare Advantage will financially strengthen Medicare.
The highest-need and the lowest-income Medicare members have dual eligibility for both Medicaid and Medicare. Some of those members have been badly damaged by social determinants of health issues and inequities. And some of them actually received team care for the first time in their life when they enrolled in Medicare Advantage Special Needs Plans.
The costs are also lower for Medicare when that happens. The 2023 Medicare trustee report said that Medicare Part A had a decrease in their expenses when some of the most expensive patients enrolled in Medicare Advantage Special Needs Plans. That’s far better care for those members.
The Medicare Advantage Payment Increase for 2024 is now Projected to be 3.32%
What we know for an absolute fact from that trustee report, is that the $403.3bn expense that we saw for 2022 for Medicare Advantage will not grow beyond the 6.7% income increase level that we’ll see for the Medicare program overall. CMS is currently projecting a 3.32% increase in the payment for 2024.
We know that we’re absolutely safe and financially secure with the long-term financial future for those Medicare Advantage members, because there’s no possible combination of circumstances or processes or transactions that can achieve what the Health Affairs pieces have been projecting explicitly and directly about the future bankruptcy of Medicare, based on Medicare Advantage upcoding processes.
Those warnings never made sense to anyone who looked at the obvious and highly visible fact that the plans were already discounting their prices 15% from the average cost of Medicare. And there was nothing to be gained by having higher codes in any of those areas as a source of revenue for the plans.
That was a fake news process, but it has had followers. We need everyone to now look at the actual Medicare trustees 2023 annual report and then look at the 2023 Medicare Advantage and Part D Rate Announcement from CMS, and have that information from those credible sources give us a chance to relax, enjoy, understand, and appreciate the financial future that the current payment model now creates for us all — and how well that payment approach is doing right now for Medicare.
CMS eliminated any possibility of upcoding in 2020. CMS replaced the actual coding system in 2020 with individual encounter reports, which include the diagnosis information for each patient.
That data is now current and close to perfect.
You can see from the CMS payment directions, and from the actual 2023 rate announcement narrative, that encounter-based data-gathering approach is what we use now for every plan. They report actual encounters as opposed to coding anything in a way that creates those negative outcomes that critics claim are happening.
You can see from the CMS reports, and from the current trustee report, the correct data is resulting in a 4.2% increase in plan revenue for next year. That low increase in plan cost is actually saving Medicare in a very gentle, useful, and effective way.
Anyone challenging that conclusion will see it validated entirely in a year from now. The 2024 Medicare trustees report will show how much Medicare Advantage will cost in 2025, how strong the trust fund is now, and how strong it will continue to be.
George Halvorson is Chair and CEO of the Institute for InterGroup Understanding and was CEO of Kaiser Permanente from 2002-14.
Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system.
Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.
These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.
So I wondered: what would a dynamic map of our healthcare system look like?
I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system. Now repeat for the millions of other ecosystems in our healthcare system. If that kind of dynamic mapping — showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system — wouldn’t lead to health care reform, I don’t know what would.
Knowing there is a problem isn’t enough. Effectively acting on the problem is the key, and this is where Ms. Pahlka’s insights come in. She is the Founder and former Executive Director of Code for America, a Deputy Chief Technology Officer in the Obama Administration, and Co-Founder of U.S. Digital Response. The common thread, as discussed in her book, is that governments and other non-profit entities can use technology much more effectively.
We often blame outdated technology for how slowly, and how poorly, government often responds to problems, and there is some truth to that, but Ms. Pahlka looks deeper. “We’ve been trying to fix this problem with more money for technology in government, more oversight and more rules,” she told WBUR. “And the evidence shows that’s not working. We got to take a different approach.”
The key, she believes, is less emphasis on the policy – driven by legislators or the executive branches – and more on implementation. “They see implementation as a sort of detail that less important people should deal with,” she says. “And until we change that, we’re going to continue to have problems getting the outcomes we want.”
Ms. Pahlka describes how hard working employees – some call them bureaucrats – try to respond to new laws/initiatives involving technology by generating massive requests for proposals, which they then try to outsource to vendors. It doesn’t usually work well (you could ask the VA and Cerner about that).
She urges that all those people who are charged with implementation must have more say in design and requirements. To use her example, just because someone tells you to build a concrete boat, you shouldn’t necessarily just try to build a concrete boat.
“The alternative to the status quo is pretty fundamental,” she told Nextgov/FCW. “It is moving from a structure in government… in which information and power flows one way — down — to something that is far more iterative and collaborative, where we stop conceiving of the implementers as at the bottom of a waterfall.”
She went on to say: “Product managers are able to say, ‘this has to make sense to a person.’ They’re translating. They’re designing the policy in a way that makes sense to a person,” In a different interview, she quotes General Stanley McChrystal: “Don’t do what I told you to do. Do what I would do if I knew what you know on the ground.”
How many executives, healthcare or otherwise, give their employees that freedom? How might our healthcare system be different if everyone involved in implementation of any policy stopped to ask: does this make sense to a patient?
In an article in The Atlantic, Nicolas Bagley offers: “In other words, Pahlka’s book isn’t just about tech. It’s about the American administrative state.” They’re both referring to government, but I’d argue that, sometimes for the better but usually for the worse, that’s what our healthcare system has become. Not a place of caring but of administration. Shame on us.
Really none of this is necessary and I think sometimes, we think the system is designed to make it hard and that is obviously sometimes true, but very often, it’s simply not designed at all. We have these policies and processes and tech systems like at the EDD that have simply accreted over time and it’s not so much the difference between user-friendly design and what we would call in tech user hostile design, but more kind of the difference between any design at all and just letting it accrue and accrete. Sort of a no design.
Tell me that all doesn’t ring entirely true for our healthcare system.
She offers another important piece of advice, aimed at government but applicable to healthcare: “I mean, I like to say technology and software is something you do. It’s not something you buy. You may buy tech tools, but if you’re trying to get things done through technology, it has to be a core competency and something you actually do.”
In 2023, in healthcare, technology has to be something you do.
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Some people fear cities are dying. Many believe governments can’t do anything right. And everyone thinks our healthcare system is dangerously dysfunctional. We need new ways of seeing them, as Professors Picon and Ratti are trying to do, and new ways of bringing about change, as Ms. Pahlka is recommending. If you think that’s impossible, Ms. Pahlka reminds us: “First, it’s important for people to understand that we the people have created this culture.”
Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.
Last weekend’s New York Times headline, The Moral Crisis of America’s Doctors, spotlights that there is growing concern that the monetarization and corporatization of nursing and medical professions by hospital and insurance power houses, have seriously undermined the mental health and ethical effectiveness of health care professionals. The pandemic has only heightened the crisis.
Since focusing on the social science of Medicine in the 1990’s in Philadelphia, it has been an uphill battle to convince leaders in and out of Medicine that doctors and nurses are critical to individual and societal success. Recently, I’ve come to the conclusion that this may have more to do with a general lack of knowledge of our form of governing, democracy, than a misunderstanding of the stabilizing effect of professional doctors and nurses.
What is democracy? For an answer I turned to John J. Patrick PhD, professor emeritus in history, civics and government at the Indiana University. In his “Understanding Democracy,” he explains that democracy as we know it is a “startling new development.” The practice of rule (krater) by the people (demos), or “demokratia,” dates back 2500 years to Athens, Greece. Citizens did rule by majority vote, but only free males of Greek descent could rise to the status of “citizen.” In those days, individual freedoms took a back seat to unconditional support of the city-community.
Establishing a modern democracy in America has been a bit of a struggle.
Our concept of a “representative democracy” allowed elected representatives to act on behalf of the citizens with the goal of achieving “majority rule in tandem with protection of minority rights.” By 1920, democracy was somewhat more inclusive and slowly gaining global recognition as a form of government. At the time, there were 15 democracies worldwide. But by the end of the 20th century, there were 100 representing 2/3rds of the global population.
The ascendant nature of democracy reflected changes and adjustments of the ancient model. Dr. Patrick has highlighted a few of those changes including:
“Democracy in our world implies both collective and personal liberty.”
“Differences in opinions and interests are tolerated and even encouraged in the public and private lives of citizens.”
“Unlike democracy in ancient times, which directed citizens primarily to serve the community, the primary purpose of government in a modern democracies is to serve and protect all persons under its authority and especially to secure their inherent rights to liberty and safety.”
“In an authentic democracy, the citizens or people choose representatives in government by means of free, fair, contested, and regularly scheduled elections in which all adults have the right to vote and otherwise participate in the electoral process.”
“Popular sovereignty prevails; the government rules by consent of the people to whom it is accountable.”
Democracies are anchored by Constitutions which define the the responsibilities of the various counter-balancing branches of government, and jury a system of laws or rules that apply to all citizens. The Constitution defines the limits on the power of government. It is a tricky balance. The democratic government must be powerful enough to maintain law and order. Yet it must be sufficiently restrained to avoid oppressing individual liberty.
Federalist No.51, dealt with this delicate balance, stating: “If angels were to govern men, neither external nor internal controls on government would be necessary. In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed, and in the next place oblige it to control itself.”
Dr. Patrick suggests that the rapidly expanding popularity of democracy as a form of government is its promise to deliver “ordered liberty…combining liberty and order in one constitutional government…an authentic democracy.”
This requires confidence and trust that is able to reach down into the community. It requires liberal amounts of compassion, understanding and partnership. It requires real time processing of individual fears and worries. And it requires hope.
The roughly 1 million physicians and 4.2 million Registered Nurses at their best, deliver all of the above to all comers. They are neither saints nor sinners. They are human. Those of us who have spent time educating and managing this workforce, have appealed to their sense of professionalism and their oaths of duty. We’ve reinforced that living under our impossibly high expectations is, after all, what they signed up for. Historically, in most cases, they have delivered beyond our expectations.
I see health professionals as front-line educators and defenders of democracy. As Dr. Patrick notes, “If there would be ‘government of the people, by the people, and for the people’ – Abraham Lincoln’s pithy phrase about the meaning of democracy – then there must be education of the people about what it is, how to do it, why it is good, or at least better than the alternatives to it.”
But learning in democracy, as in health care, is an intimate affair. It requires that people “touch each other.” Neither AI, nor the latest mRNA technology, can cure “what ails us.” The solutions are distinctly human.
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