Slowly but Surely

Dear Loyal Readers: with persistent effort, a new book inspired by this blog is gradually coming together.

With luck (and a little more focus on my part) The Art of Risk: A Physician’s Notes on Better Healthcare will be available in early 2018.  Stay tuned!

Here is a (very) early mockup of the cover.

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A Hiatus

Dear loyal readers:  

After nearly three years of blogging at American Healthcare, it’s time for a several-month break and for a chance to work on other things.

A new project is underway: more to come as it evolves!



Healthcare’s Age of Acceleration


I recently finished Thomas Friedman’s excellent book, Thank You for Being Late: An Optimist’s Guide to Thriving in the Age of Accelerations. In it, Friedman makes that case that we are living through an unparalleled time, marked by what he calls “accelerations” that are happening faster than humans are able to adapt.  He argues that we are living through the most dramatic inflection point since Gutenberg and the subsequent Reformation in Europe.

15544113057_23824f069e_zFriedman argues that the three primary forces shaping events are advancements in technology, global interconnection and climate change.  What is notable about these three forces is that they all show signs of exponential change, not linear.

As an example, here is an illustration from the book showing the exponential drop in the cost of DNA sequencing, plotted against the trajectory that we would have seen according to Moore’s law (which would predict a doubling of computing power every 1-2 years).


The problem with these “hockey-stick” exponential curves is that technological change happens more and more quickly (aided by the”standing on the shoulders” of earlier technology).  The change happens faster than human’s abilities to adapt.


I’m taken by Friedman’s arguments.  I’d argue that one of the reasons that healthcare workers have felt so discombobulated over recent years is exactly this issue of unimpeded technical acceleration that exceeds physician’s abilities to acclimatize.

Atal Gawande touched on this during his Stanford commencement speech in 2010, reprinted in the New Yorker:

The truth is that the volume and complexity of the knowledge that we need to master has grown exponentially beyond our capacity as individuals. Worse, the fear is that the knowledge has grown beyond our capacity as a society. When we talk about the uncontrollable explosion in the costs of health care in America, for instance—about the reality that we in medicine are gradually bankrupting the country—we’re not talking about a problem rooted in economics. We’re talking about a problem rooted in scientific complexity.

Besides discombobulating physicians, I’d argue that scientific and technical complexity also threatens to overwhelm patients. Our ability to do increasingly exceeds our ability to decide what to do… You can see this dynamic during every complicated end of life discussion, where the technical promise of immortality seems often at odds with human needs.

In an earlier post I wrote about the concept of “human scale”

In philosophy and design circles there is a concept known as “human scale”.  The general idea is that we humans are best able to engage with a world that is similar in scale to the way we are built. In a universe that ranges from atomic to cosmos-sized, measured by time periods ranging from subatomic to geologic, we humans optimally engage with what the brilliant scientist Richard Dawkins calls the “Middle World.”

This Middle World is measured in pounds and feet, and in minutes and lifetimes.  Steps, corridors and wall-heights in our buildings reflect the length of our legs. Our senses and intuitions work best at this scale: nobody has “commonsense” ideas about the orbit of an electron, but we do about, say, catching a bus. When things become too big or complex, they can become abstractions and our “commonsense” no longer applies.

Here’s my bet: going forward, physicians aren’t going to need to be technical experts.  Instead, in the age of computer learning, the physician is going to need to be the person who makes healthcare human scale.  That’s the important work ahead.

Friedman, incidentally, arrives at a similar conclusion.  He writes:

…the highest-paying jobs in the future will be stempathy jobs— jobs that combine strong science and technology skills with the ability to empathize with another human being.

Photos:  Don McCullough cc license, Flikr


On the Tragedy of the Commons: the Toxic Effects of Drug Co-Pay Coupons

Last week I was driving through Phoenix when I saw this sign at an intersection:


It struck me that this was a perfect example of what happens when clever business folks figure out a way to short circuit the normal laws of consumer behavior.    How’s it work?  Bring your car in and the glass shop bills your insurance company directly and either rewards you with cash, or at least pays your deductible.  Presumably folks who have insurance that will pay a lot get the $100 and folks with lower-end insurance only get $50… It’s a perverse incentive which disrupts the usual laws of consumer economics.

Driving, I was immediately reminded of a similar situation in healthcare:  pharmaceutical copay coupons.  A couple of weeks ago HBS professor Leemore S. Dafny and colleagues published a compelling perspective piece in the New England Journal discussing the corrosive effect of “copayment coupons” offered by manufacturers directly to consumers.

Like the auto glass example , these pharmacy coupons given to patients and are used at the point of sale to offset the patient copays.  For example, using a copay coupon, a patient can purchase a $1000 drug at less out-of-pocket cost (to him) than a comparable $20 generic which might have a $5 copay.  The net effect: aggregate pharmacy costs past on the the insurer are far higher because there is no patient incentive to use less expensive but comparable generics.

savings-card-newpageMy favorite example of this is the contemptible drug Nexium, which for all purposes interchangeable with the generic Prilosec (Omeprazole).  (In fact, before it was non-generic, Prilosec was the “purple pill” [™ I’m sure] and Nexium inherited the title once omeprazole was generic at pennies a pill).

According to GoodRx, today 30 tablets of Nexium cost $300 cash price at most national pharmacies, whereas 30 tablets of generic Prilosec cost just $24.  For the user using the Nexium Savings Card, Nexium costs $15 as compared to a generic co-pay that might be $20.

The problem with the coupons is that they dramatically undermine the insurance company’s/ PBM’s abilities to “tier” medication, which is the primary leverage they have over pharmaceutical manufacturers. Dafny writes:

By severing the link between cost sharing and the value generated by a drug, copayment coupons can undo the beneficial effects of tiering. With such coupons, consumers’ cost sharing may actually be lower for higher-tier brand-name drugs than for lower-tier therapeutic substitutes or generic bioequivalents. Since insurers typically cover about 80% of the total price of a prescription, however, the combined amount that the insurer and the consumer spend for higher-tier drugs remains substantially greater.

According to the authors, over half of all non-generics now have coupons available.  It’s come at a terrible cost to the system:

We estimate that coupons increase the percentage of prescriptions filled with brand-name formulations by more than 60%. Back-of-the-envelope calculations suggest that, on average, each copayment coupon increased national spending on all drugs by $30 million to $120 million over the 5-year period following generic entry. In our sample, consisting of 85 drugs facing generic competition for the first time between 2007 and 2010, we estimate that spending on the 23 drugs with coupons was $700 million to $2.7 billion higher than it would have been if the coupons had not been issued or had been banned.

At the end of the day, this Jiu-Jitsu at the point of sale only drives up the aggregate cost of medication, which is then necessarily passed onto consumers in the form of higher premiums.  As an old colleague was fond of saying, and which I repeat often, healthcare is a balloon: squeeze one area and another bulges.  This spigot of money flowing to the drug companies needs to be offset by reduced spending elsewhere, or by higher annual premiums.  It’s a perfect example of the tragedy of the commons, where individual users acting independently according to their own self-interest behave contrary to the common good of all users by depleting resources through their collective actions.

If you think that these increased premiums don’t matter, consider Ms. Rosa Ines Rivera, a cafeteria worker at Harvard’s School of Public Health who, with colleagues, is on strike, primarily to protest proposed increases in health insurance costs that Harvard wants to pass to employees.  I was struck by an opinion piece she submitted to the New York Times yesterday:

Why is the administration asking dining hall workers to pay even more for our health care even though some of us pay as much as $4,000 a year in premiums alone? I serve the people who created Obamacare, people who treat epidemics and devise ways to make the world healthier and more humane. But I can’t afford the health care plan Harvard wants us to accept……the cost of premiums alone could eat up almost 10 percent of my income.

It’s the same conversation that many employers and employees are having, as they realize that drug company revenue “optimization” has come at a steep cost to the average American.

Specialists and Practice Guidelines: On the Cash Cow in the Room

Here’s a personal story about medical overuse and willful ignorance. Stay tuned for the punchline.

First, a little background: a couple of weeks ago I came across a great study on medical overuse, specifically adherence to national recommendations published in 2012 regarding the use of the PSA (prostate specific antigen) blood test to screen for prostate cancer. Continue reading

The Employee “Shrug” is the Moment When Your Extraordinary Startup is no More: On Reversion to the Mean

I have family in Canada, and so often find myself flying from Boston to Toronto. There are two ways to fly:  you can take Air Canada from Logan to Toronto’s International Airport a couple of times a day.  Or, for the past 10 years, you can fly on a small turboprop operated by Porter Airlines from Logan to a small municipal airport located on an island in Toronto’s harbor.

Since it started flying in 2010, I’ve always preferred Porter because it’s a scrappy little airline that successfully disrupted the big guys by offering great service, friendly staff and easy airports.  To me, the airline was always a textbook example of how small entrepreneurial companies that have a relentless focus on the customer can win.

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Squeezing the Balloon:  Thoughts on a High-risk, Low Margin Business

I recently ran into an old colleague who works as a consultant to one of the large national pharmacy chains.  We got to talking about the various clinical services that the pharmacy has explored over the years, beyond low acuity retail care.  It turns out that, after an auspicious start, the big national pharmacies are increasingly shying away from providing clinical care and are beginning to lease their in-pharmacy clinics to local healthcare systems to run.

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