Entries in Reform & Regulatory (4)


Imagining the Future Us

By Kim Bellard, October 17, 2018

One of the most thought-provoking articles I've read lately is Tom Vanderbilt's Why Futurism Has a Cultural Blindspot in Nautilus.   In it, he discusses how our technological visions of the future seem to do much better on predicting the technology of that future than they do the culture in which they will be used. 

As he says, “But when it comes to culture we tend to believe not that the future will be very different than the present day, but that it will be roughly the same. Try to imagine yourself at some future date.... Chances are, that person resembles you now.” We need to keep this in mind when thinking about the future of healthcare: not just the nifty new technologies we'll have, but who and how we expect to use them. 

All too often, especially in healthcare, we develop technology to solve incremental issues, not foundational ones.  All too often, especially in healthcare, we develop technology and then try to fit it into our existing culture, rather than imagining the culture we want and developing technologies to help achieve it.

It's not so hard to imagine how technology will change what health care is likely to look like in the not-so-distant future. But, like imagining that "office of the future" in the 1960's, what will the healthcare system in which they are used look like? 

Here are some open questions about the culture in which all these cool technologies will be used. Will we live in a culture:

  • that accepts health problems becoming financial disasters for some people?
  • in which poor people can expect to get less care, to be less healthy, and to live less long?
  • in which where you live dictates how well and how long you live, and the quality and quantity of care you receive?
  • that treats social determinants of health and public health as secondary considerations?
  • that treats health as primarily a medical concern, with too many people delegating responsibility for their health to their healthcare professionals and expecting some kind of medical interventions to deal with any health problems?
  • that expects "treatment at any cost for any chance," especially for terminal issues? 
  • that treats services like dental, vision, or "custodial" care as step-children?
  • with an ever-growing array of medical experts? 
  • that treats medical expertise as primarily a local/state-level issue, rather than a   national/international  one?  

If the healthcare system of the future looks pretty much like the healthcare system of today, just with more and better tech, we will have failed.  And probably be broke. 

We need a different culture for health, and that culture needs new designs.  Marcus Engman, the former head of design for Ikea, told FastCompany:  “I want to show there’s an alternative to marketing, which is actually design.  And if you work with design and communications in the right way, that would be the best kind of marketing, without buying media.”

I read that and I think "healthcare."  Substitute "health care" for "marketing" in Mr. Engman's quote and we start to get to what Steve Downs calls Building Health into the OS -- that is, designing to make health an integral part of our daily lives.  That's design.  That's a culture change.

We have a culture of health care -- or, more accurately, of medical care -- rather than a culture of health.  Technology can exacerbate this, or help change it.  It's up to us to imagine the future in which we're most likely to be healthy.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


First, Let’s Blow Up All the Hospitals

By Kim Bellard, August 27, 2018 

A few recent stories are, I believe, reaffirming one of the big problems about healthcare: hospitals are 19th century institutions operating under 20th century business models in the 21st century. It’s time to rethink what we want a “hospital” to be.

The Boston Globe reported on Stanford’s new Lucile Packard Children’s Hospital, which cost a cool $1.3 billion and is touted as, of course, the “hospital of the future.” As they describe it, it doesn’t look like a hospital at all, but rather: “It is some hybrid of hotel, museum, and high-tech laboratory.” The Globe notes a similarly ambitious, $1.2 billion renovation at Boston Children’s, along with big hospital projects in numerous other cities.

The problem is that hospitals are big and getting bigger, going from building to buildings to campuses. They are expensive and getting more expensive. At some point, we have to ask: is this really how we want to spend our healthcare dollar?

Some hospitals are figuring other ways to spend their — I mean, “our” — money on our health. Take Nationwide Children’s Hospital. Located in a somewhat blighted neighborhood of Columbus (OH), its Healthy Neighborhoods Healthy Families (HNHF) program “treats the neighborhood as the patient,” as their summary in Pediatrics put it.

The hospital is leading a partnership that has built 58 affordable housing units, renovated 71 homes, given out 158 home improvement projects, and helped spur a 58 unit housing/office development. They’ve also hired 800 local residents and instituted a jobs training program. They’re already seeing lower murder rates, higher high school graduation rates, and are studying impacts on emergency room visits, inpatient days, and rates of specific conditions such as asthma.

“This is a national trend,” Jason Corburn, professor of city and regional planning at the University of California, Berkeley, told NPR. “It’s happening in cities across the country,” citing similar efforts in Atlanta, Boston, New York, and Seattle.

It is true that hospitals (excuse me, “health systems”) are diversifying — building/buying satellite locations, free-standing emergency rooms, urgent care centers, and physician practices — but those big buildings remain the locus, and their sunk costs weigh on hospitals’ finances.

There’s a great quote from Philip Betbeze of HealthLeaders: “the future of the hospital is not a hospital.” The future requires, as Richard Darch, CEO of Archusmore recently wrote, “radically and fundamentally rethinking the hospital, and even discarding the term ‘hospital’ to the history books.”

I’d go further: not a building, not even a campus, but as a dispersed array of services — some medical, many not — that are delivered as close to our homes as possible (and, preferably, in our homes).

It requires us blowing up our concept of a “hospital.”

Don’t donate money for hospital expansion/renovation plans. Don’t buy bonds for them either. Don’t sit passively on hospital boards that push for them or expensive new equipment.Instead, we should be questioning: how can a “hospital” most impact our communities’ health? What kinds of investments in our communities’ health can they be making? How we do push healthcare and health down as close to where and how people live as possible?

The argument will always be, well, payors won’t pay for those kinds of things. The business models don’t support them. To that I say: it’s time not just for new kinds of “hospitals,” but also new kinds of business models.

Let’s get to it.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting



My Care. Your Rights

by Kim Bellard, June 27, 2018

I have, it seems, been laboring under a misconception. All these years I liked to believe that the healthcare system was about the patient. That was naive. I knew that a few people in healthcare were too focused on the money part of things, but what I was not paying enough attention to was that, for some healthcare professionals, what they do is about their beliefs, not my care.

The case in point was the recent situation in Peoria, Arizona, where a young woman was denied service by her pharmacist. Nicole Arteaga was nine weeks pregnant when her doctor told her the baby’s development had ceased. The doctor gave her an option for a surgical procedure or for a prescription drug that was likely to cause her to miscarry, and she choose the latter.

The pharmacist understood what the drug did, questioned why she was taking it, and refused to refill it due to “ethical reasons” — which is permissible under Arizona law (and in several other states). As she detailed in a Facebook post:

Ms. Arteaga ultimately was able to fill her prescription at another pharmacy — across town . What if there hadn’t been another pharmacy in town, or another pharmacist who didn’t have a “moral objection” to filling her prescription? What if, for medical reasons, there hadn’t been time to investigate other options?

Example number two: the Supreme Court just overturned a California law that required “crisis pregnancy centers” to tell pregnant women about the availability of abortion services. These centers typically oppose abortion on religious grounds. Justice Kennedy concurred with the majority, claiming: “Governments must not be allowed to force persons to express a message contrary to their deepest convictions.”

Governments have, of course, for years had no qualms about requiring abortion providers provide a number of messages that are contrary to their deepest convictions — some states require that they require pregnant women to get medically unnecessary ultrasounds before obtaining an abortion! — but apparently it matters whether you agree with the message or not.

None of this should, in 21st century America, be a surprise. We now have a “Conscience and Religious Freedom Center” within HHS, aimed at protecting “health care providers who refuse to perform, accommodate, or assist with certain health care services on religious or moral grounds.”

But it is not just federal law and it is not just about abortions. In Texas, for example, pharmacists have “exclusive authority” about whether to dispense a drug. They can choose when they do not wish to, and they don’t have to explain why then they opt not to.

Where does the line get drawn? What about a healthcare professional refusing to treat gay patients? What about one refusing to treat minority patients? What about male healthcare professional refusing to treat a female patient?.

You see, it’s not supposed to be about their religious or moral beliefs. They have every right to have them, and to express them. But when someone becomes a healthcare professional, it’s not supposed to be about them or their beliefs. It is supposed to be about what is best for the patient. It is about using their medical knowledge and training to help the patient as best they can, to the utmost of their abilities.

Our healthcare professionals don’t have to be like us. They don’t even have to like us, and they certainly don’t have to agree with us. But when we can’t depend on them doing what is best for us, then we’ve got a real problem.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting


A Visit to Planet Gawande

By Clive Riddle, June 22, 2018

We still don’t know much at all about what the heck the Amazon-Berkshire-JPMorgan healthcare triumvirate will be doing. But we do now know who will be running it. The renowned Dr. Atul Gawande has been appointed its Chief Executive Officer, effective July 9th.


 The announcement quotes Atul: “I’m thrilled to be named CEO of this healthcare initiative. I have devoted my public health career to building scalable solutions for better healthcare delivery that are saving lives, reducing suffering, and eliminating wasteful spending both in the US and across the world. Now I have the backing of these remarkable organizations to pursue this mission with even greater impact for more than a million people, and in doing so incubate better models of care for all. This work will take time but must be done. The system is broken, and better is possible.”

Amazon’s Jeff Bezos says “we said at the outset that the degree of difficulty is high and success is going to require an expert’s knowledge, a beginner’s mind, and a long-term orientation. Atul embodies all three, and we’re starting strong as we move forward in this challenging and worthwhile endeavor.”

For those who don’t already know all there is to know about Atul Gawande, let’s take a quick visit to Planet Gawande and check out the man who will be commanding the mystery ship Amazon-Berkshire-JPMorgan.

Atul’s website homepage succinctly provides this description: Atul Gawande is a staff writer for The New Yorker, and author of four books; (2) Atul Gawande practices general and endocrine surgery at Brigham and Women’s Hospital; and (3) Atul Gawande is Executive Director of Ariadne Labs, a joint center for health systems innovation. Of course, item #3 will require editing. As the already updated Ariadne Labs website announces “Atul Gawande transitions to Chairman and becomes CEO of new health care organization.”

What are Atul’s roots? He was born in 1965 in “Brooklyn, New York, to Indian immigrants to the United States, both doctors. His family soon moved to Athens, Ohio, where he and his sister grew up, and he graduated from Athens High School in 1983.”

As an undergraduate and in medical school, he dived into the worlds of politics and healthcare policy. He volunteered for Gary Hart's and Al Gore's presidential campaigns. He served a health-care researcher for Rep. Jim Cooper (D-TN). He became Bill Clinton's healthcare lieutenant during the 1992 campaign. He served as senior HHS advisor after Clinton's inauguration and directed one a committee in the Clinton Health Care Task Force, before returning to medical school, re3ceiving his MD in 1995.

During his residency his career as a writer launched with Slate, and soon he was writing essays for the New Yorker. His June 2009 New Yorker essay, The Cost Conundrum was widely read and influential,  in which he compared the health care of two towns in Texas to show why health care was more expensive in one town compared to the other.. He continues to occasional whip out New Yorker Essays, with these being the titles of his works during the past 18 months:

  • Curiosity and What Equality Really Means, The New Yorker, Jun 2, 2018
  • Is Health Care a Right?, The New Yorker, Oct 2, 2017
  • How the Senate’s Health-Care Bill Threatens the Nation’s Health, The New Yorker, Jun 26, 2017
  • Trumpcare vs. Obamacare, The New Yorker, Mar 6, 2017
  • Trumpcare, The New Yorker, Feb 27, 2017
  • The Heroism of Incremental Care, The New Yorker, Jan 23, 2017

He has also written more technical papers and studies in journals including the New England Journal of Medicine and has authored four books:

Of Gawande’s most recent book, Malcolm Gladwell wrote, “American medicine, Being Mortal reminds us, has prepared itself for life but not for death. This is Atul Gawande’s most powerful – and moving – book.”

Of course, the platforms from which Gawande has drawn the experiences and perspectives that he writes about is from being a clinician, researcher and academian. He practices general and endocrine surgery at Brigham and Women's Hospital in Boston, Massachusetts. He is a professor in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health and the Samuel O. Thier Professor of Surgery at Harvard Medical School.

His outside affiliations have included Ariadne Labs where he has been Executive Director, Lifebox, Safesurg.org, WHO Safe Surgery Saves Lives initiative and the Center for Surgery and Public Health.

Ariadne Labs might be the most instructive, in regard to the approaches Guwande might take in his new gig. Ariadne Labs is a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health, founded in 2012 by Gawande and others.

Here’s more about Ariadne Labs direct from their website – which says their mission is “to find solutions to some of the most complex problems in health care, including life-threatening errors in surgery, maternal and neonatal mortality, failures in end-of-life care, and fragmented and ineffective primary health care systems. Leveraging a network of expertise across the Harvard-Brigham system, Ariadne Labs’ designs, tests, and spreads simple solutions to address failures in health care delivery worldwide.”

Here’s what Ariadne Labs lists as its more prominent innovations:

  • The Surgical Safety Checklist, developed in collaboration with the World Health Organization, shown to reduce post-surgical deaths and complications by 47 percent worldwide.
  • OR Crisis Checklists, a compendium of 12 checklists to guide surgical teams through critical lifesaving steps when sudden emergencies occur in the OR. In simulation testing, Ariadne Labs demonstrated that when the checklists are not used, clinical teams completed only 77 percent of lifesaving steps in an emergency. When the teams used the checklists, they completed nearly 100 percent of lifesaving steps.
  • The Safe Childbirth Checklist, developed with the World Health Organization to address the major causes of maternal and neonatal mortality. Implemented with Ariadne Labs BetterBirth Program of peer-to-peer coaching, the intervention has demonstrated significant improvement in the quality of care during labor and delivery in low-resource settings.
  • The Delivery Decisions Team Birth Project, a solution package aimed at reducing C-section rates in the U.S. by improving communication between clinicians and laboring women, defining the basic care women in labor should receive and prioritizing women’s preferences for care. The project is being tested with tens of thousands of patients across the United States.
  • The Serious Illness Conversation Guide, a structured tool to help clinicians and patients have meaningful conversations about what matters most to patients. The guide is the centerpiece of the Serious lllness Care Program, a systems-level intervention to ensure that all patients with serious illness receive care that aligns with their goals and values.
  • The Primary Health Care Vital Signs, a global data resource for measuring and monitoring the strength of primary care systems in countries around the world, developed with the World Bank, WHO, and the Bill and Melinda Gates Foundation as part of the global Primary Health Care Performance Initiative.

We’ll all stay tuned to see what happens next on Planet Gawande.