Monday, February 25, 2013

The Destructive Recreation of Health Care

A dark wind is beginning to blow through the tortured landscape of health care in America. At the confluence of the corporate cold front with the warm front of technology innovation, a storm is brewing. A storm that may grow into gentle and much needed rain showers, or the grandest tornado ever experienced by mankind, and unlike the wondrous works of nature, the path taken here is completely within our control. The US government and all its federal, state and local branches spent over 1 trillion dollars of our tax money on health care for the poor, elderly and disabled last year and we spent well over 1.5 trillion dollars of our own on health care for everybody else. Most of these monies are going to medical service delivery systems, some is going to financial management intermediaries and a fraction is going to companies providing services to these corporate entities.

Obviously, this level of expenditure is unsustainable, and when we look at other developed countries, we realize that we could be spending a lot less for similar results. However, this is America, and while we must find a way to reduce the number of dollars spent on health care, we must do so without adversely affecting our health care corporate citizens.  This leaves us with two options. One is to simply not provide care to some of us some of the time, i.e. lower the volume and increase profit margins, and the other is to find cheaper ways to provide health care at higher volumes with lower margins. As long as the sum total of corporate profit remains unchanged (or happily improves), any combination of the above should work well for our purpose. Since we are a monetary democracy, we will have to carefully combine strategies so that moneyed citizens continue to enjoy the same levels of service, while the less savvy voting masses do not perceive significant rationing or cheapening of their health services. The non-voting folks are obviously free to perceive whatever they want.

The first thing to do is to change the discourse from all antiquated and touchy feely definitions of health care to a more modern conversation about consumer goods and services, which in a free society implies well understood variations in quality, availability and ability to purchase, based on one’s socio-economic status, closely mirroring our three groups of citizens described above.
The second thing to do is engage the fiery wave of information technology sweeping the planet. In the realm of consumer goods, information technology is accomplishing nothing short of magic by transforming traditional goods, like books, into electronic services, and by orchestrating the manufacturing and distribution of everything else. Many service industries, such as banking and travel, have also been transformed from labor intensive enterprises to largely computerized electronic transaction hubs, with very little human intervention needed, and mostly insensitive to geographic location. These transformations resulted in lower prices, lower expectations, increased availability and convenience for paying consumers, paired with record profits for corporations. Seems like the perfect solution for our health care puzzle.

So we begin by transitioning medical record keeping from paper to electronic format, and by standardizing medical transactions so they can be eventually captured by predictive algorithms that will accept standard inputs from consumers and industry knowledge bases, resulting in the dispensation of standard medical advice pretty much on demand. Very much like using Travelocity to book a vacation. If you are a physician, you are probably growing a bit uncomfortable at this point, because this is precisely the type of work you do now.  But wait, we are not as ignorant as you think. We completely understand that some medical transactions require human touch and that even the best medical algorithms still need some form of supervision, but do we really need an overeducated doctor for every routine medical encounter? For very simple things, the autonomous algorithms should be just fine, for medium complexity a trained technician oversight should do the trick, and for complex stuff, or for people with lots of money, a doctor can be added to the mix. This model of operations kills two birds with one stone. It immediately solves the artificially induced shortage of educated physicians, making more of them available for the wealthy, and it drastically reduces the cost of medical care for the masses because technicians don’t need formal education and uneducated workers can be both cheap and plentiful. We just need to secure a good supply of people without any formal education, by convincing everybody that absence of education is now the ticket to a good job and middle class status. And here is where our ominous meteorological event is now unfolding.

In a JAMA article almost a year ago, Drs. Emanuel and Fuchs began by defining the “obsolete” physician, “an incisive diagnostician and empathetic clinician, a productive researcher, and a scintillating teacher”, as a “triple threat” and terrified us all at the mere thought of encountering such a dangerous creature in real life. They then propose a new model based on the assumption that people are incapable of excellence, and “no physician can be a competent triple threat”, therefore why bother trying. Instead, we should apprentice most medical students to be practitioners of a narrow trade, and leave scientific research activities and critical thinking (a.k.a. autonomy) to a select few. This should shorten training periods, lower costs of training, and obviously we wouldn’t have to pay these guys as much, once the “threat” is eliminated. In a more recent article in the Atlantic, Jonathan Cohn is advancing the thesis one step further. After exploring the emerging wonders of algorithm driven medicine, and drawing from the expertise of medical quality beacons, such as Tanzania, India and Brazil, Cohn is suggesting that health care will prove to be the salvation of the “middle class”, because “[i]f technological aids allow us to push more care down to people with less training and fewer skills, more middle-class jobs will be created along the way”.  Middle class jobs, according to Mr. Cohn, are those that “don’t require college or a bachelor’s degree, just a technical program”. So our uniquely American solution to the health care problem is two pronged: eliminate as much expensive education from medicine as possible, and simultaneously ensure that the vast majority of citizens are devoid of enough education to know the difference.

This pioneering stance in health care is reverberating through other realms as well, and reinforcing the notion that technology has freed us from the need to educate ourselves and our children. The Economist for example is taking on the legal profession, which may not be as education intensive as medicine, but it still commands large consumer prices. Instead of educated attorneys, why not use computerized algorithms provided by at a fraction of the price? And most importantly we should allow investors to buy legal firms and employ (uneducated) lawyers so they can create a more efficient legal system for consumers. Sort of like the miracle solution now applied to health care, where professional people are forced to surrender their autonomy, and now their education, to shareholders and managers. The term efficient here, as in health care, means that ethics and obligations to put clients/patients first are superseded by financial needs of the few, and cheapness needs of the impoverished many. Having professionals stripped of their education and economic power is only half the job to be done. If we are to be successful in reducing prices of everything down to the new "middle class" levels of affordability, without significant civil unrest, we have to make sure that we maintain the ratios of educational attainment, between our new professionals and the typical consumer, constant. To that end, we must convince everybody that we are in an education “bubble” and sending our kids to college is detrimental to the realization of the American Dream in this technology era. Or as Mr. Charles Murray gently puts it in a CATO institute Quarterly Message on Liberty “the BA is the work of the devil”.

In a letter to Charles Yancey dating from 1816, Thomas Jefferson stated that “If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.” The education Thomas Jefferson thought was necessary in his times had very little to do with picking cotton and making nails. Similarly, in our current “state of civilization” the prerequisite education to freedom has nothing to do with learning a technical trade to better serve the corporate masters of computer algorithms, which seems to be the preferred prescription of the educated elite, liberal and conservative alike, for everybody else. The only question remaining, before we swallow the pill of voluntary ignorance, which has been shown to work for the benevolent tyrants ruling the United Republic of Tanzania, is whether the long term side effects of this treatment are congruent with our expectations, or what’s left of Thomas Jefferson’s hopes for the nation.


  1. Good essay. I'm reading it less than an hour after listening to an NPR feature this morning on "labor displacement" in the home building sector.

    In many ways the same dynamic is taking place in health care, driven more by rising costs than the recession. You mentioned the magic word "bubble" in regard to the education industrial complex, but bubbles are everywhere in the economy, protected from bursting by a growing number of special purpose, profit-driven interests. The education industrial complex embraces all kinds of enterprises from tech schools that promise job training but with no connection with actual employment to just about any curriculum requiring "student loans" having more to do with the banking industry than education.

    Health care is one of the biggest bubbles of all, growing like an invasive species in the fertile profit-driven soil of tax and insurance revenue streams. The footprint of most health care systems in America is often as big as an industrial park. There are so many clinics, labs, private practices, specialty centers, agencies, imaging centers, retail outlets selling durable equipment and disposables, pharmacies, the list is endless. And that doesn't take in to account the ancillary non-medical businesses from window-cleaning, landscaping and waste removal to uniform sales, food service outlets and parking garages. It takes your breath away to think of it. And every dollar supporting this growing monster is in one way or another part of the cost of health care in America.

    As you know, all through the country can be found excellent operations delivering good outcomes at lower costs than most. And the principle difference is something like a reverse economy of scale -- smaller, in this case, is better. It's not necessary to have a score of available (for-profit) imaging, surgical or orthopedic centers inside a half-mile radius when one or two can deliver the same results, quicker and more economically, and under the same ACO umbrella.

    No one seems to be noticing, but we are watching the deflation of a bubble as big as any in our lifetime. And the smaller it gets, the more it will improve, in both quality and costs.

    1. Hello John,
      You may be right about health care and all those other industrial complexes we allowed to grow like weeds, but my concern here is a bit more limited and more precise, and at least for me, absolutely terrifying.

      I don't want to see those expensive services in all sectors replaced with stuff tailored for not only poor people but more importantly for uneducated people. I don't want to see education being redefined as job training. I want doctors and grocery store cashiers and everybody in between to have a fair chance at reading Shakespeare.

      As de Tocqueville remarked almost 200 years ago "There is hardly a pioneer's hut that does not contain a few odd volumes of Shakespeare. I remember that I read the feudal drama of Henry V for the first time in a log cabin."

      We cannot and should not give this distinction up. There is no other way to sustain democracy.