Dear Madam/Mister Future President

As I am writing this, you don’t yet exist, and I hope you never will. As I am writing this, at least half a dozen people are still standing in the quadrennial jousting tournament we call elections. Elections in America is that brief and fleeting period of time when Washington DC turns its gaze to the rest of the country feigning passionate interest in our lives. This time around America is staring back at you in seething anger. In the olden days, this would be the proper time for tar and feathers, for pitchforks, and for burning you in effigy. Nowadays, this is the time for Twitter trolling and lack of what you call decorum in public discourse. Like all well fed, self-described benevolent aristocrats in the past, you seem surprised at our indifference to your accomplishments, and shocked at our plebian preference for rough and tumble champions of our own choosing.

Try not to worry too much. Time, and the robust voter suppression machine you and your “donors” built over centuries of enlightened democracy, is on your side. You will prevail. There will be no impractical socialist in the White House, and no vulgar businessman will be allowed to touch the intricate web of global domination your donors weaved over decades of hard work and heroic determination. Not peacefully. Not without a violent American Spring. Not in our lifetime. Not while you have a good “ground game” to get votes. Not while you have big data to “profile”, “target” and “persuade” voters. There really is nothing I want to tell you, or ask of you, because I know precisely what you will be doing in the next four years, but let’s continue this farce where you pretend to be a public servant, and I pretend to be an engaged citizen.

You are obviously “electable”, which means you passionately advocate for nothing in particular, in long erudite sentences that rise at the very end (like JFK). You certainly look “presidential”, which means that you’re not too fat or too old or too short, your nails are trimmed and your hair is combed.  You addressed every policy nook and cranny in your issue-oriented debates, in your canned stump speeches and in your ten point policy proposals that will become obsolete once the last polling station closes on November 8th. But there is one thing nobody is talking about. No clever moderator is asking, no candidate is volunteering an opinion, let alone a “plan” to tackle what is perhaps the defining issue of our times.

“It's about the next 20 years. In the '20s and '30s it was the role of government. '50s and '60s it was civil rights. The next two decades are going to be privacy. I'm talking about the Internet. I'm talking about cell phones. I'm talking about health records and who's gay and who's not. And moreover, in a country born on the will to be free, what could be more fundamental than this?” –Sam Seaborn, The West Wing, Episode 9: The Short List (for Supreme Court appointees), 1999

The events of the new millennium do not seem to support Sam Seaborn’s prediction, and your campaign is stark testimony that privacy is to be forfeited without much pushback from any quarters. We could argue that principled liberals of the previous century were ill equipped to appreciate the true benefits of the Faustian deal we are now making with the Lords of the Global Digital Panopticon. One could also argue that since the days of Sam Seaborn, privacy has become all but extinct, and lo and behold the sky of freedom hasn’t fallen. Or has it?

Let’s take a quick look at your campaign operations. Did you avail yourself of a voter database? Are you paying for special software that “appends the richest set of consumer and interest data, allowing the most sophisticated targeting” of voters? Do you employ an army of techies in the basement of your national headquarters, like the landmark Obama digital campaign did? Do you have an app on iTunes that tracks your “supporters”, their friends and their families, everywhere they go? Is your voter segmentation machine spitting out properly scripted “messages” at the most opportune time for the most receptive individuals? Do you think this is what Thomas Jefferson meant by freedom and liberty? Or do you think that’s what your kindergarten teacher meant by lying and cheating? Do you even care?

Politics in an age without individual privacy is as principled as marketing toilet paper. Your brand is softer, stronger, more absorbent, bigger, smaller, whiter, greener, and very much preferred by wild bears in the forest. You stand for nothing and everything. You stand for moderation in the North and you stand for God in the South, and you stand for Nelson Mandela to offset all the white old men who manage your campaign. You stand for America in the abstract, and use personal misfortunes of citizens to illustrate your history book, but even if your poor mom or dad were of the people, you have long ago ceased to be one of us. The reason we are asked to vote for you is the same reason we are asked to choose Charmin instead of Cottonelle, with the same de minimis consequences.

Now let’s take a look at Obamacare, which you are certain to tinker with, one way or another. In your mind, Obamacare is about money. It’s about premiums, deductibles and percent uninsured, but if that’s all Obamacare was about, it wouldn’t have required hundreds of densely typed pages, and it wouldn’t have triggered a tsunami of lesser legislations now percolating through Congress. In reality, Obamacare is how your donors use the latest technology to ensure that future elections are free from glitches that allow old communists and potty mouthed billionaires to come close to disrupting a carefully constructed world order. Obamacare is not about a human right to health care and it’s not about keeping Americans from dying in the streets, as your rogue competitors seem to believe. Obamacare is how Google, Apple, Facebook, Amazon (GAFA), and their Silicon Valley brethren, take control of human life on earth, and get rich beyond the dreams of avarice.

Obamacare is about replacing personal and slow medicine, with high-tech, high-speed, precision medicine administered through metallic algorithms supplied by your donor community. Obamacare is about managing expectations (you should be familiar with that little game), to make the busywork of tracking and scoring citizens seem like medical care. Obamacare is about shifting the locus of medical decision making from individual people and their doctors to the invisible hand of computerized bureaucracy. Obamacare is to health care what high-speed trading is to stock markets. To this end, Obamacare must unleash a biblical flood of personal information for its doomsday machines to consume, and dutifully share with other stakeholders, such as your campaign software vendor. Any remote notions of physical and mental privacy are therefore obstacles to progress.

Perhaps it is logical that your party and the other party as well, have viciously turned on their front runners in an effort to select a nominee with the best ROI record for those who consider themselves owners of a global humanity.  Perhaps it’s not by accident that Obamacare which was first known as HillaryCare, and then as RomneyCare, may eventually be known as BushLeagueCare. Perhaps, as our own, bought and paid for, disruptive innovators love to point out to their less enthusiastic colleagues, this is all inevitable. Perhaps, but somehow, at some point in this long game, the courts will have to weigh in and decide if the framers of our Constitution intended to set up a government whose sole function is to capture and deliver its citizens to global moneyed interests for lifetime exploitation.

This Saturday, Justice Antonin Scalia died. In this election year the usual and customary horse trading to seat an “acceptable”, thus by necessity mediocre, judge on our Supreme Court bench for life, may not be an option. The insurmountable task of nominating the next Supreme Court Justice may land in your lap, pretty much on your first day in office. There is a bold and beautiful solution to this quandary, a grand bargain that rises above your petty party politics, and for that you’d have to turn again to the liberal fantasy called The West Wing (Season 5, Episode 17: The Supremes, 2004). Unless the Obama administration, which over the years exhibited a peculiar interest in reenacting The West Wing, beats you to it, you will get to appoint (unopposed) two Supreme Court Justices and the rare opportunity to stand “in the gaze of history”.

Unfortunately, whether you belong to Clan Clinton or are hailing from the Bushes, I am having difficulty imagining you giving up any perceived party advantages for the sake of judicial excellence on the Court. I can certainly imagine the angry socialist and the mercurial businessman rising above the pettiness, but this wasn’t meant to be. Not this year. The next four years are yours, and you will need to hurry up and bolt the doors and bar the windows. A really big war, preferably in Europe, would help tremendously. Either way though, your days are numbered. We are no longer progressive or conservative. We are either feeding at your trough or we are not, and there are many more of us than there are of you, and one of these days we will have nothing left to lose. Not even our privacy.

The Era of Value Based Care

The Centers for Medicare and Medicaid Services (CMS) is working hard to transition physicians’ payments from volume to value of services. The current Acting Administrator at CMS is a former top executive at United Healthcare, a commercial health insurance corporation. The previous Administrator at CMS is currently the president and CEO of America’s Health Insurance Plans (AHIP), which is the dominant health insurance lobbying group. It may therefore behoove us to rephrase the opening sentence: The corporate-government health care conglomerate is working hard to transition physicians’ payments from volume to value of services.

In response, health care delivery corporations, which are employing large numbers of physicians, are joining their forces through mergers, acquisitions and other arrangements to better manage the transition of physician payments from volume based to value based models. When you ask the architects of this supposedly tectonic shift from volume to value to explain their enterprise, you get back lengthy dissertations about better service at lower cost due to computerization, analytics and standardization of an industry long overdue for modernization. The basic argument is that health care in the U.S. sucks on many levels, and proper management that employs the latest technologies and business methodologies will fix everything that needs fixing.

But what does it mean to pay doctors for value instead of volume? Does it mean that we don’t pay physicians unless we get better? Does it mean we don’t pay for health care unless we are “kept” healthy by our doctors? Does it mean that we don’t pay a red cent for advice or procedures that we judge worthless? How long do we have, post service, to decide if what the physician did was valuable? Thirty days? Five years or 50,000 miles whichever comes first? A lifetime? The answer emerging from opinion pieces published by members of the corporate-government conglomerate, which are intended to soften the ground before official rules and regulations are promulgated, is much simpler and should be much more familiar to any small business owner, or anyone who visited a restaurant or a hotel.

So here is how this is envisioned to work. Physicians will still get paid a base amount per service provided. If the corporate-government conglomerate judges the work of the doctor to be beneficial, they will throw in a 5% gratuity bonus. Moving forward, if physicians can reduce the overall COGS (cost of goods sold) for the corporate-government conglomerate, they will get a moderate percentage of net profit. Finally, if doctors are willing to take full P&L (profit and loss) responsibility for health care services, they can get a slightly bigger piece of the profit to offset the risk of massive loss. Essentially, if you are a physician, and if you agree to do what the corporate-government conglomerate wants you to do, and if you are really good at it, and if you are willing to put your money where your mouth is, you should expect nothing but financial prosperity in the era of value based care.

The things you would have to do to enjoy the value based financial bounty are not very difficult, particularly when compared to the practice of medicine. The goal is to keep the corporate-government conglomerate happy without distinguishing yourself from the generic woodwork of the new system. There is safety in the herd, and you should aim to be somewhere close to the middle of the herd. Stragglers, and those who venture too far out in front, are usually eaten. Below are a few strategies to help you position yourself for long and uneventful survival.

Percentage Medicine

If you dabbled in the game of tennis, whether as a player or an avid spectator, you are probably familiar with the term “percentage tennis”.  Playing percentage tennis means staying away from corners and lines and spectacular shots. It means playing it safe, taking little if any risk, getting the ball over the net without fanfare, and absolutely no aces on serve. Percentage tennis is how middling players, who lack exceptional talent or physique, are advised to play the game. Serena Williams is not playing percentage tennis. Great champions never do.

If you like to think that you are a great doctor, brilliant diagnostician, or anything else preceded by some sort of superlative, tone it down. This is not about excellence. It’s about percentages. Wasting your precious time on the quickly fading Miss Henrietta Wilkins, who spent the Great War welding big chunks of metal in the shipyard, and a variety of other losers, who will never bring their biometric indicators up to corporate-government conglomerate standards, is not considered good percentage medicine. Ideally, you could ship these folks to the nearest community center, but if you can’t, see if you can reassign them to your NP/PA, or some outsourced care management service, and stay away from direct contact. If you want to personally help people, you should consider volunteering in a soup kitchen on Wednesday afternoons.

Generally speaking, seeing patients one-on-one is not a good use of your time. Your initial efforts should be directed to shaping a robust patient panel that can be managed by your care team working at the top of their license. Later on you should switch to maintenance mode and work the analytic dashboards, Excel sheets, pie charts, bar charts, and all the reports and data provided to you by the corporate-government conglomerate. These things are usually marked with red-yellow-green risk indicators, so it’s not that difficult to get started. Watch your reds. If they’re amenable to change, have your staff change them. Otherwise find a way to quickly remove them from your panel. Don’t neglect the yellows either, because if you’re not careful, they have a tendency to turn red without much advance notice.

This is how percentage medicine is played. This is population management and this is also precision medicine because some of those colored risk scores are accurate to the second, or even third, decimal point which is something your over educated human brain could never calculate on its own. As long as your panel looks green, but not too green, because that may be indicative of gaming, you should be safe. If you feel a sudden urge to jump back in and play doctor, maybe with an ominously red marked patient, resist it. Go take a brisk walk around the block or listen to a motivational TED talk. Try making a nifty Power Point presentation for the next leadership meeting (Power Point art can be very relaxing) or book some travel to a health innovation conference.   

Fake it ‘till you make it

When you see patients, and you will have to for a while longer, you will need to present a caring and expert, yet humble, persona that reflects well in satisfaction surveys. You will have to be persuasive, without coming across as overbearing, when you steer clients towards product lines that are most beneficial to the corporate-government conglomerate, which is either your one true customer, or your direct employer. You will have to cultivate an engaging and compassionate image to elicit the trust of your clients. You will need to be friendly, but not too familiar, to maintain a certain aura of non-threatening expertise. You will need to say please and thank you, and you will need to display properly calibrated humility when apologizing for the shortcomings of the new and improved system, without throwing your superiors under the buss.

Since value based health care is a team sport, you will need to cultivate a non-disruptive, non-elitist image to present to the team. The team of course includes representatives of the corporate-government conglomerate, some of whom you will interact with in person, and others who will be watching you through rolled up dashboards and reports. Read a couple of value based policy papers or newspaper articles (they’re about the same as far as depth and substance are concerned), and memorize a few key words and phrases, such as “transformation”, “lifestyle and behavioral modifications”, “less is more”, “consumers want to be kept healthy”, “patient activation”, “triple aim”, “quadruple aim” (there is no quintuple aim yet, but watch for it soon), “our health care system is broken”, “$3 trillion”, “medicine has always been about information processing”, “the single most important thing to have is good data”. Stuff like that. When in doubt, just prepend “patient-centered” to whatever you plan to say next.

After a while, all of this will become second nature. If you get really good at it, you may want to go for a leadership role within the corporate-government conglomerate. It pays much better, and there are decent opportunities for advancement. Another option is to drop out of whatever is left of patient care and join the entrepreneurial side of the house. You can join a startup, or make your own. You need not be a techie or understand technology in any way. Startups are hungry for MDs, so they can advertise products “built by doctors”. Investors love that type of stuff and potential customers still have some residual respect for physicians. It won’t last long, so do it now or you may miss the boat.

One thing is certain though. A passive-aggressive attitude, or its burned-out martyrdom cousin, won’t do you any good. If you really and truly can’t get on board with the destructive recreation of your profession, you’d better quit. Get out and open a boutique cash-only practice or subcontract with one of those hit and run value based telemedicine services for the healthy or just find something else to do. Write a book, buy a little farm and make organic goat cheese, dabble in politics, start a movement. Have some fun. Life is short.

Iowa is voting on Health Care tonight

In his last State of the Union address, President Obama stated that “anyone claiming that America’s economy is in decline is peddling fiction”. I agree. The American economy has roared back from the Great Recession with 14 million new jobs, a ridiculously low unemployment rate, a booming stock market and 57 brand new American billionaires in 2015 alone.

The American people on the other hand are in a completely different boat. Almost a third of us are not working. Half of us have practically no savings and a record number is surviving on public assistance. Wages are stagnating and the middle class is shrinking. Student debt is skyrocketing and 20% of our kids live in poverty. Whereas in the immediate past the economy and the welfare of the people used to be one and the same, nowadays these terms have little if anything to do with each other.

The President did acknowledge that “the economy has been changing in profound ways” and therefore “a lot of Americans feel anxious”. To allay our collective anxiety, the President announced an unemployment program that will pay up to $10,000 to those who lose jobs to the economy fixing racket, money that can be used to retrain machinists, welders, builders and such, to flip burgers in the booming job market of the fixed economy.  The anxiety reduction program will also ease the transition to a “work-sharing” economy, where lower wages and no benefits, augmented by public assistance, a.k.a. the Walmart and Uber models, are the new normal.

Health Care is about the Economy

After fixing the economy, our government is now full throttle ahead with fixing our health care. My expectations would be that health care will be fixed in very short order, with very similar results. Health care expenditures will plummet, uninsured rates will be near zero, quality measures based on cost and utilization will be stellar, and most people will end up with little if any medical care when they fall sick. To ease our anxiety, or in health care parlance, to provide us with “peace of mind”, everybody will be awarded a Medicaid managed care card, if you’re lucky, or a high deductible insurance exchange plan that kicks in after you go bankrupt.

In the midst of the previous century, when people talked about “the economy”, the term conjured visions of molten iron being forged, of combines sliding gracefully through oceans of golden wheat, of gigantic cranes towering over monumental construction projects, of dusty rugged Americans building and making with pride and determination, of former soldiers poring over text books, of men walking on the Moon. Today, “the economy” brings to mind images of stock tickers, conference rooms with sweeping views of Alcatraz or Central Park, fancy men in fancy suits getting in and out of black limos, and endless streams of brightly colored graphs, percentages and statistical trends. The economy is no longer about us.

Health care is no longer about us. Health care is about waste, fraud and abuse. Health care is about “bending the curve”. Health care is about global competitiveness of corporations. Health care is about carving up a $3 trillion opportunity. Health care is about private equity, mezzanine funding, return on investment, valuations and public offerings. Health care is about the economy, and the economy is no longer about us.

Perhaps this was never about us, but if “time is the fire in which we burn”, America was the one unique experiment where a group of people came together to protect each other’s rights to freely determine how they wish to burn. The idea spread a little bit, but not much, and now it is collapsing under the hubris of an Information Revolution, which looks more like a slow motion coup d'état to transfer control of the burning process from millions of hands to a global “digital assembly line” where physical objects, virtual algorithms and human beings are melded into one efficient production system. This is a kinder and gentler slavery nation.

John C. Calhoun

Historically, the enslavement process was physically harsh and cruel, because back then the work of a slave was physically harsh and cruel, and because the only tools available for recruiting and maintaining slaves were physically harsh and cruel. Today you give a guy an iPhone app and he willingly and painlessly joins the driving plantation. You give a guy a free Internet search tool and he unconsciously and painlessly joins the advertising plantation. This is a major improvement, since as grandma used to say, you catch more flies with honey than with vinegar, and from a respectable distance it looks like you’re generously feeding the dumb little critters.

The grand objective of slavery has always been the amassment of wealth by the magnificent few on the backs of the faceless many. The only things that changed over the millennia are the means by which this is accomplished, and the rhetorical subtleties used to justify the practice of slavery. Notably, health care has been playing an increasingly prominent role in the intellectual quackery employed by evil people towards their evil ends. As early as 1837, John C. Calhoun was extolling the superiority of health care benefits available to the enslaved, especially the compassionate palliative care at the end of life, when compared to the “forlorn and wretched condition of the pauper in the poorhouse”.

It never occurred to Mr. Calhoun that there ought to be a third option, that his own young country has challenged the world order by simply stating that all men are created equal, and challenged the most powerful King in the world, and his mighty armies, precisely so that those equally created men can be free men. But John C. Calhoun was not speaking about us. His oration was about the economy, and the economy thrives on servitude, pauperization, and wretchedness, mitigated only by the “kind superintending care” of masters. If John C. Calhoun were alive today, he would probably be running a billionaire foundation to help “all people lead healthy, productive lives”.

Alexander Hamilton

It must have never occurred to Dr. David Blumenthal either that 200 years after our Declaration of Independence, for a brief moment in time, we had a third option. After watching a Broadway show and perhaps reading one biography of Alexander Hamilton, Dr. Blumenthal found it necessary to write the strangest article in defense of the Hamiltonian version of Calhoun’s “superintending” care, which Obamacare essentially is, or aspires to become with the help of its equally superintending technology bonanza. The article is a case study in demagoguery and the building of alternate realities from partial truths and innuendos, which is how health care reform was and still is being advertised to the masses.

Perhaps we shouldn’t be surprised by Dr. Blumenthal’s admiration for Alexander Hamilton, because Alexander Hamilton was not about us. Mr. Hamilton had great misgivings about the “imprudence of democracy”. He admired the British aristocracy, and insisted with all his might that the “first class” of “the rich and well born” should be awarded a “distinct, permanent share in the government” to counterbalance the bad judgement of the masses, and to prevent change to the status quo. If Mr. Hamilton, the champion of strong central government run by financiers and corporations, were alive today, he would probably be equally smitten with what Dr. Blumenthal represents.

This Night in Iowa

Tonight in the great State of Iowa, we the people are kicking off the only peaceful process available to us to make health care, the economy, and the entire political process, about us. This year we seem to have a bountiful crop of candidates seeking greatness. Some are “rich and well born” asserting their Hamiltonian right to that “permanent share” in government. Many are lifelong corporate servants looking for the next step in their pitiful enterprise. And two are very different than the rest. Two are challenging the status quo, which is so near and dear to the “first class” and its vast infrastructure of minions and pundits, feeding at the commandeered public trough, and whose entire job now is to convince us that neither one of these two men are fit for office.

One is a career public servant, a man of principle, of lifelong held beliefs that health care should be about us, and the economy should be about us, and that central government should be by, of and for us. The other is rich and well born, a swashbuckling traitor to his “first class”, who realized that he cannot possibly have a great country when the great majority is enslaved. The two couldn’t be more different in personal style and fiery rhetoric, but at the heart of it all they both want to reclaim the “permanent share in the government” that was stolen from us by the “first class”, and unlike their corporate serving competitors, who say one thing and do another, neither man is accepting patronage from those who they aim to disempower on our behalf.

For decades the “first class” owned media and punditry, carefully nurtured the appearance of an “ideological divide” designed to keep us engaged in mortal combat over hyped minutia, while the enslavement process proceeded at a brisk pace in the background. Tonight, the people of Iowa have the opportunity to begin refocusing our sights on the real ball. This election is not about Republicans vs. Democrats, it’s not about Planned Parenthood or ISIS coming to kill us in little Toyota trucks, it’s not about men vs. women, blacks vs. whites, young vs. old, educated vs. uneducated or poor vs. less poor. This election is about all of us, it’s about being a nation of free people vs. a replaceable cog in the global “digital assembly line”, and it’s about our hard fought right to govern ourselves, centrally, locally and individually.

We can’t make health care about us until we make the economy about us, and we can’t make the economy about us until we make government about us, and we can’t make government about us until we make the political process about us. We can’t make the political process about us until we dethrone the “first class” from its permanent power perch, and deny the “rich and well born” the ability to buy every election and serve us with a nauseating mélange of sleek and polished John C. Calhoun disciples, promising “kind superintending care” for the rest of us.

Tonight Iowa will vote for Bernie Sanders, will vote for Donald J. Trump, or will vote for the status quo. These are our only choices in 2016. Choose wisely, America.

Meaningful Use is dead. Long live something better!

At the J.P. Morgan Healthcare Conference in San Francisco, Mr. Andrew Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), announced on January 11th that “The meaningful use program as it has existed will now effectively be over, and replaced with something better”, and later clarified on Twitter that “In 2016, MU as it has existed-- with MACRA-- will now be effectively over and replaced with something better”. Meaningful Use is dead. Just like that. No apologies. No nothing. As someone who’s been lamenting the havoc wreaked by the program on both doctors and patients, I should be elated nevertheless. Well, I am not.

Let’s start with appearances. The J.P. Morgan Healthcare Conference is the “largest and most informative healthcare investment symposium in the industry which brings together global industry leaders, emerging fast-growth companies, innovative technology creators, globally minded service providers, and members of the investment community”. In other words the event is all about money for the millionaire and billionaire class. J.P. Morgan Chase itself is the largest financial institution in the country. It is the embodiment of Wall Street and its death grip on our collective neck. Was this conference really the best place to make such momentous announcement?

Besides, why would these extractors of wealth be interested in the fate of something as obscure as Meaningful Use? Shouldn’t they discuss more lucrative schemes, such as running all possible blood tests on one tiny blood droplet, or how the makers of Microsoft Office and the largest online retailer of everything are going to jointly solve for cancer? Shouldn’t they be analyzing trillion dollar addressable markets of genomic rainbows, and how mergers, acquisitions and inversions can help squeeze whatever is left in the turnips that are you and me?

Of course they should, and they did all that and much more. But changes to the Meaningful Use program are of strategic importance to all other rainbows, grails and unicorns. Why? Because Meaningful Use, other than funneling a respectable amount of billions of dollars into the health tech sector, is the enabler of data collection which fuels all other investment opportunities. Furthermore, pretty much everything that could be sold to satisfy Meaningful Use, has been sold, so what’s next? As the Meaningful Use money making opportunities are ending, CMS is “moving to a new regime”. Interesting choice of words notwithstanding, the Meaningful Use successor consists of punishing doctors for nebulous “outcomes”, and of course all sorts of new technologies to better transfer all medical data into places where J.P. Morgan clientele can monetize them.

Let’s talk about substance. Meaningful Use has been created by an act of Congress, and enshrined for posterity in a subsequent act of Congress, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). It is not clear to me how a political appointee can invalidate acts of Congress at will, although this probably makes perfect sense in the rarefied circles convened by J.P. Morgan. If nothing else, the absolute confidence that Congress will oblige, and the President of the United States will sign whatever is put in front of him/her by the Wall Street lobby, is a perfect illustration of who is running this country and how it is done. A somewhat less politically disheartening explanation is that the demise of Meaningful Use has been greatly exaggerated in this announcement.

Meaningful Use, as we discussed in the past, is not just about onerous burdens on physicians. It is also about regulating design and production of medical software to serve the needs and wants of government and large corporations. From reading Mr. Slavitt’s remarks, I suspect that the latter effort is far from being over and may actually be greatly fortified under the “new regime”. If you design clever software, and mandate its purchase and daily use, there is very little utility in paying users to show their work, which is what Meaningful Use for physicians really meant. You do however want to keep those unwittingly exploited users calm and cooperative, which may explain why CMS wants to “get the hearts and minds of physicians back”.

Enter the American Medical Association (AMA). While across the ocean, the British Medical Association (BMA) is aggressively supporting its striking members in a nationwide struggle for the soul of medicine, the AMA is launching a “Silicon Valley integrated innovation company” to monetize its members in service to the new CMS regime. In a fortuitous coincidence, the creation of this new “stand-alone, for-profit entity”, Health2047, was announced in San Francisco on the same day the J.P. Morgan conference was convened. The goal of Health2047 is to leverage physicians’ expertise to “help forge new paths and bring commercial solutions to market faster”, and of course to make boatloads of money for investors, including the AMA.

Meaningful Use is dead. Long live something better! And what is that better something? It is paying physicians for outcomes. It is the use of evidence based medicine. It is interoperability and “user-centered” design. It is Accountable Care Organizations, value, patient centeredness, coordination and such. It is also the making of markets “by leveling the technology playing field for start-ups and new entrants”, because when Epic makes money, nobody on Wall Street or in Silicon Valley gets a piece of the action. It is about engagement and analytics and population health, calculations, penalties, incentives and lots of new technology things. It is “like the second generation iPhone”.

After collectively sinking billions of dollars in Certified EHR Technology over the last five years, hospitals and doctors will now be expected to foot the bill for new software and computer products to support the lifestyles of a new generation of Silicon Valley entrepreneurs and the insatiable greed of the old generation of Silicon Valley investors. Why? Because the next app is sure to fix health care in America. It’s always the next one. There is always “something better” you can buy. Planned obsolescence, which is fueling the obscene fortunes of Silicon Valley and destroying life everywhere else, has finally arrived to the $3 trillion health care sector. It took a bit longer than the folks at J.P. Morgan expected, I’m sure, but we’re in business now. Let the good times roll…..

Make Health Care Great Again

Click here to view: Reading of the Donald J. Trump children's book by Jimmy Kimmel

We don’t win anymore in health care. After repeatedly drilling in our heads that America’s sick care system is a disaster, that those who care for the sick are incompetent and stupid, and that the sick themselves are losers, Meaningful Use was advertised as the means by which technology will make health care great again. The program has been in place for 5 years and the great promise of Meaningful Use is just around the same corner it was back in 2011. The only measurable changes from the pre Meaningful Use era are the billions of dollars subtracted from our treasury and the minutes subtracted from our time with our doctors, balanced only by the expenses added to our medical bills and the misery added to physicians’ professional lives.

Meaningful Use, a metastasizing web of mandates, regulations, exclusions, incentives and penalties, is conveniently defined in the abstract as a set of indisputably wholesome aspirational goals for EHR software and its users, which stands in stark contrast to the barrage of bad news flooding every health related publication, every single day. Health care in America used to be the best in the world, but now our health care is crippled. Meaningful Use of EHR technology will improve quality, safety, efficiency, care coordination, and public and population health. It will engage patients and families, and it will ensure privacy and security for personal health information. With Meaningful Use leading the way, health care will be winning so much that your head will be spinning. You won’t believe how much we’ll be winning.

Be afraid, be very afraid

Bombastic? Laughable? Easily dismissible by educated people? Not so fast. According to Dr. David Blumenthal, president of the Commonwealth Fund, and former National Coordinator for Health IT, “we probably have the worst primary care system in the world”. Yes, worst system in the whole wide world, worse than Niger, Malawi and Somalia. Probably. According to a hobbyist “study” that extrapolates its “results” from a handful of other studies based on an admittedly inaccurate tool intended for different purposes, 440,000 people are killed in hospitals due to preventable errors each year – “that's the equivalent of nearly 10 jumbo jets crashing every week”. Or, with a little more math, half of all hospital deaths, and one in six US deaths, are due to negligent homicide perpetrated by psychopathic doctors and nurses.

How is that for buffoonery? I suspect that the beautiful minds appalled at populist or outright racist fear mongering rhetoric claiming that thousands of Muslims were dancing on rooftops on 9/11 in New Jersey, have zero problems with self-servingly stating that “hospitals are killing off the equivalent of the entire population of Atlanta one year, Miami the next, then moving to Oakland, and on and on”, based on equally valid he-said-she-said evidence. Both virulent strains of outlandish demagoguery are insisting that they, and only they, can keep us safe from things that go bump in the night. Supersizing the ghoulies and ghosties and long-leggedy beasties makes us more likely to relinquish control of our lives to those who might deliver us from terror.

The Meaningful Use program rests on a narrative where medicine is witchcraft, our doctors are murderers, our hospitals are cesspools teeming with death, our citizens are Lemmings unable to wipe their noses, and the machines of the illuminati are our only salvation. When the premise of an action is delusional, one cannot expect the outcomes to be anything but.

Smoke and mirrors

When you read “studies” advertising that Meaningful Use increased the rates of mammography by 90% in three months, you should assume that the only thing that was increased is the rate of ticking boxes for stuff that was not documented before, and practically no material changes have occurred. When you feel vindicated by the 99% rate of patients given a clinical summary after each visit, keep in mind that the vast majority of those summaries were posted to a portal that nobody uses, or just fake-printed to PDF, and the few actually given out were dutifully tossed in the recyclable trash bin. When you read about the billions of dollars in tax money successfully spent on Meaningful Use, you should understand that this is just the tip of the iceberg, and the indirect costs to each and single one of us are larger by orders of magnitude.

For most of us simpleton believers, who mistook fiery demagogues for brave-hearted visionaries, the disappointment is a throbbing daily humiliation, manifesting itself in polite low-energy petitions to powerful bureaucrats to take pity on us and roll back some of the most onerous aspects of the program. There are signs indicative of some forthcoming acts of mercy, but those are as disingenuous as the original false narrative of Meaningful Use. After five years of Meaningful Use of EHR technology, the initial hope has failed to translate into promised change. Or has it?

From its inception, the Meaningful Use program had two sets of requirements. One set defines what EHR vendors must build to stay in business, and another set specifies what doctors and hospitals must do to collect gratuity payments from Medicare. Over time these requirements sets began to diverge. Once clinicians became conditioned to compulsively collect data, overt reporting is being replaced with covert extraction through the backend (i.e. application programming interfaces, or APIs). The Certified EHR Technology mandated by the program was never intended to extend abilities of clinicians as much as it was designed to generate standardized measures of their performance. Administrators and regulators cannot control an industry from afar without incessant measurement and the power to reward and punish individual practitioners. Meaningful Use is designed to enable remote control of medicine, its doctors and the people they serve.

We are not alone

Back in 2001 our rulers identified another field where America was losing big time. Education was a disaster, a huge mess with rampant disparities and across the board low quality. Like health care, education of small children is an ideal place for intervention if your aim is to control populations and increase the value derived from each person. With overwhelming bi-partisan support the ruling class passed the No Child Left Behind Act, mandating that all children are above average by 2014. An avalanche of funding for computers, measurements of schools and teachers and incessant standardized testing of students descended upon our schools. For the last fifteen years, schools were engaged in life and death accountability games of reward and punishment, and our children became merely biometric indicators for school and teacher performance assessments.

As 2014 came and went, with many children still stubbornly below average, with multitudes of teachers still burnt out, and education morphing into a misnomer for the standardized testing doomsday machine consuming all but the rich and privileged, the federal government took a step back and passed the Every Student Succeeds Act of 2015. Leaving aside the downright idiotic terminology used for naming acts of Congress, the new legislation is reluctantly beginning a process to diminish federal control of schools. Considering the cumulative damage to our education system, perpetrated by toxic bureaucratic ineptitude which is  crowding out the ability of real educators to address real problems, this halfhearted attempt may very well be too little too late.

Failure is not inevitable

I don’t know about you, but I am getting tired of having to live up to Winston Churchill’s image of America. We don’t always have to try everything else before we do the right thing. We shouldn’t have to wait fifteen years before declaring that in retrospect Meaningful Use was meaningless. We know now that it is. Removing a few reporting requirements for physicians, while beefing up patient scoring measures, is not enough. Playing with reporting periods at the last minute and granting ad-hoc exclusions to make people shut up, is not enough either. Randomly linking physician fees to Meaningful Use EHRs may be enough, but it’s beyond disgusting.  The Meaningful Use program must end. Plain and simple. And most importantly, the underhanded EHR certification schemes must be halted immediately.

Standardization, quantification, computerization, gamification, engagement, and infantilization of the populace in general, do not produce better educated or healthier citizens. Education reform has failed us on a grandiose scale. Health care reform, to which Meaningful Use is foundational, is based on the same failed concepts as education reform. It will also fail in due course and spectacularly so. It is actually failing as we speak and with the exception of elite institutions, which are benefiting financially from as much health care reform as can possibly be inflicted on the rest of us, we all know it’s failing badly. 2016 presents the perfect opportunity to demonstrate to the entrenched perpetrators that in America accountability is a two way street, and value is a freely defined personal concept.

American health care has been hijacked by very bad people, and it’s time for us to quit being sad little losers who just sit there and bitch. It’s time to take our health care back and it’s high time to deliver to those horrible people the thorough schlonging they so richly deserve. It’s time to make American health care great again.

In 2016, resolve to go out and vote. Vote in the primaries, vote in local and general elections, ignore the propaganda, educate yourself and as old Harry Truman advised us all, vote for yourself, for your own interest, for the welfare of the United States, and for the welfare of the world.

Bingo Medicine

It was a dark and stormy night. My computer didn’t catch fire while typing the previous sentence. No alarms were triggered warning me about the quality of such opening. I wasn’t prompted to select subjects and predicates from dropdown lists. I typed the entire sentence, letter by letter, not at all dissimilar to its first rendering back in 1830. Computer software in general, and Microsoft Word in particular, magically removed the hassles of quills, ink, paper, blotters, sharpeners, ribbons, whiteout, carbon paper, dictionaries, and all the cumbersome ancillary paraphernalia needed to support authoring, but made no attempt to minimize the cognitive effort associated with writing well.  Authoring great literature today requires as much talent and mastery as it did in the days of Edward Bulwer-Lytton.
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For several decades, software builders have tried to help doctors practice medicine more efficiently and more effectively. As is often the case with good intentions, the results turned out to be a mixed bag of goods, with paternalistic overtones from the helpers and mostly resentment and frustration from those supposedly being helped. Whether we want to admit it or not, the facts of the matter are that health IT and EHRs in particular have turned from humble tools of the trade to oppressive straightjackets for the practice of medicine. Somewhere along the way, the roles were reversed, and clinicians of all stripes are increasingly becoming the tools used by technology to practice medicine.

A common misconception is that EHR designers produce lousy software because they don’t understand how medicine is practiced. The real problem is that many actually do, and the practice of medicine is precisely what they aim to change. These high clerics of disruptive innovation would have you believe that “resistance to change” is equivalent to the resurrection of paper charts, thick ledgers, and medical information coded in secretive hieroglyphs. The truth is that physicians want to use modern computers, but they resent being used by computers. And the truth is that if we shed the orthodoxy imposed on us by self-serving “stakeholders”, computer software can indeed help address various problems in health care, some in the here and now, most in a distant future.

One thousand and one elements

This may sound strange to some, but the first step towards putting EHRs back on the right track should be to stop trying to help physicians practice medicine. Clinical decision “support” in the form of alerts, disease specific templates, mandatory checklists, required fields and rigid workflows are some of the things that must be removed from EHRs for two reasons. First, most of these “features” don’t work very well anyway. Second, more often than not, the real purpose of said support is not clinical in nature. For example, alerts about generic substitutes for brand name medications, data fields that must be filled and checkboxes that must be clicked to satisfy billing codes, PQRS or Meaningful Use, and the wealth of screens to be traversed before an order can be placed, have no clinical value.  And in most cases the opposite is true.

Some experts argue that EHRs are failing because they are nothing more than an old paper chart rendered on a computer screen. Many others are outraged by the fabled lack of interoperability (dissemination of information) or the lack of EHR usability, i.e. number of clicks, visual appeal, color schemes and ease of information retrieval. I would suggest that these dilemmas are peripheral to the one foundational problem plaguing current EHR designs – the draconian enforcement of structured data elements as means of human endeavor.

When Google mapped the Earth, it did not begin by mandating how to build and name roads and buildings. When we indexed and digitized books and articles, we did not require that authors change the way they write prose or poetry. When we digitized music, we did not require composers and performers to produce binary numbers at equidistant time intervals, and we did not make changes to musical instruments to allow for better sampling.  We built our computerized tools to ingest, digest, slice, dice and regurgitate whatever humanity threw at us, without inconveniencing anybody. This is why good technology seems magical.

EHRs on the other hand, are obnoxiously demanding that people change how they think, how they work, and how they document their thoughts and actions, just so that the rudimentary software prematurely thrust upon them can function at some minimal level of proficiency.  People don’t think in codified vocabularies. We don’t express ourselves in structured data fields. Instead of building computers that elegantly adapt to the human modus operandi, EHRs, unlike all other software tools before them, demand that humanity adjust itself to the way primitive computers work. The self-appointed thought leaders, who are taking turns at regulating the meaningful clicks of EHRs, are basically demanding that we discard the full spectrum of human communications, in favor of gibberish that supposedly serves a higher purpose.

All the pretty horses

What is the purpose of EHR documentation templates? There is practically no EHR in use today that does not include visit templates. Visit templates are a list of checkboxes, some with multiple nested levels, which allow documentation by clicks instead of by typing, writing, drawing or dictation. Visit templates are created for each disease and contain canned text for findings judged pertinent to that condition by template creators. In all fairness, many physicians like documentation templates because with just a few clicks you are able to generate all the documentation required nowadays to get paid for your work, pages and pages of histories, review of systems, physical examination, assessments and plans of care. Do doctors like templates because they believe this extensive documentation is necessary, or do they like templates because the checkboxes alleviate the pain of typing thousands of meaningless regulatory words? I suspect the latter.

Clinical templates, along with the automated clinical decision support they enable, are advertised as time savers for physicians. The time saved is the time previously spent with patients, and most importantly the time spent thinking, analyzing, and formulating solutions. For most, it’s also the time spent rendering thoughts in a manner that can be understood by another person. Furthermore, when your note taking is template driven, most of your cognitive effort goes towards fishing for content that fits the template (like playing Bingo), instead of just listening to whatever the patient has to say. Even in “efficient” practices where staff does the clicking and physicians have the luxury of asking “open ended” questions, the patient story, the quirky details that are irrelevant to the template, are not documented (highlighted, circled, noted on the margins, etc.) anymore. Is this a good thing?

If we proceed on the assumption that IBM Watson and the likes are eventually going to be artificially intelligent enough, and big data are eventually going to be big enough, to respectively analyze and represent a complete human being, then yes, we can safely dispense with old fashioned human expertise. However, we are most certainly not there yet, and regardless of industry rhetoric, we are not certain that we will ever be there, and we are not even sure that we want to ever be there. While this utopia (or dystopia) is portrayed by interested parties as “inevitable”, chances are that for at least several generations we will be forced to contend with imperfect digital renditions of medicine, instead of allowing EHRs to follow the growth of underlying technologies. This is akin to summarily confiscating and shooting all the horses, on the day Henry Ford rolled the first Model T off his assembly line. Where would America be today, if we did that on October 1, 1908?

Furthermore, what type of doctors are we producing when we teach medicine by template, supported by clinical decision aids based on the same template, and assessed by quality measures calculated from template data? Medicine does not become precise just because we choose to discard all imprecise factors that we are not capable of fitting into a template. Standardization of processes and quality does not occur just because we choose to avert our eyes from the thick edges were mayhem is the norm. Dumbing physicians down is not the optimal strategy for bringing computer intelligence closer to human capabilities. EHRs should not be allowed to become the means to stifling growth of human expertise, the barriers to natural interactions between people, or the levers pushed and pulled at will by greed and corruption.

Bildungsroman style

Instead, EHRs could be the scaffolding for IMB Watson and other emerging contraptions to grow and become truly useful tools for both doctors and patients, and yes, also for legitimate and beneficiary secondary uses of clinical information. Instead of mandating that doctors think and work in ways that serve Watson’s budding abilities, we should require that Watson learns how to use the normal work products of humans. Instead of enforcing templated thought and workflows, whether through direct penalties for doctors or indirect certification requirements for software, we should work on teaching Watson how to parse and use human languages in all their complexity. Watson should grow up to be the multi-media scribe behind the computer screen, the means by which the analog music composed by physician-patient interactions is digitized into zeros and ones without loss of fidelity and without interference with actual performance.

Billions of years of evolution endowed the lowliest human specimen with cognitive abilities that machines will most likely never attain. The glory is in the journey though. We need to accept delayed gratification, and we need to accept that the challenge will span centuries, not just one boom-bust cycle of a fleeting global economy. We need to accept the fact that we will all die long before the ultimate goals are achieved, instead of declaring victory whenever each negligible incremental step is taken. If we are going to create a new form of intelligent life on earth, we need to assume the same humility Nature, or God, has been exercising since the dawn of time and counting. Otherwise, we are all just a bunch of hacks looking to make a quick buck on the backs of our fellow men and women.

The Middle-Aged Consumer in the Coal Mine

Whenever you read a health care article, paper, book, blog post or even tweet, that substitutes the term consumers for patients, and the term providers for doctors, or physicians, you should inherently assume that the authors are advocating for something that will not benefit you or the people you care for, something that will most likely harm you financially and if you happen to be less than independently wealthy it will harm you physically in real and immediate ways. These advocacy pieces usually come dressed in the sheep clothing of empowerment, liberation, convenience, savings and democratization, but underneath it all, and often unbeknownst to the authors themselves, there is always an ominous incarnation of the wolf of Wall Street.

Whenever you read something emanating from selfless, do-gooder (usually public or supposedly not-for-profit, but certainly for-revenue) institutions, alliances, consortia, coalitions, and such, note how you are always addressed in the third-person plural. There is no “we” in what passes as enlightened health care conversation. As Dr. Victor Montori astutely observed, there is no “sense of a shared fate. Of a shared journey with our kin.” The wolves of Wall Street, and the hyenas of Silicon Valley dancing at their feet, have no kin and no intention of sharing in our fate.

Consumers and providers are a uniform mass of transactional entities, neatly described by a finite number of discrete financial events. Consumers and providers are hence computable entities. You don’t often see articles about consumers being sad or happy, consumers laughing or crying, consumers falling in love or dying. Providers are never sued for malpractice, never accused of fraud, never disillusioned and they never commit suicide. The vocabulary used for consumers and providers requires that we strip everything human from the subject matter, and leave all that is mercenary and precisely quantifiable in dollars and cents. As the consumer/provider vocabulary is ported to health care, the entire endeavor by necessity is divesting itself of human considerations, including kinship and any remaining sense of a shared fate.

Consumers, although sometimes patronizingly described as savvy, are not assumed to possess any particular wisdom. The only discriminatory behavior ascribed to consumers is the ability to discern cheap from expensive. Consumers are expected to incessantly shop for consumable stuff, like so many rats frantically searching for bits of cheese in a carefully constructed maze. We are expected to shop when things are hunky dory and when things are down in the dumps. We are ordered to shop in the face of national tragedies, and now we are ordered to shop when personal tragedy strikes as well.  We are ordered to shop for life saving medicine. We are ordered to shop for surgeries, and we are ordered to shop for “relationships” with our “providers”. We are effectively ordered to shop for dear life, and to “share” and “rate” our shopping “experience” to better inform the maze designers.

The government of the United States wants us to shop for health insurance every twelve months. Health insurance companies want us to shop for cheap services all through the year. ProPublica and the unparalleled paragon of social beneficence called Yelp, are volunteering to help us do a better job at shopping for “providers”. Glitzy startups like Amino, will “harnesses health Industry data for consumers”, to show us some information about some doctors, for no particular reason and free of charge, because “the initial goal is to create an appealing product, and then figure out a business model later”. Yes, it makes perfect sense that Mr. Vinod Khosla and company would sink almost $20 million in something not projected to have any returns. After all, the entire Silicon Valley Empire was built this way, and now the time has finally come to fully align health care with Silicon Valley and Wall Street ways of doing business.

A fundamental shift in how we are being programmed to think about health care is therefore underway. The rather recent term “consumer-centric healthcare” is now brazenly accompanied by musings on who will be “herding” consumers’ medical records. Following the subtle transformation of health care to “healthcare”, we are beginning to shift the conversation to just “health”, because the “care” part seems redundant. Health care is not too expensive because insurance companies operate like Columbian drug cartels and pharmaceutical companies are essentially drug cartels. Health care is not too expensive because hospitals are coalescing into regional and national monopolies, unchecked and undeterred by the perpetually fund-raising legislative and administrative corps of career politicians. Health care is not too expensive because people who work for a living haven’t gotten a raise in decades. No siree, Bob!

Health care is too expensive because consumers lack the wisdom to be healthy, and providers, i.e. the nondescript entities tasked with pushing “appropriate” processes and products to consumers, are failing to keep consumers healthy (a.k.a. profitable). Consumers must be reformed to be healthier, and providers to be more productive producers of health. To prime the pump, health care itself needs to be transformed from a quirky personal service to a standardized population management industry ripe for plunder (a.k.a. disruption). And then, who better to reform consumers than the high tech propaganda machine? Over the years we were reformed to happily ingest every edible poison known to mankind. We were reformed to bash the brains out of fellow consumers every Friday after Thanksgiving. We were reformed into a trembling mass of righteous fear and indignation that can only function (when properly medicated) in “safe spaces” devoid of intellectual ambiguity.

We were reformed to not just accept, but clamor and pay a premium for the right to carry consumer profiling devices in our pockets, which are used to chart our future in minute detail. Healthcare “futurists” are painting for us abstract visions of healthcare where “health is primary”. Futures where medicine is devoid of hospitals, human doctors and human patients. Futures where you buy genetic analysis from 23andMe on your TV, and fixing your baby in utero is a weekend DIY project. Futures where we need not care for each other because the iPhone Gods are caring for us all. Will we be happy? Will we be free? Que sera, sera….

But our health has always been affected mostly by social order, and less so by health care. As Silicon Valley and Wall Street are taking command of our health, what will be, will be affected by factors far removed from the myopic analysis of our healthcare experts. Fortunately, we are bringing our canary on the journey down this shaft. Unfortunately, the canary is dying.

Mortality rates have began to rise for white, middle-aged Americans without a college education, arguably the people most vulnerable to the mercantile siliconization of life. They use mostly alcohol and opioids to numb the pain and eventually they numb it for good. Unless we find our way out of these toxic dungeons where life is money and money is life, right here, right now, most of us, consumers and providers alike, will suffer the same fate. This is the real clear and present future of consumerized health.