Consumer Centric Healthcare

As we think about how to modify the ACA (aka Obamacare) into something different (aka Trumpcare) I would encourage everyone involved to think about one central tenet – put the person/consumer/patient at the center of the system, not the employer, not the insurer, and not the doctor.

I have written a few times about consumer centric healthcare here at AVC. I believe that patients should and will increasingly take control of their health care and that will be a good thing for costs and outcomes.

Our healthcare investment strategy at USV is largely based on this premise. My partner Andy who has done a lot of the critical thinking that has informed our investments in this sector, wrote this post on his personal blog six months ago explaining how we think about this sector.

Technology will have a lot to do with this. If the regulators will allow it. There are laws on the books in many states (NY State is among the worst) stopping patients from going around doctors and getting diagnostic tests, radiology exams, and, can you believe it, eye exams, using technology instead of humans. We must change those laws and I am involved in efforts to do just that. I would encourage others to engage on this issue. It’s important.

Andy Kessler had a good piece a few weeks ago on all of this. He points out that a lot of the data we need to train machine learning models are stuck in data silos controlled by big companies like Epic Systems. If Trump and his people want to make a better healthcare system, they should require Epic and its competitors to provide open APIs into these data silos so that people/patients can get access to their data and authorize third party systems to have it too. That one move would be huge for AI in healthcare, which we need to get costs under control.

Our problems in healthcare are largely structural. We have allowed employers and insurers to finance our healthcare system and take control of it. We need to get people back in control of healthcare. Technology can be the lever that will do that. If we allow it to happen.

#hacking healthcare

Comments (Archived):

  1. William Mougayar

    Weird about these names, Obamacare or Trumpcare. Why not have a US Nationalcare, period. It shouldn’t be Obama’s or Trump’s or anyone’s.In Canada, Trudeau was the father of the current healthcare system that had ONE key tenet: UNIVERSALITY. We don’t call it the Trudeaucare. It’s the Canadian Healthcare Act (CHA) system, and it’s a damm good one.

    1. Elia Freedman

      Obamacare (and suspect Trumpcare) is called that as it is intended to be derogatory. Lots of people don’t understand that the ACA and Obamacare are the same thing, apparently.

    2. Richard

      Technically,the current system is called the affordable care act. It’s the failure of “balance of powers” of our three party govt (which seems to increase with each term and that Trump will likely exploit) and the ignorance of basic American Govt by most people that leads most to think this is obama care.

    3. ShanaC

      Because McCarthy invented a fear of socialism via fear of communism/the Russians.Since then, anything that hints of socialism is seen as the devil’s work in the US. Including universal healthcare

      1. rtehrani

        Chavez & Castro may have something to do with it as well.

    4. Twain Twain

      Obamacare/Trumpcare was officially called the Affordable Healthcare Act. I think the media gave it a moniker that attributed the incumbent President to it.

    5. PhilipSugar

      It is always foreign people that suggest this. I travel 200k miles a year. People don’t understand: US /= your country. The entire population of Canada would not rank it as a top state. The diversity we have is huge, so much more than anywhere else.We have part of what you ask for in Medicare. It is out of control.I agree with Fred the problem is we have given this to companies, insurance companies, hospitals, and the government.I ask you where else do you buy something and not know the price?Milton Freedman said it best:1. Buy something for you with your money: Care about quality and price2. Buy something for somebody else with your money: Care about price not quality3. Buy something for you with somebody else’s money: Care about quality not price4. But something for somebody, else with somebody else’s money:Government: quality and price don’t matter.We have that right now with our insurance with companies paying.So we get what we have.Drug companies advertising drugs on TV. I have a friend that has a company that just takes what the drug companies disclose and provide to you before you decide to take the drugs.When you go overseas and are sick you can go to the pharmacy and not go through the system.I am an equal opportunity hater:Insurance companies. Had one double my bill because one employee had a complex pregnancy (isn’t that the damn purpose of insurance)Hospitals: They will try and milk the system as much as they can: My wife’s uncle died last week. They didn’t want to take him off of life support because it would hurt their occupancy rate.Drug Companies: Try and get people on as many drugs as possible. If you are on more than six nobody has any idea what the interactions are.Doctors: They want to protect their domain just like lawyers, they don’t want PA’s, NPs, or Pharmacists.Lawyers: Well everybody hates them but they make medicine defensive. You saved somebody’s life but they then died? I would deny all of them healthcare.

      1. Girish Mehta

        Struggling with your point about population and diversity…how does that relate to the issue ? Disclosure: Since you made the point about foreigners, I ask that living in India, whose population is several times that of the US and has very high diversity. And yet health care in India is of very high quality, lower cost and simpler than the US – Not for the entire population of India, but for a number greater than the entire population of the US.

        1. dgay07

          Haven’t been exposed to India’s health care system for a couple of years, but in my experience this is not true. I know quite a few people who have gone to the best Indian hospitals in Bangalore and have had horrible experiences. In one case, a colleague who was living there had to have his wife fly back to the US and had immediate surgery upon entering the US to fix what was done in the Bangalore hospital. I also know many Indians who get their medical care done in Singapore. And if not mistaken I don’t think India has an actual formalized health insurance industry, at least not nation wide, most visits are cash only. Perhaps health care for the wealthiest ~325M of India is comparable, but for the majority of India health care is very poor. There have also been an increase of wellness chains that are used as health care facilities for general practice, but they are all cash only. I think that is the primary point- All these other countries say we have great nationalized health care here, why doesn’t the US? Well much easier to say when the population is under 100M. And in my experience in health care consulting in some of these countries (UK, Germany) health care options are limited compared to the US- nurses aren’t as broadly educated, GP’s aren’t incentivized by private companies, hospitals only carry limited options of medicine, etc…

        2. Amar

          Hrmm.. I no longer live in India now. I was born and raised in India and spent the first 20 years of my life there. My experience does not line up with your statement. We did have access to great healthcare and it was low cost but it was almost entirely private. This thread is about nationalized federal healthcare. I try and stay in touch with events and trends back home. India does not have a good or working public healthcare system.

        3. PhilipSugar

          I ask you if you break a bone in India who do you go to? A super expensive hospital or a a bone setter?https://www.ncbi.nlm.nih.go…I know the answer.

      2. LE

        Insurance companies. Had one double my bill because one employee had a complex pregnancy (isn’t that the damn purpose of insurance)Non healthcare related but worth noting. Liberty Mutual (with all of those stupid commercials) has a notice on my policy about cell phone and computer rider. The cost is cheap (something like $65 per year) to add. Seems like a no brainer. There is a cheap deductible that seems ok also. No brainer. Buy it! Then it turns out that we are getting a 17% discount on our policy for no claims. So if we get this rider and make a claim we lose that. Make two claims and our rates go up 25% or 20% something like that. Not sure what your homeowners is but ours is in the thousands. Bottom line: No advantage to buying policy at all it’s a loss. I have no clue how I managed to get that info out of the helpful person over the phone either so I could decide not to buy.

        1. PhilipSugar

          Insurance companies are awful.

          1. LE

            Yeah but at least they are stupid. I’ve mentioned the time that a painter decided to use one of my empty rental units he was painting to do a side job painting chairs for a restaurant he was doing work on. I told him I was replacing the carpet but I never said fuck the carpets up. Or that he could spray paint there.So I walk in and I’m really pissed off seeing all of these spray marks all over the place and the chairs. I’m ready to yell or something. But then about 30 seconds later I realize ‘shit I will make an insurance claim on this’. So I take pictures and make the claim. Insurance company pays it no questions asked (about $6k iirc.) Didn’t even send anyone to take a look. Just send us the pictures Not fraud either. He ruined the carpet and made it that I had to replace.

      3. William Mougayar

        Yes and No. I don’t think the US is that much more complicated if you want to make it work. Canada is a huge country. France and the UK each have about 66M people, Germany 80 million, Japan 130 million. These issues existed within the US with a much lower population than today. Once a system works, scaling is less of an issue for managing it.The US’ natural reaction is not want to learn from other countries, because you think you’re different and nothing else will work. But I think, you CAN learn from other countries in the area of healthcare, not shamefully. Just as the whole world learns from the US about tech and startups, and they do it wholeheartedly.I have been a student of the US/Canada health care system for a long time. My first 11 years at HP were spent in the medical products groups division, and I interacted with hospitals and the system both in Canada and the US (I can name you a dozen big US hospitals I have been to and trained their staff there, or had relationships with some doctors). I even wrote a seminal (internal) paper comparing the US and Canadian healthcare systems deep and wide.US healthcare costs have always been way higher than other countries, 50% more than the 2nd highest, and it’s a myth that it’s better on the whole than other countries. Just because the country is complex is not an excuse for keeping that way. The issues you outlined are real with these 5 stakeholder groups. See these numbers:…I know it’s difficult to entangle a mess, and I’m pretending I know the exact path to a better solution, but it seems that people are content with the system they have. What if there was an equivalent to the Women’s march yesterday, but one demanding a better US healthcare system, with millions across the nation, with a plan to do what’s right, not to just stitch up what is already broken?Side story: Got sick in Paris last May and went to the pharmacy and interacted with the pharmacist almost like a doctor on the spot, and bought some over the counter meds with advice and all that for 40 Euros. Done.

        1. PhilipSugar

          That is exactly my point William.I agree.But what you don’t understand is that we have people both in inner city and in rural that will literally go to a doctor because they will give them money to get the government reimbursement.Yes, money.For a while it was in the form of pain pills which you can sell, but it still exists. Look up Medicaid fraud. It is rampant. Rampant.

          1. William Mougayar

            I didn’t know about that. So there are 2 issues intertwined.

          2. ShanaC

            Medicaid fraud is less than 1% of expenses. Regular for profit insurance is actually much higher, in part because they don’t have the scale that hhs has.

          3. Roboticus Aquarius

            Thank you. Publicly available data certainly suggests that Medicare/Medicaid fraud is at worst about the same as for profit insurance on a per-capita basis, and perhaps significantly lower. Addtionally, my understanding is that for-profit insurance usually spends several percent on finding reasons to deny coverage. It would be cheaper just to pay the fraud, using high level statistical analysis to nail the big cheats

          4. ShanaC

            pretty much.

      4. JamesHRH

        Friedman quote is an all time truism.

      5. ShanaC

        I’ve seen people get unnecessary care by doing this(ex-cofounder, back surgery), as well as personally know of someone dying from late stage cancer of the jaw because this was his primary method of dental care (which he did irregularly)(friend of mine ex boyfriend, getting basic dental crowns in Mexico after waiting too long. Regular dental appointments would have caught the tumor early)

    6. PhilipSugar

      And I give lasik eye surgery as my one shining example. Most insurance companies won’t pay for it. You have to pay for it. So you know what happened???? Quality way up, price way down.Now certainly for catastrophic events just like car accidents you need a backstop.

      1. William Mougayar

        yup, that’s a good system, and prices / quality are in check because of healthy competition. (it’s very comparable to the US, in Canada)You didn’t mention dental in your list of grievances 🙂 I think dentists also are now abusing the system where there is excessive insurance at play.

      2. Elizabeth Spiers

        Volume matters in your example. There are a lot of one-off and chronic healthcare problems that only affect a small percentage of people but are very serious. If you rely solely on a purely capitalistic system to develop affordable treatments, it will never happen because there aren’t enough patients.

      3. Jon

        The lasik example has some merit, but it is a cherry picked example. It’s an elective surgery that is scheduled in advance, it’s outpatient, and you do not need an MRI or CT-scan to diagnose/evaluation. Not too many procedures have these qualities, so I am not sure how broadly this example translates.

      4. conorop

        A simpler example is glasses or contacts. These are not covered by insurance. It’s ridiculous.

  2. pointsnfigures

    I have looked at this in finance too. It’s similar. We need a real market in healthcare, when individuals have choice and price transparency. Competition for service is tougher because it’s so localized, but insurance shouldn’t be.

  3. Tom Labus

    The shift to employer health happened during WWII since there were wage and price controls and at the time this seemed a perk. Certainly, we have the tech to move away from this but not sure about the political will.

  4. William Mougayar

    Epic is #2 and #7 in popularity for EMR software. Here’s how it stacks up in the US among EMR vendors. All and all, there are close to 100 of them. But this fragmentation problem is not just a US system issue. It’s prevalent in other countries, because each hospital is run differently. And these are in-hospital EMR systems. Your family doctor and docs you see outside the hospital run different systemsThere needs to be EMR portability standards. My data, my ownership, and I can give a window of it to anyone I wish.https://uploads.disquscdn.c

  5. JimHirshfield

    So many political thorns in this issue. I haven’t seen anything that leads me to believe the politicians care about people’s health. They seem to care more about protecting profits and killing something just because the other side created it. And, oh yeah, it looks like socialism… which must be like communism, because they both end in ism, right?

    1. falicon

      Agree. This is correct(ism).

    2. SubstrateUndertow

      Well one can make the case that there are certain social organizational functions that are by their unique foundational nature most effectively run as collective (governmental-run) monopolies with competitive supply chains running in parallel at the periphery.The militaryThe policeThe education system (or at the very least as non-profits)SwersWaterHEALTHCARE ( US for-profit healthcare has had decades to prove it is a failure! )doing the same thing over and over and expecting a different result and all that

    3. ShanaC

      I’m angry about this being true. The fact is, my care is/was linked to someone like Beau Biden’s health. And while the Senate can sit around feeling sad for Joe Biden’s loss, they don’t realize that by truly linking the healthcare of all of us and then spending money on studying all of us, they could have kept Beau alive, as well as millions of other people.Selfish people

    4. Kirsten Lambertsen

      Money, baby.I was at a startup pitching event ~3 years ago in NYC, and a big deal VC dude was there to give the opening talk. He was very swaggery and boasty about certain investments he’d made that we’d all heard of. Quite sure of himself.At one point he asked the audience of about 150 startup founders why insurance might be a great industry for a startup to get into. Now, being a digital type, disruptor type, and general upstart and entrepreneur, I raised my hand and said, “Because it SUCKS.” I expected him to smile and say, “Exactly. There’s an industry that could USE some DISRUPTION.” (Right? That’s what we technorati do? Break into industries that suck and make them better!)Instead, he gave me stink eye for a few moments like a very cross 8th grade algebra teacher and said, “Because. It. ‘Sucks.’ [sniff!] No, not because it ‘sucks.’ Because the margins are among the best in business…” And he went on to explain about all different kinds of insurances and how much money in the margin there is, etc, etc.

      1. PhilipSugar

        Oh, don’t get me wrong they are the truest form of assholes and I mean that. I have two good stories on that. One was my doubling of rates when I knew they had made literally several millions in profits for the past several years, and yes I had an employee that ran up a $500k bill because his tiny (in stature) wife had a really tough pregnancy with his two huge twins.The second was when I hired a temp as a receptionist for a family leave. She said what’s my job with the voicemails that get left after I leave? I said you come in write them down on this pad and give them to people. It was a long time ago, I’m sure you are too young to ever have seen but they actually had pads you wrote down phone messages on :-)She said: Ok, that is great. I was working at Blue Cross Blue Shield and my job was just to delete them. I broke my heart, I had to ask for a new assignment.

  6. falicon

    The healthcare vertical is going to be your Oak Island.There is *definitely* something there and it sure does seem like it just might be a priceless treasure…but odds are high you’ll go broke or crazy trying to solve that puzzle…Good luck though!

    1. TRoberts

      I can appreciate a visual Oak Island metaphor, but in this case, there are clear waypoints & definable objectives along the way towards progress. Not a single objective at the end of the tunnel, rather, specific checkboxes for payment, pharmaceuticals, physician access, and so forth.Each mission can be defined and quantified; success can be measured and graded for each objective.An Oak Island is apropos in one sense: a lot of half measures and abandoned attempts have been made in the past with outdated tools.

  7. William Mougayar

    Re: “Our problems in healthcare are largely structural.”, It is sometimes easier to build a new system than to fix an old one.Part of me thinks that this can only be solved via a generational approach to evolving it. The current spaghetti system is so embroiled that it would be easier to start implementing universal/open medical records for young people (under the age of 25 for e.g.) where their records are (mostly) fairly light. Then they grow with it.

    1. TRoberts

      “It is sometimes easier to build a new system than to fix an old one.”The US currently operates an essentially national single-payer/provider health care system for ten million or so people, the VA healthcare network.Efforts aimed at modernizing that system (as with many related VA / DoD issues) are the poster child for your statement.Even with so much control & a captive market, for myriad reasons they cannot apparently bring the old system into the 21st Century.

      1. SubstrateUndertow

        Isn’t that mostly politics more than true technical difficulties ?

        1. TRoberts

          “The technical challenges are vast.”…But as an interested outside observer, I would say yes, bureaucracies are a major obstacle on top of the technical ones. And in that way, your point reinforces Mr. Mougayar’s observation.One more reason he’s right: it can be easier to start fresh than to reform.

    2. SubstrateUndertow

      Without the protections provided by a universal single payer system it seems too financially risky for individuals to allow much sharing of their health data even anonymized records that could be penetrated by insurers via cross referencing techniques.

    3. awaldstein

      two separate systems?your medical records start at birth so at 25 you have a ton of data there.not following.

      1. William Mougayar

        not really. at 25 (assuming healthy normality here), your medical record is tiny. even up to 35-40 most likely. problems, issues, chronic cases start to appear later in life. it is a known fact that cost of healthcare tilts higher with age.

        1. LE

          It would be interesting to know the research on end of life care costs in countries with other healthcare systems.I think it’s well known that end of life care in the US accounts for some huge percentage of health care spending.It’s also possible that this is because hospitals have to pay for a slew of things they can’t charge for (charity care, writeoffs etc) so they are making hay when the sun shines as it during EOL care it’s open checkbook. So I would be curious on the costs for end of life in other health care systems.

  8. David Miller

    While I agree with the premise that healthcare should become consumer-centric, that doesn’t necessarily mean that costs will come down.The overwhelming dollars in the healthcare system are funded by government programs and by large self-insured entities that bulk-buy medicine. This formula isn’t going to change anytime soon even if Obamacare changes. Individuals and employees of small businesses affect the system only at the margins.There is way more promise in my view in changing the laws to require that (anonymous) data be available for third-party analysis. The airlines publish flight safety data to to FAA that makes the entire system smarter, so maybe creating an incentive for private parties to contribute to a clearinghouse like that would work.

  9. dendy young

    100% agree that we must make the system patient-centric and eliminate the tax barriers: either make healthcare all pre-tax or all after-tax, but not have some people using pre-tax monies and others having the disadvantage of post-tax costs. Second step is total transparency in what healthcare costs: we can still have subsidies, but people should know how much they are and who is getting them.

  10. Yeknot

    thanks for sharing

  11. Brandon Burns

    I have several friends at Epic Systems who implement its software in hospitals. It’s all largely custom, because each hospital has its different way of doing things. And because the entire industry — Epic, its competitors, and the consultancies that hospitals hire to implement and manage Epic software in hospitals — makes the majority of its money from the human labor involved in customizing and managing software for hospitals, they are not incentivized to create an API, as the streamlining of everything would slash their profits. Instead, they indulge the whims of individual hospitals that don’t really know any better, instead of making steps to create a unified network.If change is going to come, it’s probably going to come from a new, TBD player.

    1. Brian Manning

      Absolutely right. There’s a totally new wave of software coming to healthcare that’s built around usability and workflows and provider needs, rather than government mandates. Government driven software development = not ideal.

      1. Noah Rosenblatt

        Getting away from costs for a moment, this is what excites me most. How will technology change the way consumers (basically everyone on earth) interact, collaborate, and organize the medical aspects of our healthcare lives. This collaborative technology (connecting consumers, their nurses and doctors, their specialists, their insurance company, their pharmacy, etc) is still trying to find its way in the most basic of industries, like the real estate industry my company operates in Manhattan. But the regulatory hurdles and privacy laws seem to be the biggest hurdle to get over to make such an ecosystem even feasible. But from top to bottom, from consumers pov, things could be so much simpler that enables users to better understand, track and treat short and long term illnesses. Man, makes me wish I had a zillion $$ to take a stab at the ui of such an application

    2. ShanaC

      And regulations around that player

  12. Brian Manning

    Worth recalling that in healthcare putting the patient at the center sometimes requires us to the put the provider at the center. Unlike many industries, in healthcare, the consumer is not able to make informed decisions and tradeoffs (because of the complexity of their condition or the effects of the condition). And they’re also not able to pay for services the same way we pay for other services. EMR 2.0 is already underway where systems will be built around connecting providers rather than creating silos. And patient generated data, while still in the early stages, is off and running. Combining great tools and data from both the provider and the patient is the goldmine. Hard to do one without the other.

  13. rtehrani

    I believe our company has cracked the code on solving the healthcare issue with tech. At least the insurance part of the problem… We are a transparent marketplace – like TripAdvisor for doctors. We facilitate the transaction as well. Patients get lower prices and doctors save a ton of money because there is no insurance overhead which is substantial.

  14. Richard

    What a naive blog post. Spend a day on the pediatric oncology floor, a stroke center, a cardiac floor ……and you’ll see how silly you sound. Americans can’t even dig themselves out of the type II diabetes epidemic even though they have all the information necessary to do soAre people over the next 25 years going to becoming more or less dependent on institutions, that’s the real question. There were 500,000 people outside your window yesterday shouting, if you want to know the answer.

    1. fredwilson

      Maybe yours is naive comment. Consider that possiblity

  15. William Mougayar

    There’s another thing about Consumer Centric Healthcare where technology is not even part of it. Much of it starts in the supermarket and where / how we buy our foods. Go to an average supermarket, and you will see how much junk processed foods there is. I was recently in Amsterdam and was pleasantly surprised to see that food supermarkets have only tiny parts with bad foods. The emphasis on fresh, local, un-processed foods was staggering.

    1. LE

      Agree. What people are also missing, and I am always mentioning this, is that food and overeating of processed tasty foods [1] add to healthcare expenses by requiring drugs to counteract the foods that we shouldn’t be eating or are eating to much of.Even when you take acid reflux, drugs (like Nexium) you have people that are taking that that instead should be making diet corrections so they don’t need to be on that drug for life (which also causes it’s own set of problems).[1] We can call this PETF (people eating tasty foods)

  16. Twain Twain

    Few things are PEOPLE-centric when big $$$ are involved.Insurance and finance are set-up to put people into quant boxes and ratios (risks, income bands etc).For people-centricity … well, we’d need to re-engineer the whole of economics so the data is about quanta AND qualia, on a par.

  17. Vendita Auto

    Is it possible for any individual state to opted for a different system ? A naive UK question.

  18. Kirsten Lambertsen

    Let’s repeal Nixoncare first…That’s how the whole shitshow started.”Richard Nixon, advised by the “father of Health Maintenance Organizations”, Dr. Paul M. Ellwood, Jr., was the first mainstream political leader to take deliberate steps to change American health care from its longstanding not-for-profit business principles into a for-profit model that would be driven by the insurance industry. In 1973, Congress passed the Health Maintenance Organization Act, which encouraged rapid growth of Health Maintenance Organizations (HMOs), the first form of managed care.”Corporatized healthcare is a failure. The explosion in costs is a direct result.

    1. William Mougayar

      Yup.America’s health care prices are out of control. These 11 charts prove it:

    2. laurie kalmanson… “Every country against which we compete has universal health care,” he said. “That means we probably face a fifteen-per-cent cost disadvantage versus foreigners for no other reason than historical accident. . . . The randomness of our system is just not going to work.”

    3. PhilipSugar

      I agree completely.But I am not sure why you call it Nixon Care. Usually a bill is named after the writer and the sponsor.In this case Ted Kennedy.He didn’t push it through like LBJ did for Civil Rights bills including Medicaid.Ted did. He just signed it.

      1. Kirsten Lambertsen

        Well John Spratt introduced the ACA that eventually passed (Jack Spratt? Ha ha!)But Nixon pushed managed care much like Obama pushed for the ACA. Nixon, when signing his bill, “Expanding the geographic distribution of health maintenance organizations is an integral part of the National Health Strategy that I first proposed nearly 3 years ago. “

  19. ShanaC

    I can rant on multiple areas on this, as a patient cum experimental subject cum complexity in the insurance system. So what are would you want me to rant on first?HIPAA being written in a way that means I can’t access my cousin’s, mother’s, aunt’s medical records and add the relevant sections into mine?Difficulties involving clinical trial participating because of data issues?Having to research what is best in practice for care quality, because publicly available benchmarks and lists of best practices from those benchmarks re not available?How thousands of dollars gets wasted because of how medical billing works?Some other topic perhaps?If Trump and his people want to make a better healthcare system, they should require Epic and its competitors to provide open APIs into these data silos so that people/patients can get access to their data and authorize third party systems to have it too. That one move would be huge for AI in healthcare, which we need to get costs under control.1) The issue predates Epic. Almost all EMRs are built around concepts of medical billing, and therefore WHO procedure codes, and have been for over 30 years. Kill that, and you would start unlocking some of the issues of API2)Supposedly there are APIs coming for pulling out your data for personal use, because getting your own medical records is guaranteed by law.3) patients don’t usually understand that they should share their records, or what AI does.You need to get patients active. Very active. And notify everyone that in fact, they are a patient – otherwise there won’t be any changes(PS: If there ever is an AI driven mammogram medical trial in NY, let me know. I want to participate!)

  20. Aashay Mody

    Some of you may have seen this:…Using the Tesla approach of starting at a high price point and slowly moving down the chain. Thoughts?

  21. WA

    Serendipitous. I finished an article yesterday in the print version of the University of Miami Business School Magazine. I think you all will find it very interesting. And very aggravating.It is in regard to study of hospital pricing systems, egregious overcharging being identified, and subsequently simply ignored by hospitals. Immune to the shame is part of the articles title.There is a good summary of the study here, brief yet thorough read.…Here is the study itself in PDF. I am not an engineer – however there is a ton of common sense optimization that can be done in my view. http://www.healthfinancejou…Financial services have been disrupted by online fintech from outside the banking and brokerage industry.A warehouse system and the technology of e-readers usurped the model of publishing, buying, and delivering books dating back to Guttenberg while yellow cab medallion values went from that of precious metal ingots to costume wear.The barriers and regulation for health care are high. I get it. But somewhere given the burden of the arguments already on this camel’s back is a straw. There is always a straw.

  22. joewaltman

    Amen.However, I would argue that the regulation, threat of litigation and insurance companies will pretty much ensure that human health care companies will not lead the innovation. In our case (VetPronto – tech company around veterinary care ), we are already doing a number of things that no human health care services are willing/able to do. For example, we have AI assisted triage, full care in the home (not just health exams), APIs for medical records, obsfucated email/phone correspondence between client and doctor, etc.I often wonder when I will be able to get the same level of care for my kids (or myself) that we are currently providing to our four-legged patients. 🙂

  23. Ana Milicevic

    I am surprised that we haven’t seen a hospital system w/ a strong research hospital located in close proximity to an entrepreneurial hub begin to put together a better system: one that is primarily patient*-first with a strong set of medical data can then be used for a variety of research efforts (opt-in by default). This seems like a good fit for Boston + Mass General + Tufts + Harvard + MIT, SF + UCSF + Stanford + perhaps the Kaiser network, etc. They have enough scale to pilot a meaningful program that would begin w/ primary care and obviating many of the choke points on the lower end of the cost spectrum today. Heck – the next notable alumna thinking about signing a check for new dorm or stadium naming rights should consider what it would take to fund something like this instead.*I hate the term patient. Every single one of us needs healthcare – some more than others. Once we accept that as humans we need care, perhaps we can focus on what types of care overall reduce costs across the board.

  24. Supratim Dasgupta

    I run a Global Telehealth company MonkMed and going by what you will watch in this video I think I have some very clear understanding of what needs to be done.…These ideas came from our users in 50+ countries who took control of their own health, back from their Govt.s into there own hands and essentially are alive because of that one decision they took. 95% of our patients are terminally ill patients . Our 525 days journey has been essentially listening to them minutely and doing everything to get them to live.Its a wrong assumption only US healthcare is broken and other countries are thriving. We have patients from ALL developed countries like AUS,CA,NZ,Switzerland,UK etc and situation is same everywhere with varying degrees. This common factor is Big Pharma controls all of these Govts.So here are the two things that need to happen.1. People need to take control back of their lives from Govt. It is not simple but its not impossible. Let me give you two examples one at small and one at large level.Small LevelI test Lipids every 3 months.a. My GP wants 130USD to prescribe me a Lipid Profile( Cholesterol) Test. Then a lab will charge me 80USD to draw my blood and give me my report. My GP will need another 130USD to explain me my report and recommend further action. Total cost 340USD. No Thanks, i really don’t need the GP consultation as am very well aware of what the numbers means.This 340 will go towards my 2500 USD deductible even if I have an insurance.b.I walked to the CVS on corner of 57th and 8th avenue in Columbus Circle yesterday. It has a Minute Clinic and they do blood work in house.The nurse said the test is 36USD but I need to get a consultation from her to 1. prescribe blood test 2. read out my report. Her fees 60 USD. So Total Cost 96 USD. Much better than 340USD but no thanks.c. Walk in tests without Nurse/Doctor Consultation is prohibited in MD,NY,NJ,RI, but not in CT.I can drive to Stamford 1hr away and have the same test for 39USD from or similar labs in the area.. Total cost 39USD and some gas money.I anyway drive to CT once or twice every few monthsSo I essentially brought down my cost from 340 to 39. A 301 USD saving because I did not allow NY lobbyist to dictate how i should be taking care of my health and how much i should be spending.Large Level.A single pill for Harvoni that treats Hepatitis C costs 1000USD in the US and most developed countries. There is a senate and federal investigation into this GILEAD price gouging….80-90% of ill people are denied this through insurance/medicaid/medicare because Insurance companies don’t want such high price to cut into their margins.700 000 people die each year and 185 Million are infected of this disease worldwide.…The same pill licensed by GILEAD in India costs 10USD per pill. Total cost of 6 month treatment in US and developed countries? 180,000USD, Same treatment from India, 1800USD.So what does someone who wants to save his life from this fatal disease do?a. Get on a plane and go to India and get the medications yourself ORb. Get them mailed through friends or family in India or through numerous trusted companies like FixHepC who test efficacy of the meds in their state of art labs in Australia and ship them to your doorstep.In UK,AUS, NZ and most developed nations you can self import medications upto 90 days at a time. In the US its restricted to life saving medications only but FDA allows it.180,000USD is out of reach for most Americans. 1800USD many can afford.So how about the treatment? A US doctor can monitor you, which is nothing but checking your Viral Load test every 4-8 weeks.In both the cases by making a decision to take control back of your life Individual wins and Govt/Big Pharma Lobby looses.I can keep going on and on but I hope you all get the picture how spirit of human resilience is the moist powerful tool to combat any lobby in the world.Point 2.Now coming to power of tech in disrupting Healthcare. One thing i learnt in my 525 days is in Healthcare everything will boil down to your service. MonkMed is the only company where if you are undergoing treatment e.g. say liver treatment from us, You can view your progress/alerts vis-a-vis 500+ patients who are undergoing the exact same treatment. you can break it down to your genotype and other parameters etc. Our patients love this feature but its not how we got to where what you saw in the video. Its because of the deep connect our patients have with our doctors who work tirelessly answering phone calls, emails , texts and basically become part of our patient’s families. We sometimes feel we have created a telebased service of the golden family physician who was part of your family in the golden bygone era.Please let me know if you have any comments or questions.

  25. Salt Shaker

    Name me one other product/service where you can’t do upfront due diligence on pricing in advance of purchase? Yes, I can find out what a physician charges for an office visit or a relatively standard diagnostic, but it ends there.Cleaning up this mess starts w/ mandated transparency and published rate card pricing (using industry agreed to defs/standards), particularly on tests, surgical procedures and meds. Also, open our state-by-state borders on healthcare for greater competition, something that Trump strongly advocates.Open, transparent and fair competition will lead to a reset on pricing.

    1. PhilipSugar

      Yes, yes, yes.

    2. haremonious

      My dad had a hip replacement recently, at the Hospital for Special Surgery in NYC. He went to a pre-surgery consultation with the surgeon, and, out of curiosity, asked how much the operation cost (insurance would cover it). The doctor replied: “I don’t even know how much this consultation costs.”

  26. Alamin Uddin

    Epic and most of its competitors do allow data access via HL7 to third parties. But getting that data can take 6-12 months through HL7. So it’s mostly pointless and takes up too much developer time. Some companies like Athena and DrChrono have developer programs that work much better.However, the platform that connects people and their doctors while being EMR, Health system, payor, employer etc. agnostic is the platform what will solve our healthcare crisis.

  27. Chimpwithcans

    This is such a big change proposed by Fred/USV, but it is also remarkably simple. Open up the data, and see what happens. Would be fascinating to watch. Amazing how much impact legacy systems and methods have on a population and an industry.

  28. Vendita Auto

    I am a staunch supporter of the UK’s NHS system as I am the innovation brought about by some private companies such as shown on this short but extremely informative vid”Fascinating Update: J. Craig Venter@Davos 2017 Healthcare – Human Genome – Human Lifespan

  29. Peter Radizeski

    Ever notice that it is just Big Pharma, Insurance and Politicians talking about ACA? It isn’t about the patient or healthcare. It is about the big $$$ that Pharma and Insurance want to keep. Insurance is Overhead to a doctor or health facility (hospital, pharmacy, clinic).

  30. Caleb Kemere

    Interesting hyphenation “con – trolled by big companies like Epic Systems”. My wife works in a clinic which services a unique patient population (adults with congenital disabilities). Apparently gathering anonymized data from Epic is so challenging that they typically have to hire a consultant to do it, and to maintain some simple statistics they keep a parallel excel spreadsheet because the aggregated data that they have succeeded in getting out was incomplete. Remarkable and incomprehensible that they have not used their market power to facilitate research more easily. If Uber is worth $60B, what is Epic worth?!

  31. Jay Janney

    Here’s a quote from the Wall Street Journal oped page, that talks about a way to improve ACA.”Many companies would like to accommodate this by giving employees a “defined contribution”—a fixed amount of money—and letting them choose their own health insurance. Thanks to the 21st Century Cures Act, small employers now can do this. They can put pretax dollars into accounts called Health Reimbursement Arrangements, or HRAs. Workers can then use that money to buy their own health coverage.””Small companies were already exempt from ObamaCare’s employer mandate, but this has taken on increased importance. They are now the only employers that can choose how health insurance will be subsidized by the federal government. They can (1) use pretax dollars to provide health insurance directly; (2) pay higher taxable wages and allow the employees to buy their own insurance, benefiting from the ObamaCare tax credits if they quality; or (3) put pretax dollars into an HRA. Extending this freedom to all employers would be a remarkably effective solution to ObamaCare’s many problems.”I would expand this to allow employees to use whatever they don’t spend on premiums to go towards covering deductibles and co-pays.One benefit to this is that employees can choose the type of coverage they want. Recently I downgraded my plan (increasing my copay and deductible), to save about $400 a month on premiums. I calculated that financially I am better off as long as I don’t have a catastrophic illness (and I have money saved for that).I would add some government assistance for those who have illnesses which require heavy co-pay/deductibles.

  32. Joya Malin

    This story is very interesting as it relates to a few of the trends that we are seeing in the healthcare arena; there will be some major changes to the industry over the next few years.http://www.hekaconsulting.c

  33. Semil Shah

    If you happen to get this, would love a post one day on this line: “We must change those laws and I am involved in efforts to do just that.” What’s the list of issues that USV or you have engaged with at the legal/lawmaking level to open a sector?

  34. William Mougayar

    What you have described is something close to what Canada has. For that to happen, the government becomes the insurer really, and they dispense funds and reimbursements, but you don’t pay them anything because you’ve already paid it via your taxes. (It’s a bit more complicated, but I just simplified it)

  35. ShanaC

    Everyone is a patient, even when we are in peak health, just to make sure we stay that way. And we all fail to remember that.

  36. PhilipSugar

    See my comment on lasik surgery.

  37. LE

    but let’s get rid of the 35% “market” tax called the health insurance industryMake sure you find jobs for all of those people who are employed as a result market tax. This could be the new rusted factories.One of the reasons that cigarettes weren’t just made illegal had nothing to do with the power of big tobacco and lobbying or failed prohibition. It had to do with the fact that people would be put out of work. It had to naturally peter out over time. And not just people working making cigarettes or farmers. Anyone and everyone who interacted with the industry in some way.

  38. Richard

    It’s not clear where your rant is going. We have the best healthcare system in the world. If you change the incentive system too much, we will all be eating stale whitebread. Take a trip to the VA sometime and then to USC or UCLA, and if you ever are in need of healthcare, tell me where you go.

  39. Supratim Dasgupta

    I actually stopped paying insurance last year. I would rather pay fine than have that stupid insurance. It also helps me build a cost effective service for people/wo insurance.

  40. Kirsten Lambertsen

    Yes.Does anyone want to ‘shop around’ for the best healthcare or the best insurance? I sure as hell don’t. I just want the best healthcare all the time, because when I need it I’m likely not in the position or mood to be comparison shopping.We as a nation should have a goal to simply have the best healthcare in the world for all of our citizens. The market isn’t *required* to have something be the best (and as evidenced by our results, doesn’t ensure it) — only the will to do it. Should be the same with education.

  41. Twain Twain

    That’s why I use the terms “people-centric”, “human-centric” and humanist(ic) as much as possible.None of the existing AI and none of the existing economic models are people-centric.They’re numbers-centric, quant-centric and they assume that as long as the system can optimize to those then it’s “intelligent”.I like AI; it’s useful for lots of efficiency improvements. Still, we shouldn’t lose sight of how effective it is wrt understanding that a happy patient tends to recover from medical problems faster than an unhappy one.

  42. William Mougayar

    A fraction of the USA’s 🙂

  43. LE

    A lobbyist is just someone paid to get across to lawmakers a point of view.There is nothing to prevent any citizen (other than good communication skills, time, energy and a can do attitude) from going down and holding meetings in Washington. I did it and it was actually fun to do. Fun. After a great day with several meetings on the train home I met the congressman from my area. He wanted to know why I went to Washington. His staff followed up with me a zillion times (was almost annoying) for years. An attorney from the commerce department wrote to me back and forth a few times very nice letters. And I didn’t do anything special and I’m not anyone special either. Hardest part was having to wear a suit and miss a day of work.Your frustration stems from the fact that you see people who can afford to hire and pay people instead of having to do the heavy lifting themselves. But the fact is you are a creative guy and can write well so there is really nothing preventing you from making your voice heard if you want to take the time to do so. What’s holding you back is that you run a small business and don’t have the time to do so. [1][1] I feel your pain on that for sure. Because as we know larger business has people who wake up in the morning and just think about these types of things.

  44. LE

    That’s knee jerk and you don’t even mean it. [1]Not everyone who works for Insurance companies suck. Not everyone is the guy turning down your claim or being a dick.[1] I am going to have those displaced workers put in a dream of yours and keep telling you they want to hear you play Piano Man one more time.

  45. Chris S

    Agreed, assuming we consider a system to be a coordinated network of parts, or elements, or whatever designed to provide care for a large group of people or perhaps even the country as a whole. Sufficient money can buy you access to the best elements of care, but that’s not a system and it excludes an awful lot of people. As a country, we spend almost double the OECD average per person on health, yet our outcomes are substantially below average. One can argue justice, rights vs obligations, etc. (which I’m *not* gonna do here) but when it comes to dollars spent vs outcomes, we’re not best. Unfortunately we’re often enamored by high-tech, high-intensity “medical” care, with relatively low marginal returns.

  46. PhilipSugar

    If you have the money to pay it is true, if you don’t it is completely not.

  47. JamesHRH

    You have the best health care in the world.

  48. Vendita Auto

    Mine is definitely a rant :The WHO estimated that eight million people a year will die of smoking-related diseases by 2030, mostly in developing countries.I posed the question on Linkedin to International Insurance groups (health?) Do You Invest In Anyway (Bonds) In Tobacco Companies ? Never receive a reply. Yes it is legal to invest but morally reprehensible. The cost to the public purse in healthcare ? more than the $49B we ultimately pay for + the Pain & Sorrow and yet continue to discuss if healthcare is affordable ???

  49. PhilipSugar

    I am with you 100%. If I had to choose between insurance executives or lawyers it’s no contest. Employees? Well some need a job.

  50. jason wright

    something dramatic must have happened since the turn of the century for the US system to have moved from 31 to 1 ( I assume you are expressing the American “We”);…Spending the most money does not equate to “the best”.

  51. lpress

    I’ve never been to the VA, but have had a couple of bad experiences at UCLA.One was with a high-pressure salesman physician who advised me poorly and also failed to do a retinal exam before cataract surgery, resulting in a detached retina. Another time my wife broke her wrist and was required to see a cardiologist before surgery to repair it. (CYA — the surgery was clearly mandatory).The soonest a UCLA cardiologist could see was two weeks later. No doubt there was a cardiologist somewhere in southern California who could have seen her the next day, but UCLA would not give her a referral out of the system. (We solved the problem via a friend of a friend of a UCLA cardiologist who agree to see her during lunch, but that is no way to allocate medial resources).UCLA was acting as a competitor in a (highly imperfect) market. Hospitals and doctors know their overhead and variable costs, but “consumers” are in the dark – without data on treatment efficacy, physician skill and success rates, etc.

  52. Supratim Dasgupta

    Canada is also increasingly getting influenced by Big Pharma. There are many medications that Canadians are not able to afford and cannot import from cheaper countries. Ironically Canada has lot of Mail order pharmacies that ship to the US.

  53. PhilipSugar

    Respectfully no. I do not think people should be denied core healthcare.This is the one case I am fine with UBI. I am ok, you get X to spend on basic healthcare.Catastrophic also covered.Go to Emergency room for sniffles? Nope.

  54. Matt Kruza

    Sure, but can we also agree that some market forces are effective? Obviously not every procedure can be like lasik, but there is no fundamental reason that many (perhaps most?) procedures could be cut if we let traditional economic incentives be applied. I agreed to your premise there are some differences, do you agree that there are many ways they are similar?

  55. William Mougayar

    “many medications that Canadians are not able to afford “. – Do you have proof/back-up for that statement? I find it hard to believe.

  56. WA

    Andrew – that should’ve read I just finished reading an article in the print version of the magazine from the business school here in Miami. I do know and have academic and professional relationships with several people in the school. One of the authors I also know personally. Sorry for any confusion

  57. WA

    As I do mostly voice text thing and commentary online sometimes things get lost in translation, omitted, or I’m speaking not at the same pace I’m thinking

  58. Supratim Dasgupta

    Lets say for Liver. Epculsa, Harvoni,Sovaldi. The negotiated rate is still 500-700 USD per pill. Cost of total treatment is for 3 month treatment is ~60,000USDhttp://www.theglobeandmail….Govt has not been able to pay for these medications to most people unless they are on a liver transplant list( which costs more than this).I know this specifically because we have 200+ patients from Canada.

  59. PhilipSugar

    Problem is that not everybody is a winner. There is going to be better doctors and worse doctors. That’s always going to be the case. My wife and her friend are great. Some doctors they know really care about going to the golf course, or don’t really like people.Some want to talk, others don’t even want to really look at you.It’s no different than restaurants.Now I agree I don’t want some people not to have access, but its not as simple as you say.I was teaching programming in the inner city today. The kids who wanted to come and showed up are GREAT. But I can tell you there are teachers that are demoralized that they get beaten over the head with test score results that are not their problem.My brother won the GM robotics contest from some of the kids from one of the worst Barrios in Phoenix. But that doesn’t mean they didn’t have to walk him from his car because he would have gotten his ass kicked.It’s very complex.

  60. PhilipSugar

    Actually to be brutal, I’d look at total cost.Taxes on Cigarettes? $15.5B last year Federal more than $30B stateSaved money on Social Security dying early? Many more Billions than that.Dying quick because you get cancer or heart disease? BillionsI’d argue if you are greedy you want everybody but you to smoke.

  61. JamesHRH

    Doesn’t work that way.Top 10% of CDNs leave the country for immediate access to US healthcare. People here love to natter on about a single tier of healthcare, but it has never been true.Best friend’s wife repping a great medical facility in Cayman Islands. Her biz is growing like a weed.We just took our daughter to Texas Children’s for a 2nd opinion on something. Providers here were ‘that is what I would do if I were in your position.’We joined a clinic that bends the rules, We pay nominally for comprehensive health optimization services, but the kickers are ‘same day / next day’ appointments for our children, Doctors with longer appointments (big issue here, Doctors have 15 min cap on appointments) and access to specialists.Socialized medicine is the right thing to do, but don’t con yourself into thinking that it delivers a level of service that you would find adequate, if you had the resources to work around it.

  62. Vendita Auto

    Agree re ROI which is/was my point as for greedy ask the CEO of BAT & investors they would play the I do not smoke (Pontius Pilate) card. As stated in a prior comment:Over the last few months I have been thinking (Gandhi) about peaceful protest. Think the time is coming where this will happen in some national/international form, in the UK the catalyst is funding the NHS/social services as this is very high priority across UK public concerns, one wonders if openly taking a single band-aid from a retailer would overwhelm the justice system in protest. The power of media ? I like this thought.

  63. Jon

    Dying early from lung cancer isn’t likely to save very much money on healthcare. End-of-life costs for cancer patients are huge, so having someone die from lung cancer at age 50 is way different than dying from a car accident or catastrophic heart attach at the same age.

  64. William Mougayar

    Interesting. It seems like a corner case, but not diminishing its importance for patients. Thank you

  65. JamesHRH

    That’s the dilemma but it doesn’t change the facts – best health care anywhere is in America.

  66. LE

    But that doesn’t mean they didn’t have to walk him from his car because he would have gotten his ass kickedAnd some people still wonder why the cops are the way they are. Imagine having to patrol in that environment. Unfortunately it only takes a few bad apples (and I would argue there are more than a few) to make the entire community pay the price.or don’t really like people. Some want to talk, others don’t even want to really look at you. That is the bedside manner part of it. Some of that is important and some is just window dressing. The hospitals now have the patients rate the doctors on that type of thing. Part of the reason is to avoid lawsuits (get in front of any potential problem since people are less likely to sue if a person connection at least some people).That said some people’s personalities don’t allow them to want to interact with people. Some of those choose professions in medicine where they don’t have to (like radiology as only one example). Not everyone is a people person and I am not sure that makes as much of a difference as people want to think it does.My daughter had a benign ear tumor when she was 10. My wife wanted to use the doctor (an ent) who she knew from the synagogue who she liked and was a ‘nice guy’. He was probably a good doctor not saying he wasn’t. But community doctor no major medical teaching hospital grade (they are typically the best because they actually like medicine).I located the guy at Penn that was an expert in this condition (cholesteatoma). Went to talk to him. He was quite the asshole actually. I remember telling him I wanted a plastic surgeon involved so no scars. He literally told me (in a not nice way) no not going to do that. Period. It took two operations to fix (planned that way) where she could have had face paralysis or even worse (iirc). He banked one of the bones for the future operation. In any case of course everything years later is fine, didn’t loose hearing everything is ok and no scar either.My point is when he was an asshole I thought ‘this guy is probably good if he can get all of these referrals and act like that’. I liked that he wasn’t frittering away and saw him as an aspy technician who knew his craft.

  67. ShanaC

    Anyone doing actuary work could also do work in predictive health analytics.Which is more likely to save people’s lives long term?I’m not worried about the vast majority of people who work in an insurance company, in other words

  68. ShanaC

    Current us insurance market doesn’t obey normal market forces, if anything it warps themMy favorite example:Me buying a test through color genomics, about $250My insurance buying the same test through myriad genetic, about $5000

  69. ShanaC

    Basic vs preventative?In a given year, I will definitely have 1 mri, 1 mammogram, and 1 ultrasound as preventative careIt’s also definitely not most people’s sense of basic care, but doing this is essentially how to catch cancer early (aka, cheaper) in high risk women like me.How should this be covered? Remember, doing this is expensive, but treating later stage cancer, even more so.( If you are asking why no surgery, it’s likely that the risk of complications, especially for reconstruction, could be higher than my innate risk, which is unknown as my mother isn’t a brca carrier. That, and I haven’t had children: most women and doctors want to keep breast feeding on the table, especially since it has a preventative effect.)Basic/preventative care, in my experience (and watching others) ends up being a highly personalized thing. If anything, it needs more personalization to bring down long term costs of care.

  70. Matt Kruza

    the primary reason it is so warped is due to the overall structure, which certainly isn’t near a free market. Insurance should probably not pay anything under $1k – $5k. Your car insurance shouldn’t pay for oil changes, or hell even a new transmission. Insurance should be for catastrophic. The closest to a market based system that deals with reality is government covering catastrophic claims for everyone (financed either via tax or some mandatory policy somewhat like obamacare business requirement for insurance over 50 employees) over a set limit per year. My base suggestion would be $5k, but could go as high as $10k or as low as $2.5k. Then everyone should have HSA’s. Proper incentives can be put in place so companies are incented to shift current insurance premiums into HSA contributions for all employees. And states like Indiana are experimenting putting money into HSA like accounts for medicaid recipients in a certain form. So definitely need some govt involvement, but until more transparency and competition happens its certainly not accurate to say the free market has failed. Its poor govt regulation and overall insurance market structure right now.

  71. PhilipSugar

    I am fine with basic care. I also think that if you let people that profit from doing tests they will do…..Do much more than needed, no different than prescribing drugs much more so than you need.But if that is what you want? Great do it. Pay. No different than if I don’t care about driving an old 2001 Pickup, when my wife insists on driving less than a three year old Denali XL.

  72. ShanaC

    It’s not what I want to do: I actually hate these regimens, and fought against doing it for years when I should have done those tests, because statistically every generation within a high risk family gets cancer slightly earlier than the previous generation (and no one knows why this is). If it were up to me, I’d skip all of this, except I am terrified of dying the way my grandmother did, and slightly less terrified of coming out of chemo with a mixture of chemo-brain, permanent arthritis and permanent immunocompromisation the way my mother did (and we don’t know why she did so poorly with chemo). My fear is legitimate: my grandmother got diagnosed with cancer around age 32 and was dead before 45. I’m 30, right at the edge of when my grandmother got diagnosed.It is what evidence based medicine asks me to do to not die young. (and yes, I did check in journals about this once upon a time, when many years ago someone wanted me to go for mammograms and ultrasounds 2x a year on top of the mri. I continue to check what the standard (… ) and cutting edge sense of care is, especially because unlike for say a 50 year old woman, the guidelines do change much more rapidly with much less data behind them because of the population group I am in)If you are actually curious, the new car for me is switching to tomosythesis over a mammogram or doing tomosythensis.To be totally honest, the real kicker in this conversation I am having with you.You know what we don’t have for either of usan Apgar score for our current age and biological sex, +/- other issues in our family histories. I’d bet good money that if such a checklist and scorecard were available, we’d quickly find out that both of us might not be getting the right types of preventative care.Who knows though – we don’t invest money in actually studying real preventative care to figure out what an apgar score for adults would look like

  73. ShanaC

    I find this comment disturbing because realistically catastrophes are essentially chronic problems we didn’t take care of early enough. And most chronic problems are complex – meaning we would want a large (ie: a big state level of population’s worth) of data to really study how to get rid of a chronic problem/prevent a chronic problem.It isn’t clear to me that shifting everything to a HSA solves the problem. Furthermore, absolutely no one has a real explanation as to why employers need to be involved in the solution in the first place.___I need to admit, I am actually not in favor of an insurance market at all. I’m a cancer patient without cancer, and not just any type of cancer patient either: pending results of genetic tests/getting better genetic counseling that comes with said tests (just don’t ask, long irrelevant story), I have a very expensive genome if you are a researcher looking to buy genetic material/data from another researcher/research database(patients can’t easily sell). My mother has had breast cancer . She’s also not a BRCA carrier at all. We’re very ashkenazi, a popular group for researchers to study since there are already a lot of known qualities (including foundational brca genes). As a result, I’ve personally offered my own blood up to do some very cutting edge research, like using liquid biopsies to see if you can diagnose cancer/use preventatively. I do this sort of stuff not because I want to make money (I actually was shocked when the liquid biopsy people paid me), but because I believe that I need to do something to make healthcare better for all, and I happen to be one fo the few un/lucky ones who can make a difference. This also means I see how the sausage of cutting edge healthcare is made while I am still healthy.So here are some fundamental truths:1) We totally understudy what healthy is. It is hugely telling that your doctor doesn’t give you, and there is no popular term for, an adult equivalent of an APGAR score for your age, biological sex, minus any known family conditions. The reason is there is very little funding behind this kind of research, and the amount and types of data you’d need is actually quite massive. A study like the Nurse’s study is a good start, but not really helpful – you need national population level data for all age groups, split by gender, and properly marked with family histories.2) Without a real sense of an adult APGAR score, the long uphill battle of treating chronic problems (and in reality, preventing chronic problems) is extremely steep. Short example that I am familiar with.I take breast cancer in my family as a chronic problem (because it happens so often). I literally just found out a couple of months ago that the estrogenic compounds in soy don’t have an effect in breasts. I’ve been avoiding eating large amounts of soy for 8 years, despite really liking tofu. The problems behind tofu,estrogen and breast cancer have been studied for 40 years longer than I have been alive. Soy is one of the US’s most important crops. It is patently ridiculous that the US can’t figure out within a similar time frame as they did for low dose birth control if soy would be a problem. It took an extra 10 years to get that information, despite all the relevant pathways involving soy, estrogen, birth control, etc being known! The reason: there just was not enough money to study soy.More basic chronic common problems, like headaches, actually face stronger uphill battles. It is profitable to treat them using the low hanging fruit of the current treatment domain rather than investing in a totally different clincial trial structure, research structure, ect, with a lot of risk. But if someone got to the underlying cause of why people got migaines and cured them (aka raise the adult apgar score), that company would make a whole lot of money, pending a world that would allow that to happen. Furthermore, by permanetly curing migraines, they also would cause those people who had migraines to make more money in the economy, paying it forward.We fail to see this problem in our healthcare system often3) We have a really crude medical system in a lot of ways with a ton of unknownsSee: the sheer amount of medication people take in order to not get regular migraines or alternatively how many BRCA postive women remove their entire breasts and fallopian tubes in order to not get cancer. In both cases, it is because we don’t understand the underlying causes, which means we never really got the individual to the point of true health. (I remind people that being at risk doesn’t mean you will get a disease, and that also the population that has these genes are suddenly more likely to get cancer than they were in previous generations in some ways)4) A lot of the crudeness and the unknowns could at least be solved by acknowledging the pair of tragedy of the commons issue involved in medicineThe first is that unless everyone shares all of their data, we don’t get to solve migraines nor cancer. Just the way the adult APGAR thing works.The second funny issue is: My health affects your health, and visa versa. Which is why scientists can predict my likelyhood I like to exercise, my income, what have you, through my social network…Both of us don’t really know each other well. yet here we are, our lives, our health, our bodies, interlinked. My health is your health, and your health is mine. And that is true for all of the links in our social networks and weak ties. And the saddest part of all: The person who the healthcare system lets down the most is the one who also makes us the least healthy too._____HSAs, worrying about paying doctors, labs, for drugs, is the wrong problem to focus on. All of them will get their pound of flesh in whatever system the US gets. The actual right question is how do we incentivize people to do right by each other to keep him/herself truly healthy, because the weakest link in the chain is the person making you sick. Since we treat healthcare as something we buy in this country, rather than looking at what healthy is, we’ve fundamentally broken ourselves and made ourselves unwell.And that’s why my blood continues to be valuable to researchers, and why I’ll continue to be in weird conversations with doctors who can’t decide if it is good or bad that I haven’t had cancer yet.Sad, isn’t it.

  74. PhilipSugar

    Positively. I’m great with free clinics. My wife does one at church every Sunday. Now it should absolutely not be a requirement you attend church, and it’s not. If you want to show up after mass and just come on in, fine. We have many Latino’s so there is always one person that is a translator. Neither of us speak a lick of Spanish.I have no problem with the Government institutionalizing this.

  75. PhilipSugar

    I think the huge problem is Shana doctors don’t know what they don’t know and they have gone through too much education to not understand this.

  76. ShanaC

    I agree doctors don’t know what they don’t know, which is how I end up reading medical journals on pubmed.That said, most people, including doctors, don’t understand the bravery of the uphill battle that is true health. We’ve overfunded interventions rather than continuous care. It is clear that continuous care with a goal towards health is far cheaper than treating a disease, especially a chronic disease. And that is before dealing with the ~27% with underlying conditions.Getting in front of these diseases is super expensive from a research perspective largely because we think we “consume” healthcare. If we acted as if healthcare and these diseases were interlinked social problems the way they seem to act from both a data perspective and from scientific evidence like this NEJM study on obesity… , we would not only spend less, we would have more innovation in the sector and a healthier overall population.It is appalling to me that the genomes of my mother, my maternal-great aunt, my oldest first cousin (mother’s side), maternal aunt, me, and my maternal grandfather’s plus our cumulative health history (alongside my dead maternal grandmother a’h) costs over $1.5 million for researchers to buy and sell among each other, while I am also sitting around freaking out if I am going to be able to afford a mammogram if the ACA is repealed. Meanwhile that data could be used prevent and/or cure cancer for at least one person on this site within the next 15 years, and that 1.5 million could have been used for salaries of people who do mathematical research in this area who are NOT being hired because we think medicine needs to be market based.I volunteer to join studies because I realized a long time ago that my health and healthcare was sacrificed as a tragedy of the commons. Beyond my personal health, I’d feel immensely guilty if someone died because I did not step up and volunteer to make the progress that needs to happen to save that person’s life. I already feel guilty- at least one of our current/former members had his/her spouse go through cancer treatments this past year very suddenly. Thankfully the spouse is doing well, but if there was something in me that would have caused scientists to effectively learn how to prevent that person from getting cancer, I would have given that information over in a heartbeat.Instead, I’m struggling to even join those types of databases because there is a cost of me “consuming unnecessary tests” first. I’m linked to you, you to me, and from there, our respective social circles, their social circles. Their health matters to how healthy I am, to how healthy you are, to how healthy I am.We’re not talking cars – we’re talking keeping you around for the long term by keeping me around for the long term, and visa versa. That’s how data and healthcare, for both good and ill, works