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The venerable University of Texas MD Anderson Cancer Center in Houston will accept patients with traditional Texas Medicaid health insurance, and some patients in Medicaid managed care plans. Memorial Hermann, another large health system in Houston, will accept traditional Medicaid patients and also those in Medicaid managed care plans. Neither institution will accept the Blue Cross Blue Shield HMO silver plan sold on the Affordable Care marketplace, according to NPR, and as clearly outlined on the MD Anderson website. As it turns out, the conservative state of Texas is able to obtain best in the world health care for its poorest and sickest citizens, while the private market representative, Blue Cross Blue Shield in this case, is barring its “customers” from the best and most popular Houston hospitals, including the public system (!), and all the doctors that go with these hospitals. This situation is hardly unique to the Lone Star state.

The Affordable Care Act (ACA) is mandating that insurance companies take as much money from people as they are presumed to be able to pay, then proceed to top it off with taxpayer subsidies to make up for any shortcomings, and engage in these activities without discrimination based on formerly diagnosed illnesses. For their part, the people are mandated to make these payments, whether collectively through the government, or individually through their own pocketbooks, or most often both. While the ACA prescribes in great detail the mandatory flow of money from the people to health insurance corporations, and the services due to the people in return, it leaves the definition of the means by which these services are to be provided largely to the wisdom of the corporations, as long as they can show that, theoretically, the services can be provided. And indeed in many cases, many people, in practically every state, are now receiving excellent theoretical coverage for theoretical medical services.

If you happen to have cancer, and are looking to purchase health insurance, no insurer can turn you down or charge you more because of your preexisting condition. Thanks to the generosity of the ACA, you can select any one of the diverse insurance plans offered by each payer. You can choose a plan with a tailored, high-performing network focused on keeping you healthy, which includes almost no cancer hospitals and no cancer specialists, or you can buy a lusher and more expensive plan that includes some cancer facilities and doctors, or you can buy an exorbitantly priced health insurance plan that includes the likes of MD Anderson Cancer Center. If your cancer is found after you enrolled in that affordable plan for healthy people, you can always decide to switch to a plan that treats cancer and pay the difference. It’s all up to you, and the cash in your wallet, because now you have choices you never had before the ACA was enacted. This has absolutely nothing to do with preexisting conditions. It has to do with high-performance, tailoring, focusing and all sorts of other patient-centered features and benefits.

With great choice, comes great responsibility. All but the most expensive plans available for your selection on the Affordable Care marketplace, and most employer based insurance plans as well, are consumer driven. Basically you get to make all the big decisions regarding your health care and you need to empower yourself to rise to the occasion if and when disease or accidental misfortune materializes in spite of the system’s best efforts to keep you healthy. For those with little expertise in insurance jargon the best illustration may come from the home mortgage market. See, your affordable health insurance plan is very similar to the pre-2008 affordable mortgage for your pre-2009 home. In addition to your affordable monthly payments, there is a balloon payment due the day you are diagnosed with cancer, heart disease, or just slip and fall while cleaning the gutters. This payment is also known as your high deductible, and unlike your mortgage balloon payment, your high deductible is a self-renewing source of anguish, which springs back to life every January 1st.

There are handy calculators available to let you estimate the size of your balloon payments, and hospitals are setting up specialty services to evaluate a new vital sign called “liquidity” before any procedures are undertaken. Think of it as an expanded pre-op clearance. If your liquidity is lower than the price of your treatment, hospitals may help you elevate liquidity levels through various financial instruments, such as credit card debt, and refinancing for your balloon payment. It is not by accident that entities with brilliant track records in financial markets, such as Citigroup, are seizing the emerging opportunities in the brand new health care financing market, and are introducing innovative solutions “designed to simplify and enhance the healthcare payment experience”.  Be on the lookout for more innovation here, since this market is projected to run into the hundreds of billions of dollars by the end of the decade.

To bridge the gap between our vibrant financial industry and our old and tired health care system, a new diagnosis seems to be in order. Hypoliquidemia is a disease of the financial system. It is characterized by low levels of liquid cash in your bank account, low credit scores and low socioeconomic status (SES). Other signs and symptoms may include anxiety, depression and various phobias. Hypoliquidemia is diagnosed through a series of evidence based standardized screenings, ported from the financial industry and administered by your whole-person oriented care team. Moderate hypoliquidemia is severely exacerbated by prolonged encounters with the medical system, and although not a life threatening condition in otherwise healthy individuals, it may be lethal when comorbid with other severe illnesses.  The secondhand effects of hypoliquidemia can be extremely debilitating to hospitals and physicians who fail to take the necessary financial stewardship precautions when treating large numbers of hypoliquidemic patients.

Physicians, primary care docs in particular, are at increased risk of being affected by the spread of hypoliquidemia, since they are usually the first point of contact for patients entering the health system, and also because they lack the sophisticated diagnostic tools needed to measure liquidity levels before medical services are provided. The most likely effect of treating low liquidity populations consists of increasing levels of uncollectable bad debt. The only known protection mechanisms for individual physicians are to require cash or credit card payments at the time of service, or to avoid encounters with potentially hypoliquidemic patients altogether, i.e. those with ballooning high deductible insurance plans. Finally, according to a must read article in Managed Care, hospitals are already setting up “financial screening techniques that stratify access to their services” because “having an insurance policy will not guarantee access to care in the future”.

Hypoliquidemia is reaching epidemic proportions in the U.S. and there is no cure in sight, and there will be no mercy either. For the desperate, there is an old folk remedy which has been used successfully by inadequately liquid citizens in need of nursing home care in their old age. To attenuate the effects of hypoliquidemia on serious comorbid conditions, you need to counterintuitively drive your liquidity levels to zero. You need to quit your job, assuming you have one, and deplete any and all meager assets you may still have. Since regulatory climate is extremely important to treating hypoliquidemia, you may have to move to a region with suitable environmental controls. Once all these steps are executed successfully, you should be able to qualify for Medicaid and gain access to academic centers of excellence, including places like MD Anderson Cancer Center, if that’s what you need to survive. The most common side effects of this remedy are: premature death before the course of treatment could be completed, persistent exacerbation of hypoliquidemic symptoms, suicidal ideations and universal health care delusions.

Introduction to Hypoliquidemia

In a previous post, I described how the American health care system is morphing into a system designed to service impoverished populations, and concluded that the transition “will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life”. However, a new blog post from Dr. Peter Ubel makes me think that it may not take that much time after all. It seems that Dr. Ubel has been “writing a bit lately on the need for health care providers to talk with their patients about health care costs”, and it seems that some have pointed out that this sounds very much like rationing of care for poorer citizens.

In a Forbes article explaining why this type of criticism is “misguided”, Dr. Ubel is pointing out that individual patients may have different preferences and it is entirely possible that a “patient who pays 20% of the cost of a $100,000 chemotherapy treatment might decide that the potential benefits of the chemotherapy are outweighed by the $20,000 in out-of-pocket expenses they will incur”.  If the empowered patient has $0 in his wallet, division by zero would indicate that the potential benefits of life-extending or even life-saving treatment would be outweighed by a factor of infinity.

Having settled the rationing argument, Dr. Ubel is proceeding to suggest an innovation that should help “providers” bring costs into treatment decisions, not necessarily for everybody, but just for “those who are financially distressed by the cost of medical care”. Since most “providers” don’t know much about costs of treatment, the “financially distressed” will be directed to “walk down the hall and talk to one of the billing experts in the clinic”, because “meeting with this kind of a financial expert will help patients gain a fuller sense of the costs and benefits of their health care alternatives”.

I am not sure how the “billing expert” turns into a “financial expert” in the span of one short paragraph, or how one gains a fuller sense of treatment benefits after a conversation with a coder in the back office, not to mention the technical problems in clinics where the “financial expert” positions were outsourced to India through this or that cloud-based EMR company. Presumably to address these difficulties, Dr. Ubel proceeds to list all sorts of philanthropic Internet startup companies that will help patients figure out costs of care, largely out of the goodness of their hearts. Consistent with his other articles, Dr. Ubel is advising physicians to not “resist this inevitable trend”, but rather “embrace the opportunity to help their patients better understand the full ramifications of their healthcare alternatives”.

Since unlike Dr. Ubel, I don’t find it “relatively straightforward to imagine a shift in our clinical paradigm, where physicians alter the flow of patients in their clinic” to send poor people to the back, I would like to suggest a different solution which should require no imagination at all. Let’s make poverty a disease, most likely one of those “lifestyle” diseases. Instead of just V codes, let’s give it a few regular ICD-9 codes and plenty of ICD-10, and let’s add a special CPT code for ancillary “financial expert” services that can be billed incident to a physician visit for patients diagnosed with Poverty and proper manifestation codes of commercial insurance or no insurance (which is basically the same thing when you have Poverty). Note that publicly insured individuals can only be afflicted with unspecified Poverty, and do not have out of pocket manifestations, so their claims will fail medical necessity checks and will be denied.

If you think about it, Poverty fits very well in the documentation templates of any EMR. For the HPI section, Poverty can be acute or chronic and it can have date of onset and duration. It certainly has severity levels, and it can be better with some things and worse with others. Poverty has well known co-morbidities and you can even reasonably document previous treatments. Both the Family and Medical Histories can accommodate Poverty in relatives and previous bouts of Poverty in the patient. We will need to formally add an organ, or system, to both ROS and Exam sections, and the canned Normal findings could be something like “wallet plump to palpation, credit scores clear with no discharges and no late payments”.  

Poverty with commercial insurance or no insurance manifestations, is of course a secondary ICD code which cannot be billed on its own (you are a doctor, not an accountant), so before you can document your assessment and plan for the primary diagnosis, you will need to send the patient for a “financial expert” session, either in the back of your office, or at an outside facility, just like an x-ray or a cardiology consult. After the patient has been carefully made to understand that the benefits of $100,000 chemotherapy are outweighed by the lack $20,000 in her pocket and the unavailability of assets, loans or other debt instruments, you can complete your assessment and add orders for affordable hospice medications to her plan. This can be done remotely through secure email to save the patient the inconvenience of one more visit, and the care plan can then be shared with the rest of her care team via health information exchange facilities.

After five long years of political bickering, the solution to our health care problems now emerging from all our legislation, regulations, court battles and billions of dollars to "support transformation", seems to be one which requires doctors to take poor people to the back room, one by one, and educate them on the fiscal subtleties barring them from access to proper medical care. Why try to fight this brave new system? Why resist this inevitable trend, when you can embrace the opportunity?

And there is indeed great opportunity here. First, reimbursement rates for Poverty consultations are bound to be fabulous, and the prospects of “shared savings” are almost boundless. Second, the old coder in the back office may be a poor match for “financially distressed” people, and there is no denying that medical knowledge should help things along, and an MD could be the most effective consultant. So perhaps MDs with MBA degrees will finally be provided with a proper venue to exercise their craft, and perhaps a new specialty will rise to the forefront of value-based health care. May I suggest Paupertology (: the branch of medicine that deals with ability to pay disorders of the poor)?

Health Care for the Poor: The Sequel

A new study was published in the Proceedings of the National Academy of Sciences of the United States of America (PNAS). The study is titled “Experimental evidence of massive-scale emotional contagion through social networks”, and it analyzes an experiment on Facebook users conducted by Facebook, in collaboration with researchers from UCSF and Cornell, almost two years ago. The experiment was a success, as it showed that Facebook was able to alter the emotional state of its users by making subtle and deliberate changes to the content users were shown in their news feeds. The study was subsequently edited for publishing by a Princeton professor, and accepted for publication by the prestigious National Academies, which by the way include the Institute of Medicine (IOM).

The experiment “manipulated” the News Feeds of 689,003 people, randomly selected, and then measured the effect on the subjects’ own Facebook postings, due to increased exposure to either positive or negative content from their own friends. The results show modest but significant ability to affect people’s emotional state by ever so slightly altering what they see on the Internet. The study concludes by pointing out that “the well-documented connection between emotions and physical well-being suggests the importance of these findings for public health”. And if this line of thought leadership is not creepy enough for you, there is one more little thing to note here. The subjects of this bold experiment had no idea that their friend feeds were being manipulated and that they were being studied by Facebook.

According to The Atlantic, who first broke the story, neither Facebook nor the authors were available for comments. However, the Princeton professor who prepared the study for publication, Prof. Susan Fiske, agreed to talk with The Atlantic reporter. It seems that she had some initial concerns which were addressed by the authors when “they said their local institutional review board had approved it—and apparently on the grounds that Facebook apparently manipulates people's News Feeds all the time... I understand why people have concerns. I think their beef is with Facebook, really, not the research”. Yes, the research itself is "inventive and useful", according to Prof. Fiske, and its “originality” should not be lost because “ethics are kind of social decisions. There's not an absolute answer. And so the level of outrage that appears to be happening suggests that maybe it shouldn't have been done...”  As it turns out, now that we know about the study, Prof. Fiske is “a little creeped out, too”.

The idea here seems to be that the definition of ethics at any given time depends on the personal opinion of those in the know. So if you conduct experiments on human subjects in secret, it is only your opinion that counts towards the definition of ethics. If the study becomes public, and if the public has a different opinion about ethics, you just say oops, maybe we shouldn’t have done that, but the results are way too cool, so let’s use them anyway. If indeed the study was approved by the review boards at either UCSF or Cornell, and contrary to explicit PNAS policy, there is no note to that effect in the article, it also appears that institutional review boards at academic centers will approve experiments on human subjects without consent or notification based on a solid track record of similar transgressions that went unnoticed and unchallenged in the past. Stated discomfort and feelings of creepiness emerge briefly only after public disclosure, and then we move on to the next adventure.

This little experiment is a perfect illustration of what Big Data can do for us. Big Data can spread mass happiness without “in-person interactions and nonverbal cues”, which can in turn induce “physical well-being” and ultimately improve the health of the public, at presumably much lower per capita costs. Here you have it; two of the Triple Aim goals are easily achievable by technology alone. All we need to figure out now is how to hit our third goal of better care for the individual, and this too is amenable to Big Data solutions once we get past the “creepiness” hurdle.

A recent article from Bloomberg describes precisely how highly individualized care is already provided to more fortunate patients through the beneficence of Big Data. Mammoth hospital systems turned health insurers, or just apprehensive about having to accept risk for their patients’ outcomes, are purchasing information from Big Data brokers, including credit card purchases, household and demographic information, and who knows what else. When combined with clinical and claims data these entities already have, Big Data allows health corporations to profile their customers and identify not only the ones that may put them at increased financial risk in the future, but, according to The New York Times, also the customers most likely to bring in increased revenues. And just like any other big business, health systems can then devise marketing and outreach strategies to mitigate their risk and increase their profits. Or in terms better suited for public consumption, they can provide better patient-centered care to individuals to help them get healthy and stay healthy. Problem solved.

Big Data is by definition a weapon of mass destruction. Some have likened Big Data to nuclear power, which can be used for unspeakable horrors or for the public good. This is an apt analogy, if we remember that nuclear power was first used for mass destruction, then it was (and still is) used for terrorizing nations, and when it is used to generate electricity, mountains of safety measures must be employed, and even then accidents do occur with dire consequences. Following the public discovery of unprecedented government surveillance on citizens’ communications (yes, that is Big Data), President Obama asked us to remember that "the folks at NSA and other intelligence agencies are our neighbors and our friends", and that they “are not dismissive of civil liberties”. Of course not, and the folks working in nuclear weapons plants, or nuclear reactors are also our friends and neighbors, and they are not mass murderers either. And yet, we found it necessary to enforce strict regulations on their work, instead of trusting their better angels and personal ethics.

The Facebook trial balloon floated nonchalantly by the National Academy of Sciences to gauge public reaction to mass psychological experimentation on people is most likely indicative of a much larger iceberg in the making. Creepiness is not a legal term and right now we are allowing every garage entrepreneur, every corporate entity and every governmental department to collect, distribute, sell, purchase and utilize unlimited amounts of Big Data for any purpose they see fit, including mass deception of the public, with no legal guidance and no legal consequences. We would never dream of a similar arrangement for nuclear materials. The polite reactions from self-appointed “privacy advocates” urging “transparency” and “patient ownership” of their data are woefully inadequate, because they demonstrate an utter lack of understanding of what Big Data is, how Big Data works, and how Big Data is being used. Besides, this is not about “privacy” anymore. This is about freedom, liberty and the non-enumerated right to human dignity.

The Ethics of Big Data Workers

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