No blog post this week, as Tim is out of the office. Rest assured new weekly musings will continue to come down the pipeline. In the meantime we encourage you to listen to Tim’s recent visit to the Medstreet Journal Podcast on Apple Podcasts.
Here is a short clip, and you can find the whole audio podcast at the link above.
Let’s start with a little bubble bursting, and no, I am not talking about the price of Bitcoin. Apologies to the Trekkies, but nowhere in the original Star Trek series were the words, ‘Beam me up, Scotty’ ever uttered. Captain Kirk came close a few times, but that iconic phrase is some weird amalgamation of our collective imaginations.
The very idea of the teleporter in Star Trek arose from an economic need. The original show had a very small budget (Let’s save money on costumes by making them all wear these pajama outfits all the time!) and could not afford to show the entire Enterprise spaceship landing on different planets for each episode as originally planned. So, someone came up with the idea of the teleporter, and wa-la, Kirk, Spock and the gang could magically appear wherever the script needed them to be.
We’ve been thinking about the Star Trek teleporter as a metaphorical representation of the role technology (along with consumer brand preferences) is playing in the erosion of the old adage, ‘All healthcare is local.’
Sheldon or some other theoretical physicist would tell us that actual Star Trek-type teleportation is impossible. But while we can’t disassemble, transport, and then reassemble actual atoms, we can do a lot of things that now render the restrictions of time and place far less restrictive.
Telemedicine, which sounds a lot like teleportation but then turns out to be more like a FaceTime call with your mother than a quick trip to Vulcan, is just the most front-of-mind example because of ol’ annoying COVID but is illustrative.
Once patients adjust to using technology to access aspects of their healthcare, then the range of alternatives gets a lot bigger. It used to be the options for getting your meds filled were the pharmacy on this corner or that one. To compete, you just had to be a little better than the other guy. Now you must beat Amazon, too.
Telemedicine is the same. If your patient experience is limited and clunky, your patients are just a click away from someone better. Local doesn’t mean jack squat.
I acknowledge the immediate objection. Most things in healthcare still require one human (let’s call them the least interesting and sexy thing we can imagine – how about ‘provider?’) to lay hands on the patient. Technology can help, but not replace, that process.
Fair enough.
But ask yourself this – how much more healthcare can be delivered remotely now compared to just five years ago? What about five years from now?
What will remote patient monitoring change?
How about patient-directed at-home diagnostic testing tied to a ‘provider’ via technology?
Even hospitals, never even a finalist in the ‘most innovative thinkers’ competition, are trying to imagine the ‘at home hospital.’
The point is technology will continue to abolish historical demands that care must be local, including things in your practice that you take for granted.
Next time we start talking about what you can do about this sea change.
In a time long, long ago (that is, before COVID) a lot of us used to enjoy taking the laptop and headphones to a nearby coffee shop to plop down and do a little work. Our oldest, who slipped in just in time to qualify as a Millennial, and I, just barely a Boomer, were debating our respective coffee shop preferences one day.
My choice was the ubiquitous one. I traveled a lot (yeah, this was long ago) and frequently had coffee shop meetings. I could count on finding my coffee shop on every corner, their Internet was reliable, and I didn’t have to stand staring at the menu for ten minutes trying to figure out how to get just coffee.
She stated that she preferred ‘authenticity,’ a central Millennial value that was a coded diss to all things Boomer. As typical, I was confused and agreed to meet her at one of her favorite places down in the old industrial part of town that was suddenly the hippest neighborhood around.
There I learned that ‘authentic’ for a coffee shop meant there had to be creaky wood floors, a dog laying by the door, extension cords pulled everywhere to power the laptops, and a dude behind the counter with a lot of ink and those big holes in his earlobes. There were no freshly pressed green aprons being worn by overly eager smiling staff who had completed 8 hours of corporate training on customer service.
Marketing experts frame this difference in customer values as my preferring ‘consistency’ while my oldest wanted ‘distinctiveness.’
As we explore whether the old axiom ‘All healthcare is local’ still holds true (or better, how true is it still?), part of the question pivots around this particular dimension – do patients want consistency or distinctiveness?
That may seem a bit odd given the set up of my prologue as most patients probably don’t seek out a doctor with the grunge factor of 1980s’ Seattle band, but let’s frame it this way: Do patients prefer getting to see the whites of the eyes of their personal physician or are they now increasingly trusting, and preferring, the ‘brand?’
I get that even asking that question will get me in trouble with some of my clients (not a good marketing strategy, regardless of your generation) who have patients who have been loyal to them for years, but we must ask it if we are to help you plan for the future.
There are plenty of stories about small players succeeding in the face of big brands by delivering ‘distinctive’ in a special way to a targeted and relevant audience. We love those stories. That truth will hold in healthcare as well.
But we would not be talking about these local success stories as success stories unless the larger backdrop were not about people increasingly opting for the known consistency of bigger brands. That truth is just as true for healthcare, and maybe more so since consistency, not unique and cool, matters more to my care than my coffee.
Let’s start with a quote that makes today’s post sound more erudite than it will turn out to be:
‘It will be convenient to have a name for the ideas which are esteemed at any time for their acceptability, and it should be a term that emphasizes this predictability. I shall refer to these ideas henceforth as the conventional wisdom.’
The line came from John Kenneth Galbraith, noted Harvard economist who served in Democratic administrations from FDR to LBJ as a leading voice for American liberalism.
Galbraith did not coin the term ‘conventional wisdom,’ but his use honed its meaning to how we typically use the phrase today. That is, more than an idea just being widely accepted – like the universal agreement that Red Sox fans are obnoxious – Galbraith brought forward the important nuance that since these ideas are both acceptable and comfortable to most of society, they are also resistant to new facts or data that might challenge them.
In the piece where he first used the term Galbraith was speaking specifically about academia, a place where those old bits of comfortable conventional wisdom go to hide and stay protected. Challenging the consensus does not easily lead to tenure.
But, since no one is offering me guaranteed employment no matter how little I work or how poorly I teach, I want to spend the next couple of posts taking on one of the most widely accepted conventional wisdom ‘givens’ in all of healthcare. Bloggers don’t get tenure, so I don’t have a lot of risk.
One of our clients and I were talking over the past weekend, working through some big strategic decisions his board is facing. He framed one of their big decisions around a semi-rhetorical, semi-heretical question that has been rattling around in my brain ever since.
He mused, ‘Our entire industry has operated on the unquestioned belief that all healthcare is local. Is that still true?’
Everyone who has been in this industry long enough to eat a bologna sandwich has been told by someone up the food chain that, yes, healthcare is local. That is what makes us different. We may be one-fifth of the economy, and there might be big organizations lumbering around, but at the end of the day everything devolves into local.
As you might guess with this prologue, a few days of ruminating has me concluding that the conventional wisdom is no longer true, or at least not true in enough situations that the bumper sticker slogan no longer merits a place in the pantheon of unquestioned assumptions.
In the coming weeks I’ll take a run at this from a couple of angles to see if I can make a convincing case that whatever this phrase meant when it got tenured twenty or eighty years ago no longer applies and that if your strategy is built on this idea you might be in trouble.
Wait, wait. Don’t go.
Knowing that I lead a revenue cycle management company, some of you read that blog title and presumed that today we are going to plumb the depths of medical billing. For you, that would be the equivalent of attending a three-hour elementary school orchestra performance.
Relax. My team will tell you that I have no idea what happens in the depths of medical billing, so you have no worries. And while today’s topic does have a medical billing backdrop, you will find the story far more interesting.
On Monday, US District Judge Allison Burroughs denied UnitedHealthcare’s (UHC) motion to dismiss a class action lawsuit brought by three cancer patients who were denied coverage for Proton Beam Radiation Therapy (PBRT) to treat their cancer. She decided the case can proceed.
PBRT is expensive; each of the three had paid between $85,000 and $126,000 for their treatments in 2019. UHC refused to cover these claims because PBRT, according to the internal UHC medical policy, is generally considered experimental and investigational.
I did not track down who is representing UHC in this case or their current hourly billing rates, but I think it is a safe assumption to conclude UHC could pay the three hundred Gs and get off a lot cheaper than what the legal bills will be before this is all over. This is not about the economic calculus of this one case. There is a bigger issue here.
Every provider and all those ‘back office’ experts like the people on our team know that ‘denied for medical necessity’ is one of the most important, most difficult, most opaque parts of healthcare billing.
Who gets to decide what is and is not medically necessary for the patient – the physician providing the service or the insurance company paying for it? Does the patient get to vote?
Some physicians would like to think anything they order should be paid, but that ain’t happening unless your payers are cash, Mastercard or Visa. There is a natural tension between the parties – patient, employer, insurer, provider – that plays out most of the time in the hand-to-hand combat of the denial and appeals process that occurs in the back office. But sometimes that process escalates to the desk of a federal judge. This will be worth a watch.
A quick word about the cost of PBRT. At $100,000 or more a pop, this is a very expensive therapy. The facilities cost about $200 million to build and are expensive to operate. It takes a lot of capital.
To wit, the most ironic part when reading Judge Burroughs’ denial was there on p. 16, right below the point that UHC pays for PBRT for patients younger than 19 years old. The plaintiffs allege, and it was not refuted, that a UHC affiliate has pledged $15 million to help fund the construction of a PBRT center in New York City.
Well, well.
Steve was one of those walking contradictions, an intentionally crotchety old dude that I believed stood in front of the mirror every morning to work on his scowl and practice yelling, ‘Hey, you kids get off my lawn,’ but he really was about as nice as could be.
They lived across the street and he took to our son Max. That proved to be a benefit to me because Steve had season hockey tickets at the local university and lived in a house with only females. One or two hockey games a year was plenty for them. So many times, I throw Max up on my shoulders and we’d head over and crawl into Steve’s old Jeep. He loved watching a four-year-old scarfing popcorn as we cheered for the Pioneers.
We always talked a little shop as Steve was a pediatric anesthesiologist. He covered Max when he got his tubes put in and we both had a little fun in pre-op when the versed hit. Industry talk could get his dander up pretty quick. One night as the Zamboni’s rolled, he barked, ‘You know what I say when someone asks me to donate to charity? I tell them I give to charity every stinking day because every day I take care of Medicaid patients. I gave at the office.’
Peak crotchety.
The Kaiser Family Foundation (KFF) recently released a study on hypothetical healthcare spending. KFF can be a great source of healthcare data, but sometimes math gets used in really illogical ways.
The study, complete with a great made-for-Twitter headline and a simple little bar chat, says that if private insurance reimbursement were paid instead at Medicare rates that would reduce US healthcare spending by $350 billion.
OK.
And if you gave me a billion dollars, I’d have a billion and change.
Why stop at Medicare rates? What would it be if everyone were paid Medicaid rates?
Why stop there? What if everyone were paid in Game Stop shorts? Or chickens?
Yes, yes, I know. KFF is a strong advocate for Medicare-for-All and this is part of the campaign. But it is a big, fat ‘so what’ analysis. Pick a number, any number, and spin the spreadsheet. It will give you a graph. As long as you assume no one has a brain or personal interests or the ability to respond to a such a drastic move, well then, looky there…problem solved.
This would be easy to dismiss, but it is a simplistic number like this that takes root in the halls of Congress and turns into momentum.
Unfortunately, Steve died unexpectedly several years ago, but I thought of him as I was reading this piece. This is not a topic we could have discussed in the presence of a four-year-old or Max would have learned some bad words and my wife would have banned me from hockey games with Steve.