I guess there’s just no way to have a sacred cow without also keeping a goat.

Understand, I’m not talking about a GOAT, as in Tom Brady or Michael Jordan. I mean a goat, i.e, something or someone that takes the blame for an event, failed policy, etc., perhaps more commonly called a scapegoat.

The sacred cow, in this instance, is the Second Amendment, which has become so sacrosanct in the national foundational myth of an inspired Constitution that it no longer means a great deal more than “everyone can carry guns wherever and whenever they like with no oversight whatsoever.”

That some of our fellow citizens sometimes use the guns they purchased to murder children in a classroom seems to have no impact on any effort to put even modest limits on the Second Amendment. The problem is not the sacred cow, we are told, but this “other thing,” despite the fact that simple math demonstrates that the other thing minus a gun rarely if ever results in mass casualties.

Since Uvalde, the other thing mentioned most often is mental illness. It isn’t the access to guns that’s the problem, it’s the disturbed people. 

While it goes without saying that mental illness is a problem in the United States—a weekend visit to any American city of significant size provides plenty of evidence—it’s worth saying anyway. America has a mental illness problem that, especially when combined with drug addiction, might accurately be called an epidemic.

But it’s not the poor souls living on our streets that are the most direct threat to public safety because they have very limited access to weapons. What’s more, while many of the individuals who’ve carried out mass shootings in recent years might have been described as different, quiet, troubled, or distant, few if any had an obvious mental illness. Because research has shown that less than 5 percent of shooters have a diagnosable mental illness, it bears repeating that the mentally ill are much, much more likely to be victims than perpetrators of crime.

So where, then, does this kneejerk impulse to blame mental illness whenever there is a mass shooting come from?

In a sense, it is representative of a very human tendency to find simple explanations for complex, frightening phenomena.

“I think when things happen that we don’t understand, we’re quick to try to find a reason for it,” says Jessica Gold, MD, MS, a psychiatrist at Washington University in St. Louis. “Mental illness actually is an easy explanation for people, in part because when you watch things on TV or in movies, you see a lot of violence and mental illness. So when that comes up, you’re quick to say, ‘Well, I’ve already seen that before.’”

In reality, a diagnosable mental illness plays a part in mass shootings so rarely that researchers have said: “the link between mental illness and gun violence is not there.”

The link between gun availability and suicide, however, is virtually impossible to dispute. According to this study, firearm suicides are almost four times as common in states with high rates of gun ownership than in states with low ownership rates. That the number of non-firearm suicides was roughly equivalent in both groups clearly demonstrates the connection between easy gun access and the decision to engage in self-harm.

“While firearms are used in just a small fraction of suicide attempts because they are so uniquely lethal, they are responsible for a majority of American suicide deaths,” says information from Giffords, an organization committed to ending gun violence named for Congresswoman Gabrielle Giffords, who was shot in the head while campaigning but survived.

The data clearly shows that suicides are often the result of rash, impulsive moods that, without firearm access, would usually remain just that—moods.

So why are elected leaders so quick to blame mental illness when there is another mass shooting?

First of all, because it shifts the focus almost immediately from the sacred cow, one perceived problem, to another, and because it enables society to ‘other’ the unfortunate individuals who do suffer from mental illness.

Unfairly, raising the specter of mental illness places blame on a group of people who either cannot defend themselves or don’t see themselves in the caricature that’s presented. The lack of specificity in the argument means those with depression and anxiety—mental disorders both—can immediately say, “Well, that’s not me. I’m not killing people with guns.” This is true, causally, even if people who happen to be depressed sometimes go on a rampage.

Second, blaming mental illness provides the public with a certain level of uncomfortable comfort—a ready explanation for something frightening that doesn’t ask the recipients of the explanation to rethink who they are or what they believe in.

Third, the shift to a focus on mental illness removes much of the responsibility for solving mass violence from the shoulders of public officials because the public, by and large, is not expecting the government to make a wholesale changes to physical and mental healthcare. Indeed, polling shows that Americans want the healthcare system to change, so long as their own individual healthcare remains the same.

“Too many elected officials … continue to use an age-old strategy of giving lip service without taking any action to mitigate the impact of mental illness or gun violence,” says Clinical Psychologist Benjamin Miller. “Or even more damning, blaming an issue—in this case, mental health—as the cause of our problems without acknowledging that their policy decisions have actually made conditions worse.”

As Miller points out, identifying mental illness as a simplistic cause of gun violence distracts from the very complex causes of violent incidents like those most recently in Buffalo and Uvalde. I mean, how do we deal in the short term with runaway inflation, pandemic fatigue, allegations of a stolen election, and the kind of desperation that clings to people who can’t come up with $800 in an emergency? In the long term, what do we do to unite a divided nation and counteract the corrosive power of social media?

“At the federal, state, and local levels, we elect our leaders to be servants of the people, and to represent the best and broadest interests of their constituents,” Miller writes. “But when we see that, from sea to shining sea, our entire country is experiencing rising rates of mental distress, alcoholism, drug overdoses, and suicide, at what point can we ask, who are these leaders really serving?” 

That’s not a question that requires much thought.

So, the next time a public official blames mental illness for another mass shooting, insist that they define their terms and stop blaming the truly mentally ill for something they are not doing. Insist that they do something to either lift people out of their quiet desperation or keep guns out of the hands of those with violent intent. If they do neither, maybe it’s time to replace them with people who will act more than they pontificate.

The end of the public transportation mask mandate, officially undone by federal Judge Kathryn Mizelle on April 18, may be recognized as the day the COVID-19 pandemic ended in America.

Except it hasn’t ended in any real sense. The virus continues to produce new variants of greater or lesser transmissibility and lethality; for now, comparatively small numbers of people continue to die of the virus daily and weekly; and the CDC continues to recommend that the elderly and immunocompromised take every precaution.

But America is mostly done with the virus, even if the virus is not done with us.

In truth, the virus won’t really be done mucking with things for some time … some undetermined amount of time in which reality will feel off-kilter and the country will be aware of COVID-19 but in a remote, unsettling way, like far-off thunder.

And that’s just with regard to the rate of infection. The extenuating circumstance—that a set of tenacious virus-related symptoms now commonly called long Covid might extend the performance longer than Cats ran on Broadway —has scientists and public health experts concerned about a slow-burning epidemic that lasts for years and touches most every corner of American society.

“Researchers still don’t know who’s most at risk, or how long the condition might last; whether certain variants might cause it more frequently, or the extent to which vaccines might sweep it away,” writes Katherine Wu in the Atlantic. “We do not have a way to fully prevent it. We do not have a way to cure it. We don’t even have a way to really quantify it: There still isn’t consensus on how common long COVID actually is. Its danger feels both amorphous and unavoidable.” 

But more than two years into the pandemic, the repercussions of long Covid are not that hard to define, even if the virus itself remains elusive. In several ways, both the coronavirus and long Covid are having a significant impact on American society, but the signs are probably not overt or common knowledge unless we connect some dots.

You’re probably already aware of the American labor shortage, for example. Maybe you tried to go to a nearby restaurant for lunch and found it closed for a lack of employees. Perhaps your company is trying to hire and can’t find qualified applicants. There is a decent chance that shortage of labor is in part the product of long Covid.

According to an analysis by the Brookings Institution, there are currently more than 10 million unfilled jobs in the United States. After evaluating long-Covid studies and crunching the numbers, “under reasonable assumptions given the data available, long Covid could account for 15 percent of the nation’s 10.6 million unfilled jobs.”

While many economists see a return to normalcy after the pandemic burns out or is brought under control, neither has really happened, and long Covid just pushes the finish line further and further out. That Covid infections have waned but not dissipated still has some positive economic impact, to be sure, but none of that is helped by the numbers of workers with long Covid who cannot return to the labor force full time or at all.

“If workers flood back to the job market as school and child care becomes more dependable and health risks recede, it will be easier for manufacturers and shipping companies to ramp up production and deliveries, giving supply a chance to catch up to demand,” says The Washington Post’s Ben Casselman. “That, in turn, could allow inflation to cool without losing the economy’s progress over the past year.”

The more the virus spreads, the more long Covid persists, and the greater the impact on the labor market and the economy as a whole, making it a significant concern for the foreseeable future.

Of course, a labor shortage across American industry will also impact healthcare, but that’s nothing new—healthcare was operating with fairly acute and worsening labor shortages before anyone had heard of COVID-19.

That scarcity of labor naturally creates a competition for qualified personnel that drives up healthcare costs overall, and the scarcity has worsened during the pandemic as many exhausted and often abused clinicians have opted out of healthcare entirely. Long Covid just adds more patients with chronic illness to a system with fewer providers. Costs cannot help but rise, even if how much is still an open question.

Unless the virus loses strength and becomes more endemic than pandemic, and then perhaps even if it does, we can also expect increased costs created by the unvaccinated. In several months of 2021 there were 163,000 deaths and 700,000 hospitalizations among the unvaccinated at a cost of $13.8 billion. Recent studies suggest that vaccines reduce the likelihood of long Covid without fully eliminating the possibility.

Many of the costs created by long Covid in particular may be borne by the patient, not the system.

“The system is gearing itself against individuals with long Covid,” said Dr. David Putrino, director of rehabilitation innovation for Mount Sinai Health System in New York. “And that makes them sicker and sicker over time … causing them so much stress and exertion as they’re trying to get the care that it actually makes the condition worse.”

Indeed, skepticism regarding long Covid—some medical professionals have labeled it a mental illness— calls to mind the medical response to conditions like fibromyalgia, particularly because more women than men experience long Covid.

“Extrapolating from the experience with other postinfection syndromes, the varied elements of the biomedical and media ecosystems are coalescing into two familiar polarized camps,” wrote Steven Phillips and Michelle Williams in the New England Journal of Medicine. “One camp believes that long Covid is a new pathophysiological syndrome that merits its own thorough investigation. The other believes it is likely to have a nonphysiological origin.”

As past experience has shown, chronic illnesses that are not treated directly by the healthcare system often end up as ER visits that increase both overall healthcare costs and the financial burden on individual patients, ensuring that most everyone loses.

And then there is the impact of Covid, both short and long, on American society in general, which will be felt but difficult if not impossible to actually quantify. Most countries don’t keep a running total of long Covid cases, which means the virus will sort of lurk in the background, often out of sight and mind but occasionally front and center as someone you know deal with acute illness or the long-term implications of infection.

“As people rack up different combinations of shots and infections with different variants, what worsens or soothes long COVID is also getting harder to understand,” says the Atlantic’s Wu. “Many of the experts I’ve spoken with over the past two years have told me that while they think long COVID is essential to study, it’s too complex for them to want to tackle themselves.”

Assuming what these experts say holds, the country faces a disconcerting prospect: The virus continues to evolve and infect. Meanwhile, a certain percentage of all those infected develop long-term symptoms for which there are no well-defined treatments—at least not yet. These long-haulers, as they are sometimes called, become a chronic disease class that the system works to treat in terms of symptoms but which adds costs for care, labor requirements, and probably the price of insurance premiums.

At this point, we’re left with stopgap measures, which include mRNA vaccines and which is similar to dealing annually with influenza.

Our hope and prayer at this point might be that another virus or a particularly virulent version of this one not emerge until we figure out what Covid-19 is, exactly, and how it can be dealt with.

About Irv Lichtenwald

Irv Lichtenwald is the President and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

To a certain extent, the national conversation about the importance of a robust public health system has been happening for the last couple of years in the context of dealing with the COVID-19 pandemic. And yet, rather than discussing how the system can be strengthened and expanded, we’ve instead largely limited it to what the government can and cannot ask the public to do, as though the necessity of a public health system is still in doubt.

For those who work in the arena, this is not an open question; a functioning, just society cannot sustain itself without public health. But the unfortunate product of a society with modest levels of commitment to the social contract and a jaundiced opinion of massive government budgets is underfunding and mistrust of public health.

Even so, public health professionals endure because they know they must. And within this reality, one might ask what could enhance public health without requiring comparatively huge budgets or much active participation by the public.

The answer, as with every corner of modern society, is technology. Not just any technology, however, as the digital health tools available to large medical centers are prohibitively expensive for public health and not necessarily what public health needs to do an effective job.

So, what would empower public health agencies and professionals?

The Basics of Public Health

At its most foundational, public health is about preventing the rapid spread of highly communicable diseases, and a primary tool in that prevention effort is vaccines. Without vaccines, diseases we mostly think of as relics of a less sophisticated age—smallpox, measles, mumps, polio—would continue to decimate populations and shorten life spans.

Of course, especially in the age of mRNA, vaccines are considered a technological solution. Less so are masks, social distancing, hand washing, and all other efforts to prevent disease spread. Because germ theory has come to dominate the response to disease, there is a tendency to focus on vaccines and ignore more simple, cheap measures can make a tremendous difference, not to mention the fact that poverty and education also play a role in who gets sick and who gets robust treatment.

“Both the Trump and Biden administrations have described the pandemic in military metaphors,” says Ed Yong in the Atlantic. “Politicians, physicians, and the public still prioritize biomedical solutions over social ones. Medicine still overpowers public health, which never recovered from being ‘relegated to a secondary status: less prestigious than clinical medicine [and] less amply financed,’ wrote the sociologist Paul Starr.”

And even with that focus on “biomedical solutions,” much of the American population still refuse vaccines, as well as masks and distancing.

“In theory, the answer to the question as to how to prevent future outbreaks in Upper Silesia is quite simple: education, together with its daughters, freedom and welfare,” wrote Rudolf Virchow regarding an 1848 outbreak of typhus. “However, in practice, it is more difficult to see how this social problem is to be solved … We have often referred to ‘the scientific method’. We now find that through applying it, we have moved from medicine into the social field, and in so doing we have had to consider some of the fundamental issues of our times.”

Nearly 175 years later, these fundamental social issues remain, even as the communication dynamics and greater numbers of people make everything more complex. With that complexity as a given, modern technology enables us to move beyond the benefits of vaccines and personal action to tools that enable tracking and data compilation without the public’s active participation.

The Benefits of Digital Health

In the explosion of digital health technology over recent years, the electronic health record (EHR) does a lot of heavy lifting. While the internet of things (IoT) and wearable devices probably account for many more individual innovations, the EHR has served as the flagship for health IT because it represents healthcare’s long-overdue transition to electronic systems and because EHRs can be staggeringly expensive and complex to implement.

That latter characterization, which is often accurate, illustrates why EHRs are a key component in the arsenal of public health technology tools but still primarily the tool of hospitals and medical systems, not local public health authorities.

The pandemic has also demonstrated the value of telehealth technology, but that same technology is perhaps more valuable to rural hospitals, clinics, and providers in the long term because it enables immediate connectivity with more sophisticated medical centers without the costs of travel. As telehealth solutions evolve, they are frequently integrated or interfaced with EHRs, which adds costs to the already expensive platform.

A better example of an affordable public health technology might be Twitter, which costs users nothing but is a highly effective means of disseminating key public health information. After all, public health in the United States went from spending 3 cents of every healthcare dollar in 1930 to just 2.5 cents 90 years later, so we have to value every penny. Viva la progress.

And while Twitter, Facebook, YouTube, and Instagram can cost users nothing more than their attention, a valuable commodity indeed, many wearable devices like the Apple Watch, Fitbits and similar have relatively modest costs compared with things like EHRs.

Often considered to be a public health emergency in its own right, social media channels can be tools through which public health officials can affordably disseminate information, track disease outbreaks, educate the populace, and receive feedback on initiatives and programs. Properly integrated with data gathering technology, wearable devices warn providers when a patient is close to a negative health event or when a virus outbreak is taking off within a community.

Which brings us back to EHRs. Rolling up data and spitting out reports is something most EHRs can do effectively, but unless that data is shared with health information exchanges and local public health officials, it remains in a silo and is of limited value, which is at the heart of an argument for networks, interfaces, and integrated systems.  

The challenge is that we’ll wait forever expecting the private sector to create integrated systems and comprehensive public health data. The federal government has already mandated the end of information blocking, the practice of retaining patient and health data with health IT systems, and still effective data sharing remains a challenge.

“The delegation of public-health decision making to the private sector might also accelerate the consolidation of market power,” writes Wendy Parmet. “Large employers and big corporations will be better able to assess and implement health policies that are good for their business. A vaccinated workplace may become a competitive edge, and large employers will then be better positioned to purchase vaccines and mandate them. Smaller employers and their workers will suffer as their stores, restaurants, and workplaces are left unvaccinated.”

While it’s hard to argue against the downsides to outsourcing public health to the private sector, we have to also acknowledge that public health finds itself in a unique situation, what with confidence in expertise and government agencies having reached a nadir.

Still, the government has a crucial role to play in making useful all the data private sector technological innovations have and are going to generate. Importantly, government and non-profit public organizations have a primary mandate that focuses on public benefit, not private revenue.

And while we are at it, we may as well devote a bit more of that healthcare dollar to public health if we want to get serious about future pandemics, opioid crises, deaths of despair and the like. We can be certain of future challenges; we should be equally certain of the availability of resources to meet them.

About Irv Lichtenwald

Irv Lichtenwald is the President and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

How much larger a percentage of U.S. gross domestic product (GDP) can healthcare command?

This isn’t a rhetorical question, even if it may be difficult to come up with a direct answer. After all, between 1960 and 2018, healthcare increased as a percentage of GDP from a modest 5 percent to more than triple that at almost 18 percent. Over that time period, healthcare economists noticed the rise in healthcare costs and regularly rang the alarm bells with increasing levels of concern. That, we can be sure, had as much impact on healthcare costs as screaming at the tides to recede.

The rise in healthcare’s share of GDP would be less of a concern if it were accompanied by similar growth in productivity, i.e., caring for more people so that per capita healthcare costs grew at a much slower pace, if at all. Alas, between 1980 and 2018, per capita healthcare spending increased by 290 percent, and no, this explosion can’t be explained away by the aging of the boomer generation.

While the growth of healthcare spending has fluctuated somewhat over the last few decades, these fluctuations have never been dramatic and combine to create an inexorable rise in healthcare costs that appears to have no natural apex.

It’s also important to note that public spending on healthcare in the United States is roughly the same as in the UK and Canada, but only 34 percent of Americans are covered by public spending versus virtual blanket coverage in the great white north and across the pond. Also, about a third of healthcare spending in the U.S. goes to hospitals, which is more than any other segment.

I guess we could break down further where the increases in costs are coming from but suffice it to say that they are numerous and unrelenting. What healthcare needs is not an additional financial burden that is both unpredictable and completely lacking benefit, which is the reality hackers are unleashing on healthcare (hospitals, specifically) in the U.S.

While healthcare organizations don’t always publicize the details of hacks or ransomware incidents (the former has to be made known when numerous patient records are lost) because they’re terrible public relations, we do know that these and similar incidents are happening with increasing frequency and devastating financial impact.

In 2020, for example, 92 separate ransomware attacks impacted more than 600 separate healthcare organizations and more than 18 million patient records at an estimated cost of almost $21 billion. The Ryuk group of cyber assailants, in particular, has targeted 235 hospitals since 2018 to the tune of at least $100 million in ransoms paid in 2020 alone. Of the 203 million total ransomware attacks in the United States during all of last year, Ryuk conducted roughly one-third.

“Ransomware attacks are striking every eight minutes, crippling hospitals and American mainstays like gas, meat, television, police departments, NBA basketball, and minor league baseball teams, even ferries to Martha’s Vineyard,” says a New York Times profile of former Defense Secretary and CIA Director Leon Panetta, who warned of a “Cyber Pearl Harbor” in a 2012 address.

And these are just the incidents we know about.

The implications for ordinary Americans are more dramatic than many may assume. While many hackers skip hospitals entirely to avoid the moral dilemma, Ryuk is notorious for brief, two-sentence communications and imperviousness to the “We’re a hospital. People will die.” argument. The Colonial Pipeline hack from May sent many East Coast residents scrambling for gasoline when supplies were suddenly halted.

While it may seem fortuitous that many cybercriminal elements leave hospitals alone, there is certainly reason to believe that scenario will not endure. Criminals aren’t known for their iron morals, after all, and healthcare as an industry is a tantalizing target.

How so?

For starters, more than 75 percent of devices in use today are on operating systems that have stopped receiving patches.

“Unfortunately, a lack of cybersecurity expertise paired with a proliferation of medical IoT devices and vulnerable legacy systems have placed hospital administrators in dangerous waters,” says Corey Bodzin, CTO of technology security firm Deepwatch. “Issues such as non-updatable embedded systems, lack of effective patching, and the very nature of 24/7 healthcare operations lead to the inability to remediate vulnerable systems. This makes ransomware a perfect tool for criminals targeting healthcare facilities.”

To say nothing of the fact that many hospitals and clinics operate on the financial margins and simply can’t afford expensive security consultants and systems.

Exactly how ransomware incidents cost healthcare systems money is illustrated by the experience of San Diego’s Scripps Healthcare. Before hijacking Scripps’ systems and demanding payment, the hackers took 147,000 patient records to use as both leverages with Scripps and as saleable information on the Dark Web. On top of that, the plaintiff’s attorneys are now bringing class-action suits against Scripps on behalf of those patients who had their records stolen.

Will hacking and ransomware costs lead to an even greater percentage of GDP for this one industry? Perhaps. Without question, they create far more economic turmoil with nary a shred of benefit. In some instances, ransoms may be covered by insurance, and they can be written off as expenses that then create losses covered by American taxpayers.

The more relevant question is what can be done about it.

While some have suggested making ransom payment illegal, thoughtful analysis suggests that would have little effect, in part because the government would be dictating to private businesses how they handle internal crises.

Instead, analysis by the Brookings Institution suggests success would most likely be the product of a multi-pronged defense. First, find some way to put pressure on the Russian government to crack down on hacking rings, given that most originate on Russian soil.

Next, create commercial incentives for software development companies to develop better security in their products. Currently, software developers don’t shoulder any of the burden when hackers successfully collect a ransom.

It might also be worth considering not making the payment of ransoms a tax-deductible expense.

Ultimately, an effective and equitable plan will align the incentives and penalties for all injured parties. At this point, we’re mostly leaving hospitals out on an island to make the tough decisions themselves even while the actual damage seeps into society more broadly. What hospitals need is support and the expertise provided by an entity as large and well resourced as the federal government. The national infrastructure isn’t yet in place to deal with the cybercriminality pandemic, but it needs to be in short order.

In the meantime, American hospitals and healthcare system are mostly fending for themselves and hoping not to be the next target. They can’t all be so fortunate, especially when word leaks out about the last hospital that felt the only viable option was to pay the ransom.

Irv Lichtenwald is the President and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

The conversation about transitioning the American healthcare system from fee for service (FFS) to value-based care (aka, pay for performance) has been going on for more than 15 years. Still, it felt like time travel to come across a Health Affairs book review from 2006 by the late Princeton Professor Uwe Reinhardt that could have been written last month.

In evaluating what he describes as the “utopian vision” laid out in Michael Porter and Elizabeth Teisberg’s Redefining Health Care (a title, by the way, that can be recycled without penalty just as soon as the previous use has fallen out of the public memory), Reinhardt identifies a fatal flaw: Explaining what American healthcare should do to better treat patients without touching on how it might be accomplished.

“Unfortunately, [the authors’] book offers few practical hints on how the U.S. health system would transit from its current, allegedly negative-sum game to the allegedly positive-sum utopia [the authors] envision,” Reinhardt says. “That transition would vastly rearrange the distribution of economic power and clinical autonomy in our health system. It is naive to assume that the potential losers in that transition would simply roll over and accept their fate.”

The disconnect Reinhardt identified then remains true today. What to do is common knowledge; how to do it is a head-scratching, confounding pile of befuddlement.

Except that it’s not. As with overhauling campaign financing to help fix our broken political system, those who would make real healthcare change have insufficient power and the truly powerful have insufficient interest in making change.

If Only the Data Were Enough

What I interpret Reinhardt to be saying, either explicitly or implicitly, in much of his writing is that the desire to do something is fairly inconsequential absent the will and authority to do it.

This is significant, because the technological know-how to institute value-based care has been around for a while in the form of digital platforms that compile and organize (when we tell them to) data in ways that reveal information healthcare simply could not access before the digital age—data that is essential for value-based care.

In healthcare, these platforms are not yet fully mature, nor are they fully interoperable, which is somewhat puzzling given that the technology exists in other industries to drive alternative payment models.

“Recent technological breakthroughs have exponentially reduced the cost of data storage and compute, making it easier and less expensive to store more data than ever before,” reads a passage defining big data on Oracle’s web site. “With an increased volume of big data now cheaper and more accessible, you can make more accurate and precise business decisions.”

And you can make more beneficial patient care decisions.

But while healthcare IT platforms have proliferated throughout most care settings over the last decade-plus, value-based care approaches have not.

“Physician compensation continues to emphasize volume more than value,” says a Deloitte Insights report from last fall. “Physician compensation comes mainly from traditional sources, and meaningful performance bonuses are the exception rather than the norm. In 2020, as in 2018, almost all physicians (97 percent) relied on FFS and/or salary for their compensation and 36 percent also drew compensation from value-based payments.”

Like so much of the writing about healthcare, breathless pronouncements of an idealized future driven by digital technology never quite square with the everyday lived reality of doctors and nurses.

Improved Healthcare Through Shared Understanding

Even if Oracle and other companies make clear that the technology exists now to harness big data and overhaul healthcare, the key never was technological functionality. That’s necessary, yes, but it shifts healthcare policy and payment structures little if at all.

“The biggest challenges to health care technology are governance, policy, incentives, and a complex web of business relationships,” writes Edwin Miller, chief product officer for Audacious Inquiry. “Over roughly the last decade, the number of hospitals using electronic records has increased from just 9 percent to over 80 percent .. Despite the changes, far too many of these electronic systems operate in a silo, without connecting to and communicating with other clinics’ systems effectively.”

Yes, data silos and poor interoperability are still obstacles on the technical side, but they are not what keeps healthcare from gradually realizing value-based care. One might even imagine that technological challenges might just resolve of their own accord if systems and processes shifted to value-based models.

Instead, healthcare requires a change of perspective that prioritizes … well, value … and outcomes over services rendered. It’s an assertion you’ve heard so many times that you may think it’s the norm even now. While it isn’t, yet, it is the subject of a lot of detailed analysis.

A May 2020 article in Academic Medicine, for example, even mentions Reinhardt and his earlier use of the phrase “utopian vision” to outline a treatment framework the authors believe dovetails naturally with both the needs of the patient and the ethic of medical care.

“By focusing on the outcomes that matter most to patients, value aligns care with how patients experience their health,” the authors write. “…value-based health care’s focus on better health outcomes aligns clinicians with their patients. That alignment is the essence of empathy … This intrinsic motivation is often missing in the health care system, where clinicians are directed to spend countless hours on tasks that do not impact their patients’ health.”

Like Porter and Teisberg, the Academic Medicine article presents a serious, thoughtful argument for value-based care. The authors also cite examples where forms of value-based care seem to be working and suggest that the transition must start with medical school training.

The Lingering Disconnect

Perhaps medical school is a good place to start, but it probably still won’t move the needle in terms of actually changing the way care is insured, provided, paid for, and generally overhauled.

For starters, as Robert Pendleton writes in Harvard Business Review, we might try bridging the gap between what providers and patients define as value.

“Frankly, I was stunned by the degree of this misalignment between patients and physicians (and, by extension, the care delivery organizations the doctors work for),” Pendleton says of an extensive survey conducted by University of Utah Health. “Notably, the Value survey found a striking lack of consensus on who had responsibility for ensuring that health care embodies the desired high-value characteristics. Moreover, the survey’s respondents generally displayed limited understanding of how the health care system works … for example, only 4 percent of patients and physicians recognize that an employer’s choice of health plan affects out-of-pocket costs.”

The survey results Pendleton references have reliably not changed much since this survey was conducted, and they strongly suggest that what’s most needed in creating real healthcare change is a shared understanding of what has value and what the goals are. Arguably, health systems and the countries largest payer, the federal government, can do the most to create a shared vision and then disseminate the information necessary to create buy in.

In the meantime, perhaps we can agree that more sophisticated healthcare IT platforms and more hand-wringing about interoperability, while necessary, will not magically fix what ails the healthcare system. While many, many individual healthcare organizations are doing well in moving toward value-based care, healthcare in America remains an archipelago of expensive, high-quality care surrounded by vast oceans of marooned providers.

What’s required to build the necessary bridges is shared definitions of value and collective action—objectives that may prove much harder to realize than making computer systems communicate.

Irv Lichtenwald is the President and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

We’re now in a new year and new presidential administration. At least three companies are producing effective COVID-19 vaccines, which are being administered to healthcare workers, teachers, and the elderly. By summer, hopefully a large majority of the population in most countries will be vaccinated. From where the world now stands, we can see an end to prolonged isolation, trauma, fear, grief, and economic torpor. 

But out of the woods, we are not. 

The virus mutates, perhaps more rapidly than expected. Maybe the existing vaccines will handle all variants. One can hope. 

Of course, as everyone knows, hope is not a strategy, so strategy divided up into carefully analyzed tactics are a very good idea about now. One of those tactics needs to be dealing effectively with the mental health fallout from almost a year of living in the world COVID-19 has created.

What does that fallout look like?

Back in August, the CDC compared anxiety and depression from 2019 to mid-2020 and found the former had tripled and the latter had quadrupled. Similar studies by the Boston University School of Public Health and Johns Hopkins found that depressive symptoms and psychological distress were higher than during Hurricane Katrina and similar devastations. 

If you have a fairly mobile job like software developer or marketing manager—the kind of job that requires little more than a cell phone and an internet connection—your sense of stability may not be all that upended. However, if your job is customer-facing and garners hourly wages, your life has probably been shaken up dramatically, making those already most vulnerable even more so. 

According to mental health professionals, however, what you do for a living may not be the primary concern when it comes to how people respond to COVID-19. The invisibility of the virus makes it more pernicious. When a tornado or hurricane pass, life can return to normal, but a virus enables some to deny its very existence and others to fear and resent both the virus deniers and the virus itself. 

“You can’t see it, you can’t taste it, you just don’t know,” said Charles Benight, an academic who specializes in post-disaster trauma. “You look outside, and it seems fine.”

Evaluating the COVID-19 pandemic from a behavioral health perspective elevates two questions: How will the economy get back to normal if people are still afraid to engage in normal daily activity? AND What does COVID-19 reveal about our existing mental health system?

It’s the Virus, Stupid

As a campaign consult for presidential candidate Bill Clinton in 1992, James Carville boiled the keys to winning down to three short messages, one of which was, “It’s the economy, stupid.” 

In 2021 we might say, “It’s the virus, stupid.” Getting the American economy back up and running requires managing the virus in both real and perceived ways related to public and mental health. 

Even while the federal government can fund programs that provide counseling and treatment on an individual basis (the stimulus bill Congress passed in December includes $4.25 billion for substance abuse and mental health treatment), the primary concern related to the economy is creating confidence in the safety of the public sphere. 

“Consumer confidence matters,” writes Christos Makridis in Forbes. “… concerns about getting infected are closely linked with spending behavior, including going out to eat, going to the gym, and traveling. For example, 22 percent of those who are very confident that they can protect against the virus went out to eat in the past 24 hours, whereas only 11 percent of those who were less than very confident went out.”

In other words, remove the anxiety and fear from basic decisions like going out to eat and people will more often go out. This comes as a surprise to no one. So how do we do that?

In a nutshell, by pressing forward with a comprehensive program that promotes masks and social distancing while rolling out vaccines as rapidly as possible. These efforts require at least several more months of hunkering down.

But a full psychological recovery from COVID-19 is a much longer project and dovetails with how the virus may have exposed the disconnection and ad-hoc nature of our existing mental health system.

A Leaky Boat in a Typhoon

Those who spend every day working in America’s behavioral health sector have been telling us for a long time that the system, as it is sometimes called, has few systemic traits. The sizeable homeless populations in virtually every American city attest to the fact that the mentally ill and addicted fall through the cracks all the time. 

So, a boat that was only kept afloat by the furious bailing of committed crew members is now in a powerful typhoon. 

“If history is any indicator,” says the American Psychiatric Association’s Joshua Morganstein, “we should expect a significant tail of mental-health effects, and those could be extraordinary.” 

In a position paper on the repercussions of COVID-19, the Lancet says, “The economic breakdown that is likely to occur in the aftermath of the pandemic could exacerbate healthcare disparities and will probably disproportionately affect socially disadvantaged patients … Sooner or later, health systems will be faced with widespread demand to address these COVID-19-related mental health needs.”

Also, note a few complicating factors unmentioned in the previous perspectives, namely that the country has been roiled by months of protests, political unrest and questionable tweets. 

Admittedly, leaning on a broken mental health system to reduce fear and anxiety enough that citizens feel comfortable enough to fully engage economically is not a great place to be. Still, with the existing federal funding, states can take the lead in creating consumer confidence. 

The first course of action is probably to expand facilities and providers. In many of America’s more rural areas—Alaska and Oregon, as well as most of the Rocky Mountain states and much of the deep south—services are few and far between.

The Center for American Progress calls for the continuation of expanded funding even after the virus abates, and also a more concerted effort to make sure all citizens have health insurance and that insurance includes mental health care. 

These are only a few of the numerous recommendations made for improving America’s healthcare system. Of course, those recommendations have been made countless times before. Will this time be different? Maybe, because of dollars. This time it looks like the healing of America’s economy has to also include also healing America’s psyche

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

The plain truth is that rural America has always had a market failure problem. 

In the 1930s, the problem manifests as woefully inadequate telephone and electrical service. The spaces were just too wide open, the potential customers too few, for companies to invest in America’s in-between places. 

In response to this market inefficiency, a federal government led by Franklin Roosevelt stepped in and created the Rural Electrification Administration (REA). Within 20 years, phone service was available to 65 percent of rural residents, and electricity extended to 96 percent. With the help of Washington, DC, modernity was extended to the heartland. 

And now, when market orthodoxy is almost an unassailable truth and the federal government is less trusted than ever, another market failure stares us in the face. This time the technology is fast internet service (broadband), which was a concern before Covid-19 and is now a need arguably on par with electricity in 1936. 

“The strength of High-Performance Broadband is that it will—if fully accessible to all in America—help solve some of our most critical challenges and help people overcome key barriers regardless of where they live and who they are,” reads an editorial published by the Benton Institute for Broadband and Society this past October. 

It’s not that the federal government has simply entrusted rural internet service to companies that don’t provide it, though there is some of that. Since 1995, the Rural Utilities Service (successor to the REA) and Federal Communications Commission have doled out billions in subsidies. What the feds have not done is replace stop-gap funding mechanisms with a comprehensive plan that solves particular problems associated with inadequate rural broadband almost all urban dwellers never have to face.  

At the time of the Benton Institute editorial, the most obvious critical challenge was Covid-19 and it remains so, even with the prospect of a vaccine on the horizon. It’s worth looking specifically at the ways Covid-19 has elevated the importance of broadband, particularly with regard to healthcare. 

Most obviously and importantly, the pandemic has boosted the importance of telehealth as a means of bringing clinicians and patients safely together. What was an industry experiencing modest growth is now a healthcare sector boosted by rocket fuel. 

“Between April 2019 and April 2020, national privately insured telehealth claims’ increased by 8,336 percent (as a proportion of total medical claims),” says the Health Affairs Blog. “While those ratios eventually tapered in the proceeding months as in-person visits rebounded, there’s no doubt that more patients and providers are relying on telehealth than ever before.” 

Of course, safety is only the most pressing concern when it comes to telehealth. Before the pandemic, remote patient visits were driven by the pursuit of lower costs and greater convenience—factors that will once again rise to the top when Covid-19 is managed. The difference, when we arrive at that longed-for future date, will be that telehealth will have proliferated and wormed its way more deeply into common clinical practice. 

All of that seems like progress, except that true progress doesn’t exclude millions of Americans. With limited broadband in rural areas, the blessings of telehealth will currently not fall on a large segment of the population. 

According to Health Affairs, “The lack of broadband in rural areas is one of the most striking inequalities in US society. Due to the lack of broadband availability, tens of millions of rural Americans aren’t able to ‘see’ their doctor over the internet in the same way urban Americans can. Making matters worse, financially strapped rural hospitals are being shuttered by the dozens.”

It would be a mistake to see the failure of rural hospitals as uniquely a healthcare issue on either the cause or effect side of the technology equation. On the one hand, slow internet makes telehealth visits more difficult and sometimes impossible. On the other, slow internet also makes living in rural areas and earning a decent living very challenging, which dramatically limits the rural hospital’s potential patient base. 

According to Alex Marre, a regional economist for the Federal Reserve, access to broadband improves wages, lowers unemployment, grows the population, and boosts home values, all of which creates a more stable base of support for local hospitals.

So, is there a market solution for what to date is a market failure? In a word, no. Well, not yet, at least. While the government may not be the broadband provider in the short or long term, some government involvement is probably a necessary component of the overall solution, especially with regard to money.

Another solution might be cooperatives, which helped extend the reach of electricity in the 1930s and have seen some broadband success in the modern era. 

As CEO of Oklahoma Electric Cooperative, Patrick Grace leads an effort started in 2018 to extend fiber broadband to cooperative members. Working toward providing broadband to all 43,000 members, OK Fiber currently offers 100 Mbps speeds for $55 a month and 1 Gbps speeds for $85. 

But what was true of electricity access also holds for broadband. Absent sufficient dollars, fiber networks take a long time to implement, regardless of how well managed the cooperative. For rural areas, time is of the essence, and concerted action may create a rural renaissance where there is currently a steady decline.

Returning to the Health Affairs Blog: 

“Federal investment in rural electrification helped ignite investment across the country. Manufacturers didn’t have to locate near big cities, instead, they could build factories in rural areas where land was cheaper. Electric machinery and refrigeration made farms and ranches more productive. Today, in an era where remote work is increasingly common, rural and urban Americans alike need broadband to stay connected and productive.”

Again and again, we see that public health is an interrelated web of contributing factors. It’s education, and it’s housing, and it’s family support, and it’s job security. In the 1930s public health could undoubtedly be tied to electricity. In modern times, the equivalent is access to high-speed internet. The market has had sufficient time to provide a solution. Time for the public sector to come up with a comprehensive plan that includes private industry. 

So long as we could say, “Healthcare is a business,” we could continue to avoid the moral and ethical choices from which such statements shield us.

But then COVID-19 came into the picture and the bottom dropped out of healthcare as a business. Hospitals and health systems are hemorrhaging money; the American Hospital Association estimates total losses will exceed $300 billion by the end of the year.

“The growing number of cases is threatening the very survival of hospitals just when the country needs them most,” writes Bloomberg News. “Hundreds were already in shaky circumstances before the virus remade the world, and the impact of caring for COVID-19 patients has put hundreds more in jeopardy.”

Nowhere are these dire illustrations of American healthcare during COVID more impactful than in the country’s rural areas, most of which struggled mightily even before there was a pandemic. Predominantly white small towns and unincorporated areas are where so-called diseases of despair—alcoholism, drug addiction, suicide—are at their worst. To say the closing of a hospital in these areas adds insult to injury dramatically undersells the devastation.

Since 2005, more than 170 rural hospitals have closed in America; 18 of those shut down in 2019 alone and 14 closed by mid-August of this year. When a rural hospital closes, it doesn’t just make lifesaving care more difficult to get, but it certainly does that. According to a University of Washington study, rural hospital closures drive up mortality rates in the surrounding community by about 6 percent. Comparable urban closures have no discernable impact on mortality.

Immediate access to the care a full-service hospital with specialists provides may have made the difference for Robert Finley. A resident of Fort Scott, Kansas, which lost Mercy Hospital in February 2019, Finley fell and hit his head shoveling snow and then went to sleep with what turned out to be a brain hemorrhage. During a week in the hospital, he never regained consciousness.

“When this kind of trauma happens, time matters,” explains Sarah Jane Tribble on Kaiser Health News’s Where It Hurts podcast. “It takes time for the medevac operator to find a pilot to come for Robert. The pilot then has to get there. Once he’s arrived, he still has to transport Robert to Kansas City.”

Hospital closures also blow a sizeable hole in the surrounding community. These facilities are often one of the largest employers. The hospital itself and employees—well-paid physicians among them—are a crucial part of the tax base. Satellite facilities like clinics and dialysis centers, not to mention other local businesses with which the hospital contracted, often disappear shortly after the hospital shuts down.

The challenges a hospital closure creates are often placed before people who can least afford yet another obstacle.

“By one estimate, socioeconomic factors account for 47 percent of health outcomes,” write George Holmes and Sharita Thomas in the AMA Journal of Ethics. “Poverty and inadequate transportation are two important social factors that make rural residents particularly vulnerable to a hospital closure. Rural residents experience higher rates of poverty than do urban residents and can live in communities of ‘persistent poverty,’ where the poverty rate is at least 20 percent over approximately 30 years.”

Holmes and Thomas, acknowledging that healthcare is a business, suggest that the ethical approach to closing a hospital is to engage the community as a partner throughout the process. Will emergency services still be provided after the hospital is gone? Can transportation challenges be mitigated? What will the closure do to the job base?

These and many other questions are valid. With COVID-19, however, there emerges another question that was less frequently discussed pre-pandemic: To what extent is a hospital a public good more than it is a business?

“Coronavirus is definitely a reminder that health care is, in fact, a public good,” says Dan Mendelson, founder of healthcare advisory consultancy Avalere Health. “We all have a vested interest in making sure that everybody around us is seeking appropriate medical care at the right time.”

That public good, Mendelson explains further, is not limited to the current COVID-19-fueled scenario. When people don’t have insurance or access to care, they tend to wait until their health gets much worse before seeking treatment, which guarantees either very expensive treatment or mortality. Regular exams enable early treatment, which gives clinicians the opportunity to manage illness more efficiently, effectively, and affordably.

Still, nothing illustrates the idea of healthcare as a public good quite so elegantly as a pandemic. And while many people initially thought COVID-19 would mercifully avoid adding to the struggles of rural Americans, it’s become clear that the virus does not discriminate based on geography.

The current scenario in rural America hastens the country’s reckoning with a fractured healthcare system that leaves too many sick or bankrupt or both. This day was always coming, after all.

What’s necessary to ensure the availability of care in America’s rural areas is the resolve to ensure it exists. Calling it a public good may help sell it, but ultimately what it’s called matters less than that it’s there. In many ways, the fate of rural hospitals is a test of America’s commitment to rural life as more than an exercise in economic viability. Certainly, the food produced in rural areas is a public good we’re willing to subsidize. Is not healthcare also?

The good news is that many of the ideas bandied about as solutions for the broader healthcare crisis will lift up both urban and rural hospitals and providers.

As former National Coordinator for HIT David Blumenthal and others write in a recent New England Journal of Medicine article, capitation is one payment approach that may help chronically underfunded facilities improve financial viability.

Beyond creative payment schemes, resolve manifests as public policy.

“If reduced prepayments nevertheless threaten the availability of critical services, additional public policies may be necessary to subsidize providers whose losses might jeopardize the health of communities,” Blumenthal, et al, write.

If what matters in economics is the numbers, what will ultimately matter in moving away from a predominantly economic approach to healthcare is also the numbers, but in terms of casualties. The economic approach couldn’t keep tens of thousands from dying of COVID-19 in hospital-rich urban areas, so it’s a bad argument for letting the rural poor expire because the local hospital can’t break even.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

When food production technology made it possible, wheat flour processors started to eliminate the tough exterior (bran) and nutrient-rich core (germ) of the kernel to get at the large, starchy part (the endosperm) only. The bread produced from this process is white and fluffy, and it makes great PB&Js and takes forever to grow mold, but it is almost totally lacking nutritional value.

Nutrition experts eventually pointed this out, of course, after which commercial bakers tried fortifying their bread by adding back essential nutrients stripped out by processing. It didn’t work. While white bread from refined flour is still available, nutrition experts strongly recommend whole grain products as the healthier alternative.

Opposition to this reductionist approach to nutrition is perhaps best captured by the idea of the sum being the whole of its parts: If inputs are lacking, the end result will fall short also.

Each human being is also a sum of parts, and the reductionist approach to healthcare is essential when it comes to advancing many aspects of medicine and healthcare.

“Historically, the invention of the microscope, the defining of Koch’s four infectious disease postulates, the unraveling of the human genome, and even intelligent computers are salient examples of the dramatic benefits of biomedical reductionism,” explained Dr. George Lundberg.

These successes, however, may have convinced many in both the medical community and society at large that reductionism is a necessary, if not sufficient, approach. The numbers say otherwise.

“Classical medical care interventions contribute only about 10 percent to reducing premature deaths compared to other elements such as genetic predisposition, social factors, and individual health behaviors,” Lundberg goes on to say. “Most contemporary medical researchers have concluded that the chronic degenerative diseases of modern Western humans have multiple contributory causes, thus not lending themselves to the single agent-single outcome model.”

Paging Dr. House. It turns out your particular form of genius just isn’t frequently that useful.

And nowhere is the single agent-single outcome model arguably less effective than in behavioral health and chronic disease management. What many in medicine and healthcare now realize is that a vicious cycle of alternating physical and mental ailments are the norm with both chronic illness and long-term mental health challenges.

“Depression and chronic physical illness are in a reciprocal relationship with one another: not only do many chronic illnesses cause higher rates of depression, but depression has been shown to antedate some chronic physical illnesses,” says Professor David Goldberg of the Institute of Psychiatry in London.

It’s an unsurprisingly intuitive conclusion to reach. A man with depression lacks the desire to eat well, exercise, often practice necessary daily hygiene. As his untreated depression deepens, his physical health declines as well. A woman with chronic, untreated pain feels like it will never end and her life is over. Faced with a seemingly unmanageable challenge, she falls into a funk that eventually metastasizes into full-blown depression.

A reductionist approach to these scenarios might be to encourage more exercise or prescribe antidepressants. While both are necessary, neither will likely be sufficient.

So why hasn’t a more holistic approach to patient care become the norm? In a nutshell, because it’s expensive. Chronic illnesses, generally, are the most expensive component of healthcare.

According to a New England Journal of Medicine study, patients “with three or more chronic conditions (43 percent of Medicare beneficiaries) account for more than 80 percent of Medicare health care costs.”

For this expensive, highly at-risk group, holistic care is what actually works.

The NEJM articles conclude that “an intervention involving proactive follow-up by nurse care managers working closely with physicians, integrating the management of medical and psychological illnesses, and using individualized treatment regimens guided by treat-to-target principles improved both medical outcomes and depression in depressed patients with diabetes, coronary heart disease, or both.”

Of course, the regimen included in the NEJM study is expensive—perhaps more so than what qualifies as holistic care now.

But it requires a certain type of twisted logic to argue for holding down costs by rationing care inputs—by reductively treating only just the most obvious health concerns—when this approach invariably leads to readmissions, more office visits, more disability payments, more days of work missed.

Indeed, a reductive approach to accounting—silos of financial impact across the continuity of a life lived—hides the fact that specific healthcare costs are not alone the measure of how chronic illness detracts from both individual life satisfaction and broader societal efficiencies.

The key, then, is to make holistic health both the norm and affordable. How can that be done? By creating initiatives designed to achieve a core set of goals:

Incentivize primary care: In the last two decades, the number of primary care providers (PCPs) available to patients in the United States has decreased by about 2 percent. This may not sound like a lot, but the decline comes as the population has increased, naturally, which means fewer patients have a PCP. As healthcare shifts to pay for performance, not services, the PCP is the natural quarterback of patient care. The country needs many more PCPs, not fewer, and the federal government has an opportunity to use loan forgiveness incentives and other tools to nudge medical school students in that direction.

Embrace technology: Arguably, holistic care only became possible with the digital age. Chronic disease management requires frequent measurement of patient vitals, which is very expensive without wearables and similar digital age technologies. Now, patients can regularly provide data with no clinical intervention, that data can automatically upload to an electronic health record, and that EHR can alert the clinician when results are alarming.

Make poor choices expensive: Perhaps only because smoking has become so socially unacceptable can the cost of cigarettes be so high ($7.16 per pack in Chicago with all taxes) without creating significant protests. But the data is clear that higher costs equal fewer smokers. The same types of behavioral economics programs can also apply to fast food, soda, etc. Yes, people will get upset and complain about the nanny state, but absent some attempt to change behavior, we may want to consider changing the name to the United States of Diabetes.

Reward smart choices: Healthy people use healthcare and insurance less often, which drives down costs. Duh. Combining technology and incentives (avoiding diabetes), Utah’s Intermountain Healthcare engaged almost 1,500 pre-diabetic employees in a program through Omada Health that collectively yielded 9,162 pounds lost. Omada billed Intermountain based on the level of success, and without speaking to specific numbers, Intermountain felt the cost of the program was a wise investment when compared with the costs of diabetes treatment.

These four bullets are probably just the most obvious suggestions, of course. They don’t account for the complexities of the American healthcare system focused on payment models, the profit motive, or what to do with the uninsured, homeless, and devastatingly mentally ill.

But the benefits of holistic thinking when reductionism is inadequate applies to both individual care and the healthcare system as a whole. Public health, for example, takes a holistic approach to communities by looking at how housing, transportation, and education impact general overall health. Where this approach is done well, the benefits are obvious.

Reductionist isolation will always be necessary when identifying specific genes or determining which natural elements are effective in treating disease. But it’s wise to always bring the right tools for the job.

In the late 1940s, the United Kingdom was busily reassembling country and what remained of the empire in the aftermath of World War II. Among many revelations, the war had convinced Britain’s leaders of the need to provide healthcare for all in the event of calamity upending the basic functions of a civilized society. With that, the UK’s National Health Service (NHS) was born.

In 2020, all perspectives about quality and the time it takes to see a provider aside, the NHS remains quite popular among UK citizens and is an enduring source of national pride.

With the United States in the midst of its own upheaval, it’s for a related question: Might the current COVID-19 situation give rise to significant changes to the American healthcare system? 

Virtually no one thinks the correct answer is ‘No.’ Things will change. The question is how and to what extent. The healthcare system in place in the United States now is dramatically more complex than that in use by Britons after WW II. There are so many moving parts, so many things that can break. 

So, in which aspects of the current American healthcare system are we likely to see changes after COVID-19 is dealt with?

Telehealth: Someone always benefits in a catastrophe. In this case, that someone may be Zoom shareholders.

From 10 million daily users in December, Zoom rocketed to 200 million in March and nearly 300 million a month later. Much of that was healthcare related. 

Of course, Zoom is not the only direct beneficiary of coronavirus as venerable meeting platforms like WebEx and Skype, among others, have also experienced dramatic growth.

Hospitals and health systems were incrementally implementing telehealth services prior to the coronavirus outbreak, but there was no sense of urgency that accompanies a rapidly spreading virus. Since then, the federal government, states and insurance companies have allocated funds and rewritten regulation to expand the use of telehealth. 

But there are more telehealth related-issues to address, some of which have thorns. Service and payment parity across insurance companies is an issue. If telehealth is going to be a regular component of healthcare, technology gaps will have to be addressed, especially in rural areas. 

This is something the federal government recognizes. The White House recently drafted an executive order oriented around improving rural health by expanding technology access, developing new payment models and reducing regulatory burdens. The EO tasks the secretaries of health and human services and agriculture to work with the Federal Communications Commission to “develop and implement a strategy to improve rural health by improving the physical and communications healthcare infrastructure available to rural Americans.” But until Congress gets involved and provides funding for something like this, it will probably never get out of the proposal phase. 

In fact, there are enough concerns—parity, technology gaps, added costs—associated with telehealth to wonder if it will endure after coronavirus is in the rear view. Enough about telehealth benefits both providers and patients for it to stick and proliferate, but that could also be said about any number of healthcare initiatives that seem to languish for lack of coordination and political will. 

Health Insurance: This is where the NHS analogy is the most relevant. Many millions of workers are furloughed or simply laid off with the impact of COVID-19 on frontline jobs like restaurant worker, massage therapist and barista. Those who had insurance through work may not have it anymore, leaving them doubly vulnerable—no coverage, no income—to illness or accident. 

Mass unemployment episodes reveal, each time, the weakness in the patchwork employment-based healthcare insurance system we’ve sort of made peace with for decades. Sure, Medicaid exists to fill the gaps, but it may make sense to render Medicaid unnecessary, especially since its value is questionable in particular states.

“You notice the number of band-aids that Congress is having to apply to help people who have lost their jobs,” said former CMS Administrator Don Berwick, MD. “What we have now is a whole series of band-aids and special measures. What if instead, we just had universal health insurance?”

What if, indeed. Will COVID-19 be the straw that burns the bridge of employer-based health insurance, to mangle a metaphor? That may depend on how long the pandemic lasts, who is president sometime after November 3 and how much damage is done to the national fabric before economy and society start a process of repair.

Payment Models: For years now, hospitals have been in the middle of slow shift from fee-for-service care to value-based care and alternative payment models. That transition didn’t happen quickly enough to prevent most hospitals from falling into a financial chasm. If elective procedures are a big part of revenue, it follows that revenue will fall if those procedures disappear. 

To be fair, the hit to hospital finances has been catastrophic enough—more than $200 billion in losses over four months, according to the American Hospital Association—that federal government support would have been necessary even if a full pay-for-quality model had been in place.  

But the pandemic spotlights the downside of treating essential services like healthcare as though they are mere services one selects or rejects. And it exposes the folly of not making sure everyone has insurance coverage (a payer) when the individual costs for COVID-19-related hospital admission can range from $20,000 to $88,000. 

End-of-Life Care: According to one analysis, 42 percent of COVID-19 deaths have occurred in nursing homes or assisted living facilities. The families of those unfortunate souls who’ve died while in a facility have generally endured the agony of saying goodbye outside a window or over a video link. It’s hard to believe, after COVID-19, that the assisted living industry will continue as before. 

“The crisis surely will lead nursing home administrators to reconsider the way patients are cared for,” says Modern Healthcare. “Among the ideas Harvard’s [Professor David] Grabowski believes will get a longer look in the wake of the pandemic are using telemedicine services, creating specialized Medicare Advantage plans for the homes and pursuing smaller settings.”

Perhaps. And perhaps a son or daughter that remembers coronavirus will simply choose not to risk everything by putting their parent in a home. Could enough of them make such a decision that the industry contracts? Is forced to take quality care more seriously? Attracts more serious federal regulation? 

As the deaths mount, it’s hard not to give every option serious consideration. 

Supply Chain: These days we’re bickering in public and on social media (looking at you, maskless Karen throwing food in Trader Joes) about whether or not masks should be mandated. Look back with me  to February, however, and you’ll fondly recall concerns about there being enough masks at all. 

Back then we learned that the United States had exactly one mask manufacturer, and that all other masks are sourced from overseas. That it takes longer to get stuff from China than from Amarillo creates obvious potential problems when a crisis hits, but it also pits hospitals and government entities against one another and guarantees that the winner will pay more for supplies than they would in less-critical times. 

It also creates weird, unnecessary scenarios that could be avoided using coordination and leadership. The governor of Maryland, for example, used his wife’s connections to South Korea (her country of birth) to secure 500,000 coronavirus tests, which he then put in an undisclosed location and protected using national guard troops. 

What’s the remedy? 

Modern Healthcare has called for a national supply chain czar, which in other times may have just been the head of FEMA. The suggestion, however, highlights the need for a coordinated central clearing house where supplies can be ordered, managed and dispersed based on need. 

Individual hospitals, clinics and health systems can also help themselves by using a robust supply chain software system that keeps track in real time of available supplies, covers all ordering systems and methodologies, and reacts swiftly to certain thresholds. 

The uniquely unfortunate aspect of the American political system among western democracies is that, for the most part, it responds to the demands of special interests. Think about your local representative. Chances are good the shouts of specific business interests are ringing in his or her hears so loudly that little else is audible. 

As such, there is a significant danger that the American healthcare system will return, post-COVID-19, to the same dynamic it had when the virus arrived, which will be unfortunate. What we need post-pandemic is not necessarily specific changes to hospitals, clinics, insurance companies, etc., though they could be part of an overall solution. What will be necessary is an examination of where every aspect of the healthcare system overall, inasmuch as there is one, didn’t do its job.   

Disasters are social sodium pentothal that, while active, force groups of people to take an honest look at their failures. Once the disaster is passed, however, there is a danger that Upton Sinclair’s maxim—“It is difficult to get a man to understand something when his salary depends upon his not understanding it”—will rule the day. 

No one hopes for more dramatic damage to the American economy and social fabric, but the irony is that necessary change sometimes only comes when reality is undeniable, as in a shellshocked Britain instituting the NHS. If COVID-19 doesn’t shock us sufficiently into making substantial changes to the healthcare system, it’s a pretty safe bet the same disaster will occur again.

As of today, the coronavirus has infected almost 2 million worldwide and caused the deaths of more than 125,000 people (Worldometer data as of 12:15 PM on April 14, 2020). In the United States, the relevant figures are more than 600,000 infected and north of 25,000 deceased. Without successful social distancing, those numbers could be dramatically worse.

And still, they are dwarfed by the massive numbers associated with the economic impact of the coronavirus and the illness it causes, COVID-19. In the space of just three weeks, applications for unemployment insurance in the United States skyrocketed from the low hundreds of thousands to more than 16 million.

To prop up the economy in the interim, the federal government initiated the Coronavirus Aid, Relief and Economic Security (CARES) Act, which pumps $2 trillion into the economy to achieve a number of objectives, among them make sure that healthcare providers can continue to function.

What does that mean to individual providers? It depends on the focus of your organization. Keep reading for an overview of what federal assistance means to each healthcare sector.

Hospitals: Of the roughly $180 billion allocated for public services, hospitals will receive the lion’s share—about $100 billion—in the form of reimbursements for providing COVID-19-related care, e.g., building temporary structures, leasing properties, buying supplies, hiring and training additional workers and increasing surge capacity. Importantly, seeking reimbursement for items that are reimbursed by other sources will be considered fraud.

The reimbursement program is administered by the assistant secretary for preparedness and response in the Department of Health and Human Services (HHS). With the stroke of a pen, the assistant secretary went from managing a $2.6 billion budget to directing $100 billion in funds.

Applicants will, of course, have to fill out a form, and details on how to access the form and which organizations might receive priority—the $100 billion is probably too little, after all—are still tough to come by. Still, organizations will want to start lining up numbers now in anticipation of more information.

“The sooner your team can come up with a reliable calculation of the loss you are experiencing because of declining electives or lower ER volume, the better,” says Martie Ross of Kansas City accounting firm PYA, PC.  “Also be prepared to quantify any additional expenses incurred due to the pandemic. You will want to have these numbers ready to plug into whatever formula they provide,” Ross says.

COVID-19 will also prove financially beneficial to hospitals in ways that are not directly related to the virus. As part of the CARES Act, Congress pledged to reverse scheduled cuts in Medicare and Medicaid reimbursements, effectively spreading an additional $11 billion across 3,000 hospitals.

Finally, the CARES Act also provides for accelerated payments through Medicare parts A and B. The Centers for Medicare and Medicaid Services (CMS) outlines how the program works in this fact sheet and this letter to providers. Qualified providers are those that have billed Medicare in the previous 180 days, are not in bankruptcy, are not in active medical review and don’t have any delinquent Medicare overpayments.

Clinics: With so much focus on treating COVID-19 patients in extreme distress, many ambulatory providers are finding themselves with time on their hands, which translates as decreased revenue. So dramatic has been the drop off in activity for clinic-based providers that many teeter on the edge of insolvency. 

The decrease in business for clinics is similar to the experience of other types of businesses, e.g., restaurants, theaters, etc., even while the product is much more essential. For that reason, the CARES Act provides for $350 billion in loans made available through the Small Business Administration (SBA) for entities with fewer than 500 employees.

The money is disbursed through one of two different programs (side-by-side comparison here):

Paycheck Protection: The program offers up to $10 million to cover payroll and other expenses. The program has an incentive structure in which some or all of a loan may be forgiven if the company uses the money to retain workers or re-hire those it had to let go. Retain or quickly re-hire employees before the money arrives in an account and keep them for eight weeks and the loan is 100 percent forgiven. The application process is being managed by local banks, so contact a lender with whom you have a relationship; the application deadline is June 30.

Economic Injury Disaster: This SBA program has been around for a while and offers $2 million for disaster-related losses. With the rise of COVID-19, the program now has more funds to work with and is relaxing some previous requirements. The loans are made directly by SBA and applicants can apply on the agency website. The CARES Act makes the first $10,000 a grant that the applicant should have within three days.

NOTE: Predictably, the federal government has been overwhelmed by applications for the Economic Injury program and is running days, sometimes weeks, behind the timeframes mandated by the CARES Act. Also, the money allocated to date is probably just not enough, so banks may be lending out less to each applicant than the legislation deems.

For those clinics that are able to retain workers without a loan, the federal government is providing an employee retention tax credit on up to 50 percent of $10,000 in wages per employee. Additionally, for those clinics that have an outstanding SBA loan, the agency is paying principal and interest on existing loans and new loans taken out before September 27.

Telehealth: Logically, telehealth is a ready solution for the challenge of evaluating sick patients who are highly contagious. The CARES Act recognizes that this is telehealth’s moment, if ever there was one, and provides $200 million for the Federal Communications Commission to assist providers in using telehealth. The payment criteria has been expanded by CMS, as have the types of acceptable technology and the providers eligible for reimbursement, which includes these services:

– ED visits, Levels 1-5

– Domiciliary, rest home, or custodial care services, new and established patients, all levels

– Home visits, new and established patients, all levels

– Care planning for patients with cognitive impairment

– Psychological and neuropsychological testing

– Therapy services, PT and OT, all levels

Of course, the size of the CARES Act makes summarizing it in a blog post particularly challenging, but here are a few other noteworthy items that may be of interest to both independent clinics and hospitals.

– Access to government-provided care and coverage related to COVID-19 now includes patients who reside in a state that does not make medical assistance available. It also applies to individuals enrolled in a federal program and health plan that does not have “minimum essential coverage” as defined by the IRS.

– Nurse practitioners, clinical nurse specialists and physician assistants can certify and establish a home health plan of care.

– Acute care hospitals are not prohibited from providing home and community-based services during the emergency period as long as those services are documented in the patient’s care plan.

– MIPS data submission is delayed to April 30, 2020. Those who have not submitted by then do not need to take any additional action to qualify for the automatic extreme and uncontrollable circumstances policy.

In a nod to doing better next time, the CARES Act also funds workforce programs with the goal of luring more people into public health and similar jobs. It also includes $16 billion for the strategic national stockpile of medical supplies and $11 billion for vaccines and therapeutics.

Of course, the CARES Act is a legislative effort with the goal of both meeting a contagion head-on and creating hope among citizens that this is a surmountable, temporary challenge. The stock market seemed to respond in an optimistic fashion.

But it will be helpful to remember that America is far from the end of this pandemic, and many of the details necessary to make the CARES Act effective remain to be worked out. More money will be needed. More employment insurance applications will be filed. More balmy days will be spent indoors.

In the meantime, find a personal philosophy that is not weighed down with too much expectation and emotion. Use Zoom to maintain a visual relationship with friends and family. Balance the time spent watching Tiger King with something more uplifting.

And, by all means, keep your distance. This will end unless our generosity includes sharing the virus as well as moral support.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Chances are good the face mask you’re wearing or have on hand (just in case) was made outside the United States, maybe in China.

In calmer times, that wouldn’t matter much. But when Chinese officials are trying to stem a global pandemic that started in a Chinese city, how likely is it that the country will continue to export face masks at the same rate?

This isn’t a hypothetical. With the spread of COVID-19, aka, coronavirus, we know the answer is not very, and that it impacts a great deal more than face masks.

This moment might be one of opportunity for Mike Bowen, executive vice president for one of the few companies that manufactures masks in the U.S., were it not for the overwhelming numbers—for the chasm that exists between supply and demand.

“I’ve got requests for maybe a billion and a half masks, if you add it up,” Bowen says, adding that since January he is averaging around 100 calls and emails a day. “Normally, I don’t get any.”

Of course, the challenge illustrated by Bowen’s predicament is far more expansive than the inability of one Texas-based manufacturer to keep up with a ridiculous, panic-driven spike in demand.

“Without secure supply chains, the risk to health care workers around the world is real,” said Dr. Tedros Adhanom Ghebreyesus, director-general of the World Health Organization. “Industry and governments must act quickly to boost supply, ease export restrictions and put measures in place to stop speculation and hoarding.”

And in the meantime, what can an individual hospital or health system do to try and ensure adequate supplies?

Focus on things at home. Keep it local. At a minimum, implement real-time supply chain management systems that provide timely, accurate reports so you know what you have and need.

How can a robust supply-chain management system help you in times like these?

First, by managing items across supply chain methodologies. Certainly, your hospital orders from different suppliers, and chances are those suppliers don’t all use the same methodology. With cross-stock methodology capabilities, it won’t matter whether suppliers use KANBAN, EOQ/ROP, PAR, MIN/MAX or Suppress Pick.

When the system can search without concern for methodology compatibility, your hospital can have more faith in the accuracy of current inventory, will save time previously spent contacting individual suppliers, and can more rapidly resupply as needed by quickly determining who has what and where. Need to replenish hand sanitizer and cotton swabs? Initiate one search that pulls in all existing suppliers and tells you who has what you need before placing an order.

Second, by tracking the supply of an item for both primary and secondary suppliers. As COVID-19 demonstrates, this ability to manage backorder situations is always useful and sometimes crucial. A useful, vibrant system will use a barcode to add an item to a primary provider pick list AND report on the same item to a secondary provider in the event the primary has none in stock. The need for guess work and manually retracing steps when the primary provider does not have the necessary stock is eliminated.

Finally, by comprehensively managing all items not controlled by the Drug Enforcement Administration. Controlled substances that fall under DEA jurisdiction are a complicating factor, but the system you use should monitor everything but controlled substances. Is your hospital having to manually track and order some essential items? Time to look for a new system.

Beyond these common-sense steps enabled by a functional supply-chain solution, hospital administrators may want to start looking for alternative suppliers. The disturbing truth is that the United States has become heavily reliant on China for certain products that slow to a trickle in situations like the one COVID-19 is creating.

“This is an opportunity for companies to look for different ways to do the supply chain,” said Stephanie Kennan of McGuireWoods Consulting. “I think it’s an issue that over the long term we need to grapple with because we can’t even manufacture a lot of the drugs inside the United States.”

And where China is the source of many drug-related components, India produces many of the finished drugs imported to the United States. With COVID-19, the Indian government has instructed manufacturers to get permission before exporting 26 different drugs, about two-thirds of which are antibiotics.

So, will COVID-19 be the catalyst for a whole new era of manufacturing essential products inside the United States? Perhaps it will be, and perhaps it should be. And perhaps your hospital can find a way to contribute to or benefit from such efforts.

In the meantime, however, the best thing you can do for your organization and patients is to stock up on necessary items as efficiently and rapidly as possible. With any luck, COVID-19 will be a tremendously exaggerated threat, but it will most certainly be followed eventually by a bug that is not. The key element is our preparation for threats generally, not the lethality of this threat in particular.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.

Dignity-focused organizations are not easy to define, but also not hard to recognize.

Justice Stewart

It’s all about the patient. Well, unless that patient has been to particular hospitals for treatment and is having trouble paying the ensuing bills. Then it’s about the hospital and collections agents and wage garnishments and such.

For this approach to providing care, the Lown Institute, a nonpartisan think tank advocating for bold healthcare ideas, honored a group of what they clearly consider rapacious hospitals with the ignominious Shkreli Award. Martin Shkreli, as many will remember, is the widely reviled “pharma bro,” hedge fund manager and CEO who acquired the license to an anti-parasitic drug and promptly raised the price from $13 to $750 per pill. He currently resides in prison.

In healthcare, short-term efficiency means more tasks done, more patients were seen, more tests performed more revenue generated. If this were manufacturing, short-term efficiency would be a perfectly acceptable measure of success.

“Nonprofit hospitals are meant to not only provide health care services but to contribute to community health and wellbeing,” reads the Lown Institute web site. “But many hospitals have ruined countless families’ financial security and livelihoods, by using thousands of patients for unpaid medical bills. Some hospitals go as far as to garnish their wages and repossess their assets.”

Sure, hospitals should be paid for the services they provide, but that simple axiom crumbles when one looks closely at the complexity and contradictions built into healthcare, e.g., “… the widespread acceptance at the top of health care organizations that being ‘business-like’ is a virtue…,”says Vikas Saini, MD, the president of the Lown Institute and a Harvard-trained cardiologist.

It’s not enough that some patients are subjected to the inherent indignity of testing and hospitalization, for which no one is at fault. They must also endure the humiliation of looking like deadbeats in a system that won’t identify actual costs or provide affordable care. In a nutshell, they’re not permitted to retain their basic dignity.

And it’s not just the patients. In large numbers, doctors are also questioning their choice of profession. According to a recent survey of physicians by Medscape, roughly half across generations would take less money to claw back more free time. Across healthcare settings, physician burnout is worst in large organizations, where almost half say they’re spent. Roughly 22 percent say they’ve had thoughts of suicide.

What are we to make of these survey results? In many ways, it’s clear that doctors are struggling, overwhelmed with bureaucratic tasks, diminished by the tedium of patient data entry, exhausted from long hours, bewildered by a perceived lack of respect. Once motivated by the idea of a rewarding, respected professional life, many now search for the dignity they expected after the long slog of education and training.

The common thread, then, among doctors and patients? Dignity.

Indeed, the word has more purchase in healthcare than most other scenarios because dignity is so necessary. In a lot of other situations, simple courtesy will do. When dealing with lives, nothing less than dignity is acceptable.

And is dignity something that can be achieved by those in the business of healthcare? Yes. Yes, it is. In fact, dignity in the right hands actually becomes a business strategy.

“The part of healthcare that stands out to me is the humanity of the experience,” says Dr. Joseph Alvarnas, senior medical director for employer strategy at City of Hope Medical Center. “We are born, we struggle, we experience joy, we celebrate and, in time, we die. Yet, we find ourselves in a system for which humanity isn’t the principal goal.”

The challenge, of course, is how to translate dignity into something applicable to a healthcare environment. According to a hospital turnaround study referenced in the Harvard Business Review, ensuring dignity in healthcare means giving people responsibility, autonomy, a voice.

“In the early phases of implementation, the researchers found that employees contributed most to the change initiative when they believed that doing so would increase their control over their work and work environment,” writes Monique Valcour in HBR. “When they followed up three years after implementation, they discovered that the employees contributing most actively to the shared leadership program also expressed high trust in management and perceptions of fair treatment.”

That control improves satisfaction in a work setting feels intuitive, unsurprising, even while it illustrates a tension that endures in almost every work environment.

Might the same approach prove valuable with patients? In a word, yes, but patients tend to define dignity more broadly and individually than members of a work team.

According to a study of the Dignity Care Intervention, patients identified dignity with the way the care team responded to the illness, how the illness directly affected the patient, and how the illness impacted other relationships. Providers can assist directly with some of these concerns and only tangentially with others, but they can empathize and be aware in all instances.

Ultimately, ensuring the dignity of all involved in the healthcare dynamic requires personalization—that we see one another, acknowledge the other person’s existence and collaborate to meet specific needs. But in achieving that goal, something we currently consider essential might have to be minimized.

“Short-term efficiency lets us check off a lot of items from our to-do lists, but we never actually connect with our colleagues, and therefore never really tap into each other’s fullest capacity to contribute,” writes Glenn Llopis in Forbes. “Long-term efficiency results when we deliberately honor each other’s dignity and build relationships that ultimately lead to better ideas and more fruitful results.”

But it isn’t manufacturing.

None of this is to say that the efficiency-focused measures of success in healthcare are invalid. It’s just that they’re not MOST valid, and they’re a poor measure of healthcare quality. In many ways, it feels like every segment of healthcare, including healthcare IT, has wandered away from this reality.

How do we make dignity the animating principle in healthcare? Create buy-in among participants, focus on both autonomy and responsibility, and above all show respect for the individual.  

Speaking last year at the Leadership in the Age of Personalization Summit, anthropology professor Scott Lacy recalled his time in the Peace Corps in Mali, West Africa. After he arrived, the local elders gathered round to decide what Lacy would do. Resembling a game of telephone, the elders spent 45 minutes going from person to person, each passing on information and adding their own perspectives and opinions.

“I kept thinking: Come on, time is money! Can’t we just have a conversation?” Lacy explained. “But that’s when the seed of what I was learning was planted. Looking back on that, it wasn’t about short-term efficiency. They were doing inclusive decision-making that included some back and forth, it included some affirmation words, it included a blessing, and everybody got to add their own layer … We established a consensus and a relationship that day.” 

Ultimately, it’s difficult to list the specific processes of a dignity-focused organization. It is not, however, difficult to identify organizations that are not sufficiently focused on preserving dignity. To paraphrase Justice Stewart: Dignity-focused organizations are not easy to define, but also not hard to recognize.

Having trouble getting members of the team to really invest in collective goals and shoulder vital objectives? Find ways to create autonomy, personal investment and responsibility. Empower them to care for their own dignity, and in the process get a firmer grasp on your own.

Because we have big brains and have been to the moon and have invented remarkably complex stuff, the idea persists that human beings are inherently rational. This idea is both untrue and ironic, but not in a black-fly-in-the-chardonnay way.

Rational beings, by definition, would make decisions based on proven, reliable data and learned the reason. Most of the time, human beings use impulses, moods, emotions and urges to make decisions, all the while believing they are the reincarnation of Socrates himself.

But is this a bad thing?

Many researchers argue that, no, it is not a bad thing to be what we are. Trying to constantly think rationally and calculate data would be time consuming, constraining and, perhaps most importantly, would rob humans of the tremendous power to make learned instinctual decisions.

Ah, but that “learned” decisions thing … that’s where we get into trouble.

Humans, as it turns out, generally double down when presented with information that contradicts what they believe.

Take health, for example. One study that surveyed 500 Americans on genetically modified foods found that more than 90 percent were opposed to them. This perspective mirrors that of actual scientists who work with genetically modified organisms, about 90 percent of whom think GMOs are safe and potentially beneficial.

Another interesting result of the same study: Those surveyed who were most strongly opposed to GMOs also said they were highly knowledgeable about the topic but scored the worst on tests of scientific knowledge.

“In other words, those with the least understanding of science had the most science-opposed views, but thought they knew the most,” writes Aaron Carroll, MD, MS. “Lest anyone think this is only an American phenomenon, the study was also conducted in France and Germany, with similar results.”

When it comes to making decisions about health, these tendencies have predictable and sometimes negative impact. The current furor over childhood vaccinations is probably the most high-profile example, but it’s not the only one. Health supplements are a billion-dollar industry in the United States, yet little scientific support exists for their efficacy.

With regard to the patient/doctor relationship, this disconnect between available data and chosen treatment manifests as low-value care, which the American Board of Internal Medicine created a campaign in 2012 to guard against. In a nutshell, a lot of the care Americans receive shows little medical benefit, yet it adds more than $200 billion annually to healthcare costs, according to an Institute of Medicine study. That spend might be more acceptable if it benefitted the patient or were at least benign, but often it is not.

“And so the harms from a cascade [of questionable tests and diagnostics] — such as cost, time, stress, pain from unnecessary biopsies, and overdiagnosis — can outweigh any benefits, especially when the cascade stems from an unexpected finding or when that initial test wasn’t needed in the first place,” says Ishani Ganguli, MD, an assistant professor of medicine at Harvard.

For help with this cascade of unhelpful care, we now have electronic health records (EHRs), according to one study at Boston Medical Center that evaluated EHR interventions for six months after system implementation.

Specifically, the study found a reduction in unnecessary but arguably habitual behaviors on the part of providers. Pre-admission chest x-rays fell by 3.1 percent. Routine lab orders fell by 4 percent. Total use of the lab decreased by more than 1,000 orders a month. These and other interventions, accumulated over time, can make a significant financial difference.

The reason EHRs can have this kind of impact is that doctors, like patients, are human, i.e., they fall into thought patterns that they can’t break themselves out of. All those years of medical training don’t necessarily enable providers to suddenly overcome innate behavior. When doctors are patients, as one study found out, they’re not much different from patients with no medical training.

So why aren’t humans responsive to dry statistics and data? As cognitive science has determined in recent decades, we’re just not rational creatures. At our core, we are emotional and communal beings, even if we regularly nurture fantasies about emotional independence and rugged individualism.

“Providing people with accurate information doesn’t seem to help; they simply discount it,” writes Elizabeth Kolbert. “Appealing to their emotions may work better, but doing so is obviously antithetical to the goal of promoting sound science.”

Perhaps, but one could certainly argue that ‘promoting sound science’ is not the same as reducing healthcare costs and convincing doctors and patients to make better decisions. In that regard, the Boston Medical Center study is encouraging and suggests EHRs and other forms of technology have dramatically more potential than they’ve shown thus far.

And didn’t we already know that? That little computer in your pocket that also makes calls has been repeatedly engineered to draw you in and alter your behavior. There’s no reason to assume other technology devices and programs can’t also. Indeed, put to positive use, technology becomes an aggregator of effective decisions that both relieves us of the unnecessary burden of isolated decision making and demonstrates our true connectedness.

“Relying on our community of knowledge is absolutely critical to functioning,” says Philip Fernbach, cognitive scientist at the University of Colorado. “We could not do anything alone. This is increasingly true. As technology gets more complex it is increasingly the case that no one individual is a master of all elements of it.”

So, when will the breakthrough in human self-understanding push us to embrace our true nature, make peace with our common humanity and realize that we don’t magically just know things we’ve never really studied? Probably never. In the meantime, the gradual integration of technological nudges in complex processes is proving valuable in improving how humans make decisions.

Long live incrementalism.

Perhaps it’s because we live in an age of competing epidemics and crises—opioids, impeachment, homelessness, insulin—that youth suicide trends don’t warrant a front-page headline every week.

The numbing, knee-bending statistics say they should.

Per the CDC, suicide rates among young people 10-24 years old rose 56 percent between 2007 and 2017. Suicide is now the second leading cause of death for that group after accidents like car crashes—paradoxical tragedies often caused by the excessive exuberance of youth. Of course, the number of suicides is a small subset of the number of attempts, which are up 400 percent.

The numbers give rise to so many questions, primary among them, “Why?”

The answer is by no means clear. Desperation is almost always a complex brew of family dynamics, economics, romantic relationships, peer pressure, sexual orientation, genetics, and other factors. Despite that, academic Jean Twenge notes that the rise in youth suicide tracks with the explosion of smartphone use. According to Twenge, a San Diego State psychology professor, that’s not circumstantial.

“In fact, four large studies of teens from the U.S. and U.K. all show the same thing: happiness and mental health are highest at a half-hour to two hours of extracurricular digital media use a day; well-being then steadily decreases, with those who spend the most time online being the worst off,” Twenge writes in Time. “Twice as many heavy users of electronic devices are unhappy, depressed or distressed as light users.”

Are electronic devices a cause of teen suicide? As an academic, Twenge is hesitant to make that connection without further research, but she is convinced enough of some connection that she’s unwilling to wait.

Again, the numbers. Depression jumped 60 percent between 2009 and 2017 for those between the ages of 14 and 17. Visits to the ER for thoughts of suicide and self-harm also increased dramatically. Rates of suicide for teen girls are currently at 40-year highs. For LGBTQ youth, the rates of both contemplating and attempting suicide are significantly higher.

When asked why they saw suicide as perhaps the last viable option, teens who’ve tried to end their lives mention a host of factors that conspicuously don’t include technology.

“Teens described how, when their condition wasn’t fully treated, they had intrusive, depressed, or racing, thoughts,” writes physician Stephanie Doupnik of her study on teen suicide. “Many said they had suicidal thoughts around the difficulty of coping with social pressures… Other teens told us about going through a breakup, experiencing bullying, or having a fight with a family member. For others, the triggers were the illness or loss of a loved one, or far worse, an event in which they were the victim of or a witness to violence.”

All of these experiences are difficult for a teenager, to be sure, but most are not unique. The idea around how routine challenges become precipitating events focuses on the way technology and social media increase isolation, bullying and a nagging feeling of worthlessness.  

Of course, it doesn’t have to be this way. In a general sense, technology is an exacerbator. Take a bad situation—a dysfunctional corporate structure, let’s say—and add technology, and it gets markedly worse. Put vulnerable teens in an unmediated technology environment like Facebook where anonymity encourages bad behavior and they are ducks in a shooting gallery.

So, can we just remove technology from the equation and teen suicide rates will drop? It would be easier to get toothpaste back into the tube. Young people don’t know a world where the natural culmination of an arm is not a tiny computer. Also, human development is now arguably a slightly different process because of technology.

Law professor and technology observer Tim Wu uses the analogy of carving wood with a chainsaw instead of a chisel to describe the dramatic differences between technology evolution and biological evolution.

“This chainsaw/chisel logic has led some to suggest that technological evolution is more important to humanity’s near future than biological evolution; nowadays, it is not the biological chisel but the technological chainsaw that is most quickly redefining what it means to be human,” Wu says. “The devices we use change the way we live much faster than any contest among genes. We’re the block of wood, even if… sometimes we don’t even fully notice that we’re changing.”

That pace of change—the chainsaw—is dizzying for almost all of us, but most adults are emotionally equipped to carry on. For young people, who’ve yet to wrap their heads around how the chisel of biological evolution plays out, technology evolution may feel like a tornado that spins out an infinite number of comforts and distractions but also breaks things.

Still, there isn’t scientifically conclusive evidence that technology causes depression and suicide. Much more research is necessary, and that’s where the technology can absolutely be valuable.

A current study by the National Institutes of Health, for example, is tracking more than 11,000 young people for a decade to see how technology impacts development. A problem with the study is that screen time is passively tracked based on how the subjects self-report. A more accurate measure would come with the participation of tech companies like Apple and Google. Indeed, an accurate measure of the wellbeing of young people probably has to incorporate technology, given the complexity of inputs.

“Let’s say there is a relationship between digital technology use and mental well-being,” writes Brian Resnick in Vox. “How will we know if those relationships are strong enough to matter? This is another critical question the field must answer. After all, there are endless variables that can come to influence kids’ well-being… What if it’s the case that in that mix, digital technology use barely nudges the needle?”

This is possible. In some studies, wearing glasses and eating potatoes had a greater negative impact on young lives than screen time.

Of course, Twenge argues that until we have more definitive proof, it’s prudent to limit access to screens by getting smartphones and tablets out of the bedroom, turning off screens at least an hour before bedtime, and limiting device time to two hours daily. Suicide and depression aside, these are good suggestions if only to improve connection with family and friends.

And while this research is ongoing, we’ll still have a youth suicide crisis on our hands. Again, technology can positively impact how we deal with the fallout.

Clinical reminders integrated into almost all electronic health records (EHRs) can remind providers to screen young people for symptoms of depression. Artificial intelligence can evaluate health records to identify which patients are most likely to attempt suicide. Parents can use monitoring devices to both track devices and limit use. Technology can be both the source of personal troubles and a strong solution.

Indeed, it has to be. The technological chainsaw is here to stay, but as Wu says, “The technology industry, which does so much to define us, has a duty to cater to our more complete selves rather than just our narrow interests.”

Will catering to a young person’s complete self eliminate assaults on the narrow interest of staying alive? One can hope. We know technology can be highly addictive and influential; we’re less sure of how it can effectively support healthy development and a balanced perspective. Until technologists and society more broadly figure out when, where and how technology is a net positive, the costs to young people will remain inordinately high.

Irv Lichtenwald is president and CEO of  Medsphere Systems Corporation, the solution provider for the CareVue electronic health record.