#robert kuttner

The EHR industry's origins start with a GW Bush-era law called the HITECH Act, which was later folded into Obama's Recovery Act in 2009. Obama provided $27b to hospitals that installed EHR systems. These systems had to more than track patient outcomes – they also provided the data for pay-for-performance incentives. EHRs were already trying to do something very complicated – track health outcomes – but now they were also meant to underpin a cockamamie "incentives" program that was supposed to provide a carrot to the health industry so it would stop killing people and ripping off Medicare. EHRs devolved into obscenely complex spaghetti systems that doctors and nurses loathed on sight.

But there was one group that loved EHRs: hospital administrators and the private companies offering Medicare Advantage plans (which also benefited from upcoding patients in order to soak Uncle Sucker):

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649706/

The spread of EHRs neatly tracks with a spike in upcharging: "from 2014 through 2019, the number of hospital stays billed at the highest severity level increased almost 20 percent…the number of stays billed at each of the other severity levels decreased":

https://oig.hhs.gov/oei/reports/OEI-02-18-00380.pdf

The purpose of a system is what it does. Epic's industry-dominating EHR is great at price-gouging, but it sucks as a clinical tool – it takes 18 keystrokes just to enter a prescription:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2729481

Doctors need to see patients, but their bosses demand that they satisfy Epic's endless red tape. Doctors now routinely stay late after work and show up hours early, just to do paperwork. It's not enough. According to another one of Kuttner's sources, doctors routinely copy-and-paste earlier entries into the current one, a practice that generates rampant errors. Some just make up random numbers to fulfill Epic's nonsensical requirements: the same source told Kuttner that when prompted to enter a pain score for his TB patients, he just enters "zero."

Don't worry, Epic has a solution: AI. They've rolled out an "ambient listening" tool that attempts to transcribe everything the doctor and patient say during an exam and then bash it into a visit report. Not only is this prone to the customary mistakes that make AI unsuited to high-stakes, error-sensitive applications, it also represents a profound misunderstanding of the purpose of clinical notes.

The very exercise of organizing your thoughts and reflections about an event – such as a medical exam – into a coherent report makes you apply rigor and perspective to events that otherwise arrive as a series of fleeting impressions and reactions. That's why blogging is such an effective practice:

https://pluralistic.net/2021/05/09/the-memex-method/

The answer to doctors not having time to reflect and organize good notes is to give them more time – not more AI. As another doctor told Kuttner: "Ambient listening is a solution to a self-created problem of requiring too much data entry by clinicians."

EHRs are one of those especially hellish public-private partnerships. Health care doctrine from Reagan to Obama insisted that the system just needed to be exposed to market forces and incentives. EHRs are designed to allow hospitals to win as many of these incentives as possible. Epic's clinical care modules do this by bombarding doctors with low-quality diagnostic suggestions with "little to do with a patient’s actual condition and risks," leading to "alert fatigue," so doctors miss the important alerts in the storm of nonsense elbow-jostling:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5058605/

Clinicians who actually want to improve the quality of care in their facilities end up recording data manually and keying it into spreadsheets, because they can't get Epic to give them the data they need. Meanwhile, an army of high-priced consultants stand ready to give clinicians advise on getting Epic to do what they need, but can't seem to deliver.

Ironically, one of the benefits that Epic touts is its interoperability: hospitals that buy Epic systems can interconnect those with other Epic systems, and there's a large ecosystem of aftermarket add-ons that work with Epic. But Epic is a product, not a protocol, so its much-touted interop exists entirely on its terms, and at its sufferance. If Epic chooses, a doctor using its products can send files to a doctor using a rival product. But Epic can also veto that activity – and its veto extends to deciding whether a hospital can export their patient records to a competing service and get off Epic altogether.

One major selling point for Epic is its capacity to export "anonymized" data for medical research. Very large patient data-sets like Epic's are reasonably believed to contain many potential medical insights, so medical researchers are very excited at the prospect of interrogating that data.

But Epic's approach – anonymizing files containing the most sensitive information imaginable, about millions of people, and then releasing them to third parties – is a nightmare. "De-identified" data-sets are notoriously vulnerable to "re-identification" and the threat of re-identification only increases every time there's another release or breach, which can used to reveal the identities of people in anonymized records. For example, if you have a database of all the prescribing at a given hospital – a numeric identifier representing the patient, and the time and date when they saw a doctor and got a scrip. At any time in the future, a big location-data breach – say, from Uber or a transit system – can show you which people went back and forth to the hospital at the times that line up with those doctor's appointments, unmasking the person who got abortion meds, cancer meds, psychiatric meds or other sensitive prescriptions.

The fact that anonymized data can – will! – be re-identified doesn't mean we have to give up on the prospect of gleaning insight from medical records. In the UK, the eminent doctor Ben Goldacre and colleagues built an incredible effective, privacy-preserving "trusted research environment" (TRE) to operate on millions of NHS records across a decentralized system of hospitals and trusts without ever moving the data off their own servers:

https://pluralistic.net/2024/03/08/the-fire-of-orodruin/#are-we-the-baddies

The TRE is an open source, transparent server that accepts complex research questions in the form of database queries. These queries are posted to a public server for peer-review and revision, and when they're ready, the TRE sends them to each of the databases where the records are held. Those databases transmit responses to the TRE, which then publishes them. This has been unimaginably successful: the prototype of the TRE launched during the lockdown generated sixty papers in Nature in a matter of months.

Monopolies are inefficient, and Epic's outmoded and dangerous approach to research, along with the roadblocks it puts in the way of clinical excellence, epitomizes the problems with monopoly. America's health care industry is a dumpster fire from top to bottom – from Medicare Advantage to hospital cartels – and allowing Epic to dominate the EHR market has somehow, incredibly, made that system even worse.

Naturally, Kuttner finishes out his article with some antitrust analysis, sketching out how the Sherman Act could be brought to bear on Epic. Something has to be done. Epic's software is one of the many reasons that MDs are leaving the medical profession in droves.

Epic epitomizes the long-standing class war between doctors who want to take care of their patients and hospital executives who want to make a buck off of those patients.

Tor Books as just published two new, free LITTLE BROTHER stories: VIGILANT, about creepy surveillance in distance education; and SPILL, about oil pipelines and indigenous landback.

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

https://pluralistic.net/2024/10/02/upcoded-to-death/#thanks-obama

Image: Flying Logos (modified) https://commons.wikimedia.org/wiki/File:Over_$1,000,000_dollars_in_USD_$100_bill_stacks.png

Not much, as it turns out. Kuttner describes how Mass Gen Brigham cornered the market on health-care in Boston, allowing it to flout the rules on pricing. In addition to standard tricks – like charging self-pay patients vastly more than insured payments (because individuals don't have the bargaining power of insurers), Mass Gen Brigham's price data is a sick joke.

See for yourself! The portal will send you giant, unstructured, ZIPped text files filled with cryptic garbage like:

ADJUSTABLE C TAPER NECK PLUS|1|UNITED HEALTHCARE [1016]|HB CH UNITED HMO / PPO / INDEMNITY [34]|UNITED HEALTHCARE HMO [101604]|75|Inv Loc: 1004203; from OR location 1004203|52.02|Inpatient PAF; 69.36% Billed|75|Inv Loc: 1004203; from OR location 1004203|56.87|Outpatient PAF; 75.83% Billed

https://www.massgeneralbrigham.org/en/patient-care/patient-visitor-information/billing/cms-required-hospital-charge-data

These files have tens of thousands of rows. As a patient, you are meant to parse through these in order to decide whether you're getting ripped off on that HIP STEM 16X203MM SIZE 4 FEMORAL PRESS FIT NEUTRAL REVISION TITANIUM you're in the market for (as it happens, I have two of these in my body).

Kuttner describes the surreal lengths he had to go through to prevent his mother from getting ripped off by Mass Gen through an upcoding hustle. By coding her as "admitted for observation," Mass Gen was able to turn her into an outpatient, with a 20% co-pay (this is down to a GW Bush policy that punishes hospitals that charge Medicare for inpatient care when they could be treated as outpatients – hospitals reflexively game the system to make every patient an outpatient, even if they have overnight hospital stays).

Kuttner's an expert on this: he was national policy correspondent for the New England Journal of Medicine and covers the health beat for the Prospect. Even so, it took him ten hours of phone calls to two doctors' offices and Blue Cross to resolve the discrepancy. The average person is not qualified to do this – indeed, the average person won't even know they've been upcoded.

Needless to say that people in other countries – countries where health care is cheaper and the outcomes are better – are baffled by this. Canadians, Britons, Australians, Germans, Finns, etc do not have to price-shop for their care. They don't have to hawkishly monitor their admission paperwork for sneaky upcodes. They don't have to spend ten hours on the phone arguing about esoteric billing practices.

In a rational world, we'd compare the American system to the rest of the world and say, "Well, they've figured it out, we should do what they're doing." But in good old U-S-A! U-S-A! U-S-A!, the answer to this is more prices, more commercialization, more market forces. Just rub some capitalism on it!

That's where companies like Multiplan come in: this is a middleman that serves other middlemen. Multiplan negotiates prices on behalf of insurers, and splits the difference between the list price and the negotiated price with them:

https://www.nytimes.com/2024/04/07/us/health-insurance-medical-bills.html

But – as the Arm and a Leg podcast points out – this provides the perverse incentive for Multiplan to drive list prices up. If the list price quintuples, and then Multiplan drives it back down to, say, double the old price, they collect more money. Meanwhile, your insurer sticks you with the bill, over and above your deductible and co-pay:

https://armandalegshow.com/episode/multiplan/

The Multiplan layer doesn't just allow insurers to rip you off (though boy does it allow insurers to rip you off), it also makes it literally impossible to know what the price is going to be before you get your procedure. As with any proposition bet, the added complexity is there to make it impossible for you to calculate the odds and figure out if you're getting robbed:

https://pluralistic.net/2022/05/04/house-always-wins/#are-you-on-drugs

Multiplan is the purest expression of market dynamics brainworms I've yet encountered: solving the inefficiencies created by the complexity of a system with too many middlemen by adding another middle-man who is even more complex.

No matter what the problem is with America's health industry, the answer is always the same: more markets! Are older voters getting pissed off at politicians for slashing Medicare? No problem: just create Medicare Advantage, where old people can surrender their right to government care and place themselves in the loving hands of a giant corporation that makes more money by denying them care.

The US health industry is a perfect parable about the dangers of trusting shareholder accountable markets to do the work of democratically accountable governments. Shareholders love monopolies, so they drove monopolization throughout the health supply chain. As David Dayen writes in his 2020 book Monopolized the pharma industry monopolized first, and put the screws to hospitals:

https://pluralistic.net/2021/01/29/fractal-bullshit/#dayenu

Hospitals formed regional monopolies to counter the seller power of consolidated Big Pharma. That's Mass Gen's story: tapping the capital markets to buy other hospitals in the region until it became too big to fail and too big to jail (and too big to care). Consolidated hospitals, in turn, put the screws to insurers, so they also consolidated, fighting Big Hospital's pricing power.

Monopoly at any point in a supply chain leads to monopoly throughout the supply chain. But patients can't consolidate (that's what governments are for – representing the diffuse interests of people). Neither can health workers (that's what unions are for). So the system screwed everyone: patients paid more for worse care. Health workers put in longer hours under worse conditions and got paid less.

Kuttner describes how his eye doctor races from patient to patient "as if he was on roller skates." When Kuttner wrote him a letter questioning the quality of care, the eye doctor answered that he understood that he was giving his patients short shrift, but explained that he had to, because his pay was half what he needed, relegating him to a small apartment and an old car. The hospital – which skims the payments he gets for care – sets his caseload, and he can't turn down patients.

The answers to this are obvious: get markets out of health care. Unionize health workers. Give regulators the budgets and power to hold health corporations to account.

But for market cultists, all of that can't work. Instead, we have to create more esoteric middlemen like "pharmacy benefit managers" and Multiplan. We need more prices to shovel into the market computer's data-hopper. If we just capitalism hard enough, surely the system will finally work…someday.

If you'd like an essay-formatted version of this post to read or share, here's a link to it on pluralistic.net, my surveillance-free, ad-free, tracker-free blog:

Kuttner’s op-ed is a report on the Hewlett Foundation’s recent “New Common Sense” event, where Kuttner was relieved to learn that the idea that “the economy would thrive if government just got out of the way has been demolished by the events of the past three decades.”

We can call this neoliberalism, but another word for it is economism: the belief that politics are a messy, irrational business that should be sidelined in favor of a technocratic management by a certain kind of economist — the kind of economist who uses mathematical models to demonstrate the best way to do anything:

https://pluralistic.net/2022/10/27/economism/#what-would-i-do-if-i-were-a-horse

These are the economists whose process Ely Devons famously described thus: “If economists wished to study the horse, they wouldn’t go and look at horses. They’d sit in their studies and say to themselves, ‘What would I do if I were a horse?’”

Those economists — or, if you prefer, economismists — are still around, of course, pronouncing that the “new common sense” is nonsense, and they have the models to prove it. For example, if you’re cheering on the idea of “reshoring” key industries like semiconductors and solar panels, these economismists want you to know that you’ve been sadly misled:

https://foreignpolicy.com/2023/03/24/economy-trade-united-states-china-industry-manufacturing-supply-chains-biden/

Indeed, you’re “doomed to fail”:

https://www.piie.com/blogs/trade-and-investment-policy-watch/high-taxpayer-cost-saving-us-jobs-through-made-america

Why? Because onshoring is “inefficient.” Other countries, you see, have cheaper labor, weaker environmental controls, lower taxes, and the other necessities of “innovation,” and so onshored goods will be more expensive and thus worse.

Parts of this position are indeed inarguable. If you define “efficiency” as “lower prices,” then it doesn’t make sense to produce anything in America, or, indeed, any country where there are taxes, environmental regulations or labor protections. Greater efficiencies are to be had in places where children can be maimed in heavy machinery and the water and land poisoned for a millions years.

In economism, this line of reasoning is a cardinal sin — the sin of caring about distributional outcomes. According to economism, the most important factor isn’t how much of the pie you’re getting, but how big the pie is.

That’s the kind of reasoning that allows economismists to declare the entertainment industry of the past 40 years to be a success. We increased the individual property rights of creators by expanding copyright law so it lasts longer, covers more works, has higher statutory damages and requires less evidence to get a payout:

https://chokepointcapitalism.com/

At the same time, we weakened antitrust law and stripped away limits on abusive contractual clauses, which let (for example) three companies acquire 70% of all the sound recording copyrights in existence, whose duration is effectively infinite (the market for sound recordings older than 90 is immeasurably small).

This allowed the Big Three labels to force Spotify to take them on as co-owners, whereupon they demanded lower royalties for the artists in their catalog, to reduce Spotify’s costs and make it more valuable, which meant more billions when it IPOed:

https://pluralistic.net/2022/09/12/streaming-doesnt-pay/#stunt-publishing

Monopoly also means that all those expanded copyrights we gave to creators are immediately bargained away as a condition of passing through Big Content’s chokepoints — giving artists the right to control sampling is just a slightly delayed way of giving labels the right to control sampling, and charge artists for the samples they use:

https://doctorow.medium.com/united-we-stand-61e16ec707e2

(In the same way that giving creators the right to decide who can train a “Generative AI” with their work will simply transfer that right to the oligopolists who have the means, motive and opportunity to stop paying artists by training models on their output:)

https://pluralistic.net/2023/02/09/ai-monkeys-paw/#bullied-schoolkids

After 40 years of deregulation, union busting, and consolidation, the entertainment industry as a whole is larger and more profitable than ever — and the share of those profits accruing to creative workers is smaller, both in real terms and proportionally, and it’s continuing to fall.

Economismists think that you’re stupid if you care about this, though. If you’re keeping score on “free markets” based on who gets how much money, or how much inequality they produce, you’re committing the sin of caring about “distributional effects.”

Smart economismists care about the size of the pie, not who gets which slice. Unsurprisingly, the greatest advocates for economism are the people to whom this philosophy allocates the biggest slices. It’s easy not to care about distributional effects when your slice of the pie is growing.

Economism is a philosophy grounded in “efficiency” — and in the philosophical sleight-of-hand that pretends that there is an objective metric called “efficiency” that everyone can agree with. If you disagree with economismists about their definition of “efficiency” then you’re doing “politics” and can be safely ignored.

The “efficiency” of economism is defined by very simple metrics, like whether prices are going down. If Walmart can force wage-cuts on its suppliers to bring you cheaper food, that’s “efficient.” It works well.

But it fails very, very badly. The high cost of low prices includes the political dislocation of downwardly mobile farmers and ag workers, which is a classic precursor to fascist uprisings. More prosaically, if your wages fall faster than prices, then you are experiencing a net price increase.

The failure modes of this efficiency are endless, and we keep smashing into them in ghastly and brutal ways, which goes a long way to explaining the “new commons sense” Kuttner mentions (“Reality has been a helpful ally.”) For example, offshoring high-tech manufacturing to distant lands works well, but fails in the face of covid lockdowns:

https://locusmag.com/2020/07/cory-doctorow-full-employment/

Allowing all the world’s shipping to be gathered into the hands of three cartels is “efficient” right up to the point where they self-regulate their way into “efficient” ships that get stuck in the Suez canal:

https://pluralistic.net/2021/03/29/efficient-markets-hypothesis/#too-big-to-sail

It’s easy to improve efficiency if you don’t care about how a system fails. I can improve the fuel-efficiency of every airplane in the sky right now: just have them drop their landing gear. It’ll work brilliantly, but you don’t want to be around when it starts to fail, brother.

The most glaring failure of “efficiency” is the climate emergency, where the relative ease of extracting and burning hydrocarbons was pursued irrespective of the incredible costs this imposes on the world and our species. For years, economism’s position was that we shouldn’t worry about the fact that we were all trapped in a bus barreling full speed for a cliff, because technology would inevitably figure out how to build wings for the bus before we reached the cliff’s edge:

https://locusmag.com/2022/07/cory-doctorow-the-swerve/

Today, many economismists will grudgingly admit that putting wings on the bus isn’t quite a solved problem, but they still firmly reject the idea of directly regulating the bus, because a swerve might cause it to roll and someone (in the first class seats) might break a leg.

Instead, they insist that the problem is that markets “mispriced” carbon. But as Kuttner points out: “It wasn’t just impersonal markets that priced carbon wrong. It was politically powerful executives who further enriched themselves by blocking a green transition decades ago when climate risks and self-reinforcing negative externalities were already well known.”

If you do economics without doing politics, you’re just imagining a perfectly spherical cow on a frictionless plane — it’s a cute way to model things, but it’s got limited real-world applicability. Yes, politics are squishy and hard to model, but that doesn’t mean you can just incinerate them and do math on the dubious quantitative residue:

https://locusmag.com/2021/05/cory-doctorow-qualia/

As Kuttner writes, the problem of ignoring “distributional” questions in the fossil fuel market is how “financial executives who further enriched themselves by creating toxic securities [used] political allies in both parties to block salutary regulation.”

Deep down, economismists know that “neoliberalism is not about impersonal market forces. It’s about power.” That’s why they’re so invested in the idea that — as Margaret Thatcher endlessly repeated — “there is no alternative”:

https://pluralistic.net/2021/11/08/tina-v-tapas/#its-pronounced-tape-ass

Inevitabilism is a cheap rhetorical trick. “There is no alternative” is a demand disguised as a truth. It really means “Stop trying to think of an alternative.”

But the human race is blessed with a boundless imagination, one that can escape the prison of economism and its insistence that we only care about how things work and ignore how they fail. Today, the world is turning towards electrification, a project of unimaginable ambition and scale that, nevertheless, we are actively imagining.

As Robin Sloan put it, “Skeptics of solar feasi­bility pantomime a kind of technical realism, but I think the really technical people are like, oh, we’re going to rip out and replace the plumbing of human life on this planet? Right, I remember that from last time. Let’s gooo!”

https://www.robinsloan.com/newsletters/room-for-everybody/

Sloan is citing Deb Chachra, “Every place in the world has sun, wind, waves, flowing water, and warmth or coolness below ground, in some combination. Renewable energy sources are a step up, not a step down; instead of scarce, expensive, and polluting, they have the potential to be abundant, cheap, and globally distributed”:

https://tinyletter.com/metafoundry/letters/metafoundry-75-resilience-abundance-decentralization

The new common sense is, at core, a profound liberation of the imagination. It rejects the dogma that says that building public goods is a mystic art lost along with the secrets of the pyramids. We built national parks, Medicare, Medicaid, the public education system, public libraries — bold and ambitious national infrastructure programs.

We did that through democratically accountable, muscular states that weren’t afraid to act. These states understood that the more national capacity the state produced, the more things it could do, by directing that national capacity in times of great urgency. Self-sufficiency isn’t a mere fearful retreat from the world stage — it’s an insurance policy for an uncertain future.

Kuttner closes his editorial by asking what we call whatever we do next. “Post-neoliberalism” is pretty thin gruel. Personally, I like “pluralism” (but I’m biased).

Have you ever wanted to say thank you for these posts? Here's how you can do that: I'm kickstarting the audiobook for my next novel, a post-cyberpunk anti-finance finance thriller about Silicon Valley scams called Red Team Blues. Amazon's Audible refuses to carry my audiobooks because they're DRM free, but crowdfunding makes them possible.

http://redteamblues.com