The Monthly Eye Opener: March 2025
The history of US health insurance companies turning less care into more profit, why surgeons should have coaches, and how real-time location systems (RTLS) can improve healthcare for everyone
Welcome back to the Health Doko newsletter, where I share my insights on all things healthcare, eyecare and innovation. Over time, we will incorporate reader feedback and refine the format to ensure alignment with our mission of improving the healthcare landscape in the U.S. and beyond.
The Health Doko newsletter is designed for a diverse audience including healthcare professionals, those interested in medical innovation, and most importantly, patients and their loved ones.
March’s Topics:
1. A brief history of the Ds: Delay, Deny, Defend, & Depose
2. The best athletes in the world have coaches, why don’t surgeons?
3. The need for real-time location systems (RTLS) in healthcare
Healthcare:
The killing of United Healthcare’s CEO Brian Thompson on December 4, 2024, galvanized the American public to uniformly criticize health insurance company tactics around denying and delaying healthcare services. This is nothing new – we know insurance companies have been deploying these tactics for years. But how far back does this go? Buckle up.
I want to bring your attention to two moments in history. We cannot truly understand the present without knowing the past.
The inaugural address by then President Elect to the American Medical Association (AMA), Dr. C. A. Hoffman, is given in 1972, titled “The House of Medicine” (good luck accessing the original document without a subscription to JAMA). He references the disquiet amongst physicians at the time - disquiet over the intrusion of the government and other third parties into the house. He was right to call to action the need for a unified voice in medicine, hence “The House of Medicine”, but the call was too late.
Rewind one year earlier to 1971 when the following conversation was recorded between then President Nixon and one of his two inner circle advisors, John Ehrlichman:
This is a transcript of the 1971 conversation between President Richard Nixon and John D. Ehrlichman that led to the HMO act of 1973:
John D. Ehrlichman: “On the … on the health business …”
President Nixon: “Yeah.”
Ehrlichman: “… we have now narrowed down the vice president’s problems on this thing to one issue and that is whether we should include these health maintenance organizations like Edgar Kaiser’s Permanente thing. The vice president just cannot see it. We tried 15 ways from Friday to explain it to him and then help him to understand it. He finally says, ‘Well, I don’t think they’ll work, but if the President thinks it’s a good idea, I’ll support him a hundred percent.’”
President Nixon: “Well, what’s … what’s the judgment?”
Ehrlichman: “Well, everybody else’s judgment very strongly is that we go with it.”
President Nixon: “All right.”
Ehrlichman: “And, uh, uh, he’s the one holdout that we have in the whole office.”
President Nixon: “Say that I … I … I’d tell him I have doubts about it, but I think that it’s, uh, now let me ask you, now you give me your judgment. You know I’m not too keen on any of these damn medical programs.”
Ehrlichman: “This, uh, let me, let me tell you how I am …”
President Nixon: [Unclear.]
Ehrlichman: “This … this is a …”
President Nixon: “I don’t [unclear] …”
Ehrlichman: “… private enterprise one.”
President Nixon: “Well, that appeals to me.”
Ehrlichman: “Edgar Kaiser is running his Permanente deal for profit. And the reason that he can … the reason he can do it … I had Edgar Kaiser come in … talk to me about this and I went into it in some depth. All the incentives are toward less medical care, because …”
President Nixon: [Unclear.]
Ehrlichman: “… the less care they give them, the more money they make.”
President Nixon: “Fine.” [Unclear.]
Ehrlichman: [Unclear] “… and the incentives run the right way.”
President Nixon: “Not bad.”
[Source: University of Virginia Check - February 17, 1971, 5:26 pm - 5:53 pm, Oval Office Conversation 450-23. Look for: tape rmn_e450c.]
This recorded conversation (indulge me and listen to it) tells you everything you need to know about why healthcare in the US is the way it is now. Don’t take me wrong, there were serious access to care problems in the first half of the 1900s, and most people simply could not afford direct, fee-for-service care paid to the doctor, as is certainly the case today. But have health insurance companies actually made healthcare more affordable or accessible? Insurance at its core is about spreading or sharing risk across a population, essentially pooling our resources together so that if any individual gets in an accident or becomes ill, there’s money to cover it. But health insurance has mutated such that risk sharing seems to have taken a back seat. In the case of for-profit health insurance, the mutations have accelerated since the Affordable Care Act (ACA) was passed in 2010. One of the many deleterious regulations in the ACA is the medical loss ratio (MLR), which requires that health insurance companies spend at least 80-85% of their earnings on medical care and activities that improve healthcare quality. Guess what the companies really care about? Their 15-20%, which covers their administrative costs and profit. Now if you were an insurance company, wouldn’t you want to that pool of resources to be as big as possible? Who cares if the participants have to contribute more and more, as long as that pot of gold grows, so too does the 15-20% of it. Compound this by the fact that there are so many sick people that are constantly tapping into those pooled resources and it’s no wonder health insurance premiums and deductibles have skyrocketed. For a proper deep dive I recommend reading Wharton health care management professor Scott E. Harrington’s article on the unintended consequences of the medical loss ratio from 2013. He basically laid out how health insurance companies would respond to the ACA’s MLR by hiking up prices amongst other harmful practices.
Anyways, back to 1972. There is a wonderful, prescient paragraph from that AMA inaugural address by Dr. Hoffman, I will include it below:
It has been suggested that the next major advance in the health of this nation will come through health education, not through more doctors or more hospitals or new discoveries, but through public education in health care. I believe that this is true, and our task as a profession is clear. We must persuade the American people that, next to genetics, the single most important factor in health is lifestyle, and that even more important than environmental pollution is personal pollution. I plan to devote a great deal of time and attention to this message over the next year. If we are heard, if our message is understood, it will improve the health of our people and it will free us from the burdens imposed by unreasonable expectations. Somehow, the thought of "unreasonable expectations'' seems to lead rather logically to the latest panacea: "health maintenance organizations."
It’s not that he predicted the future - issues like the rise of obesity and managed care were already within the public sphere of knowledge. He sounded an alarm, a rally cry, that fell on deaf ears.
Why this matters to patients:
Many years ago our country traded in the mentality of “we keep ourselves healthy” to “you keep us healthy”, but the fact of the matter is that nobody is going to care as much about your own health as you and your family. Then we took it one step further and changed the “you” in “you keep us healthy” from doctors to insurers. Because at the end of the day, a doctor can diagnose you with a disease and propose the correct treatment for that disease either with lifestyle changes, medicine and/or surgery, but often times it is not the doctor or the patient who determine whether or not any of that treatment is covered by insurance or affordable with or without insurance. We have become so comfortable with the idea of health insurance paying for the cost of most of our healthcare needs, but with high deductible plans and significant copay, coinsurance costs, etc., that comfort is long gone for many. But our populations’ general health is in such a poor state, coupled with peoples’ inability to afford the cost of care outside of insurance, that many people have effectively been abandoned to fend for themselves. Healthy habits start at home, at a very early age. Health is so intertwined with family presence, social relationships, geography, education, exercise, diet, socioeconomic status, and yes, vaccination status. But as Dr. Hoffman wrote, we decided to shift our focus from that to health maintenance organizations (HMOs). HMOs and all their subsequent iterations have failed. They do not maintain health, they maintain profits. We need massive cultural and governmental shifts to support the maintenance of one’s health from birth until death. I don’t see it happening. I do see us sliding further back to times when people were dying from preventable diseases, except instead of them being mostly infectious, they’re mostly metabolic and oncologic. Although with the downward trend in vaccination rates we could see that ratio change for the worse.
Eyecare:
https://www.newyorker.com/magazine/2011/10/03/personal-best
Dr. Atul Gawande published an article in the New Yorker back in 2011 about the need and benefit of surgeons having a coach. You can watch his excellent TED talk about the topic here: https://www.youtube.com/watch?v=oHDq1PcYkT4. In 2018, Harvard launched the Surgical Coaching for Operative Performance Enhancement (SCOPE) program, with an initial paper on surgical coaching techniques published in 2022 https://pubmed.ncbi.nlm.nih.gov/32740233/ (Dr. Gawande is one of the authors). In ophthalmology, there’s certainly been interest in continued surgical education beyond the limitations of wet labs and conferences. Of course, sharing surgical videos online is nothing new, and Dr. Uday Devgan’s Cataract Coach series has arguably set the bar for quality and quantity of videos relating to cataract surgery and other surgical specialties within ophthalmology. Then there is Dr. Jorge Arroyo’s Surgical Streaming Society hosted on Stych.tv, which allows surgeons to live stream their surgeries for other surgeons to watch and actually engage with the operating surgeon in real time. There is Oftalmo University started by Dr. Ivo Ferreira, which is a resource for trainees and practicing ophthalmologists alike, offering online and hybrid/in-person courses.
But honestly, nothing beats having an in-person tutor or coach. I took piano lessons for years, from around age five or six all the way into my first year of medical school around age twenty-three. While my teachers were often demanding and critical, their insights and experience allowed me to become a better pianist. Of course, 1-on-1 tutoring/coaching is the most resource-intensive and it’s what we expect in our training. But what about after we complete our training? Sure, we can learn new techniques on our own, but why do elite athletes still have coaches? They help us see ourselves, our strengths, our weaknesses, and they provide guidance and experience to avoid pitfalls while learning new skills. All I’m saying is that I would happily pay a reasonable rate for a surgeon to join me in the OR periodically to point out things I can do better and how. I know it’s not for everyone - you have to leave your ego outside the OR. Additionally, there are logistical barriers like physically getting the surgical coach into the OR and talking about the surgery while the patient is awake (most eye surgery is performed while patients are awake). Still, there are so many facets of a surgery day that a coach can help improve, including OR efficiency, ergonomics, technique, instrument and medication choice, team-skills between PACU nurses, anesthesia, circulators, scrub techs, managing unexpected intraoperative challenges and complications, and patient communication. Where’s the in-person cataract coach? Maybe Dr. Devgan can set this up?
Why this matters to patients:
I think a lot of us have the idea in our head that an older, more experienced doctor or surgeon is inherently better. Nothing beats experience. BUT without some sort of objective third party to give you feedback, how high of a standard can you hold yourself to or better yet even achieve. There is absolutely no way I could have learned to play classical piano to the degree I did on my own. What patients don’t necessarily realize is that experience does not automatically mean better. You can gain experience doing the same thing poorly over and over again. That doesn’t make you better at it. And sometimes it takes an outside perspective to say, “Hey, maybe hold the instrument this way instead of that way”. Innovations in medicine and surgery do not end when we finish our training, so for doctors to simply learn these new skills without a mentor seems like an unwanted impediment to mastering them.
Innovation:
https://www.wisersystems.com/blog/rtls-versus-asset-tracking
Kellog Eye Center’s glaucoma service ran a study in 2018 to assess the impact of real-time location systems (RTLS) on their clinic’s operational efficiency. The study is included in the following link. https://pmc.ncbi.nlm.nih.gov/articles/PMC9238160/#:~:text=There%20were%20limitations%20both%20to,skill%20level%20affecting%20process%20times. The purpose of using RTLS was to better understand the impact of a change in how they work up patients on clinic flow. The problem with normally studying any intervention on practice flow is that measuring the impact can be difficult. With RTLS, healthcare organizations can track patient and clinical team member locations in real time. While this may sound “big-brothery”, it actually allows you to identify bottlenecks and areas of waste. Here is a link to a short video of how RTLS works: https://www.youtube.com/watch?v=R0EeGloaZfY&t=15s
In their study, rather than the technicians refracting every patient, they only refracted (check a glasses prescription) for patients with vision worse than 20/30, unless the patient asked for a glasses check. Using RTLS, they were able assess the impact of the new policy on patient flow, and found that with the same number of staff they were able to see 7 more patients per day without increasing patient wait time. However, their RTLS technology wasn’t perfect - patient and team member tracking hovered around 80% compared to direct observation. While one could argue direct observation is the gold standard in analyzing clinical flow and efficiency, it is extremely time consuming and expensive to do to compared to RTLS, especially when monitoring multiple operational processes. In other words, it’s not sustainable.
Why this matters to patients:
Ever wonder what’s taking them so long to call you from the waiting room for a doctor’s appointment? Guess what, oftentimes the clinic you’re waiting in is trying to figure what’s taking so long too. With RTLS, we can all know what’s going on in a sustainable way. Some people may be familiar with this experience. Your loved one is having surgery. You’re very nervous. You have no idea what’s going on. You may try to reach out to the surgical team to find out what’s going on, but there are problems with this: 1) It pulls away team members to talk with you & 2) You may not actually be able to find out what’s going on anyways because getting ahold of the right person can be challenging. With RTLS, both the caregiver and the surgery center could get real time data on when the patient has entered the operating room and when the patient has left the operating room, is in the recovery area, or back in their hospital room, automatically and without human involvement, as it should be. It’s no different in the clinic. With RTLS, you can know how long a patient is waiting to check in, in the waiting area, in the exam room, in a testing room, waiting to check out, etc. automatically and without human involvement. Bottom line - practices want efficiency, which requires insights into inefficiencies, while patients and caregivers want fast service and a good experience. RTLS can help deliver on both.
Thank you for reading March’s The Monthly Eye Opener! We welcome your feedback and look forward to continuing the conversation on the future of healthcare.