Automating Health Care Provision

 Dealing with COVID has stimulated some thoughts about the current state of health care and where it is likely heading under the influence of Artificial Intelligence and Large Language Models.

The day after we arrived home from our Portland adventure I started an effort to see what treatment options were available.  I found out that COVID emergency procedures had been shut down and the only option which seemed available was my regular doctor at the Presbyterian Health Services clinic.  

The phone listed under my doctor's name did not work, so I dialed the main clinic number and got put on endless holding music.  I then sent the following message to the care team:

I tested positive on Tuesday evening for COVID.  I have some congestion and fatigue.  My temperature is normal.  I would like a recommendation for treatment.  

Mike Connealy

Two days later I got a reply:

Hello Mr. Connealy,  

 We received your MyChart message and due to the symptoms you have reported, your message has been sent to a Team Registered Nurse (RN). 

 We will make our best efforts to address your concerns and determine the next steps in your care within 4 business hours...

Fortunately, in the meantime I had come across another option on the Presbyterian web portal called Online Visits.  I clicked the link, and up popped a questionnaire asking for symptoms and health history which I completed in about ten minutes.  An hour later I got a thorough emailed summary of the "online visit":

Good morning— I’m prescribing Paxlovid for you, but I wanted discuss the interaction that it will have with your levothyroxine... 

Diagnosis - COVID-19 infection

My name is ALEXANDRA CARTER, MD, and I'm a healthcare provider at Presbyterian Healthcare Services. I've reviewed your interview. Based on your responses and recent positive COVID-19 test, I see that your symptoms are caused by a COVID-19 infection.

Since you tested positive on a self-test, you don't need another test. A positive self-test means that the COVID-19 virus was detected, and you very likely have a COVID-19 infection.

Most people with COVID-19 have mild to moderate symptoms and can rest at home until they get better...

As it turned out, my regular nearby Walgreens Pharmacy did not have Paxlovid in stock, but they sent me to another branch up the road where I got the prescription at no cost.

Margaret went through a similar process with her doctor, so we also used the online visit feature to get her an immediate response and prescription.  Both her doctor and my doctor's care team expressed irritation that we had sped up the diagnosis and prescription process by doing an end-run around their usual bureaucratic procedure.

So, it seems most primary care physicians are going to have to up their game with the regular inclusion of an automated process of diagnosis and treatment.  Not every condition will be as simple to deal with as our COVID experience, but progress in AI medical care provision  will surely make it relevant to treatment on a broad scale.  

The Online Visit process in this case is perhaps best characterized as AI-lite, but it was quick and effective.  While a lot of the content in the visit summary was boiler plate, it clearly took into account my responses in terms of symptoms and health history, and it was reviewed by "ALEXANDRA CARTER, MD".  (I'm assuming she is a real person.)  I wonder if reviewing AI-generated diagnoses and treatments is a full-time job and how Dr. Carter feels about doing it.

I am also wondering about how the big health care corporations like Presbyterian are going to assimilate AI, and to what ends. While speed and accuracy are likely targets, quite a lot of motivation is also likely to involve profit maintenance and enhancement. There is no guarantee that patient benefits will be on a par with bottom line considerations.

The doctor will see you now.

fixer-upper economics

It's the car of your dreams since you were in high school, a 1960 Cadillac Eldorado convertible.  The previous owner put a lot of money into restoration, and the only thing that it needs to get back on the road is a new generator.  Piece of cake.  You track down the replacement generator on ebay, spend a weekend in your garage getting it installed, and you're behind the wheel on the way to the Seven-Eleven to pick up a celebratory six-pack.

A couple blocks down the road you notice that the steering pulls to the left, there's quite a lot of black smoke coming out of the tail pipes, and the transmission is making an odd grinding sound every time you shift gears.  You are wondering if you are going to actually make it all the way to the corner store, much less all the way across town to your job on Monday morning.  What to do?

Go read Dean Baker's analysis of the U.S. health care system.  I think you'll agree that the analogy is apt, and the solution is clear.

A couple excerpts to steer you in the right direction:

... Getting universal Medicare would require overcoming opposition not only from insurers and drug companies, but doctors and hospital administrators, both of whom are paid at levels two to three times higher than their counterparts in other wealthy countries. There would also be opposition from a massive web of health-related industries, including everything from manufacturers of medical equipment and diagnostic tools to pharmacy benefit managers who survive by intermediating between insurers and drug companies.

... in the case of prescription drugs, economists seem content to ignore the patent monopolies granted to the industry, which allow it to charge prices that are often ten or even a hundred times the free market price. (The hepatitis C drug Sovaldi has a list price in the United States of $84,000. High quality generic versions are available in India for a few hundred dollars per treatment.) In this case, we are effectively looking at a tariff that is not the 10-20 percent that we might see in trade policy, but rather 1,000 percent or even 10,000 percent.

And then he says:

In this context, Bernie Sanders’ push for universal Medicare can play an important role in energizing the public and keeping the pressure on.

Baker also asserts that "Krugman is largely right" in backing Hillary Clinton's incremental approach to fixing what ails the health care system, but he offers no explanation of that seeming contradiction to the evidence he has presented.

The article's analysis of a broken down system is still excellent in spite of that one inexplicable contradiction.  Perhaps Baker will sort out the issues better in subsequent installments.  In the meantime, it stll looks to me like the only practical way out of the dilemma is to dump that old Cadillac.