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Saturday, April 19, 2014

Making sure that everyone is rowing and in the right direction

I really enjoy courses I get from the Teaching Company. The two most recent ones I have listened to (and am currently listening to) are the courses on Behavioral economics delivered by Dr. Scott Huettel (Duke) and Why economies rise and fall taught be Peter Rodriguez (Princeton/UVA). These course have given me additional insights into the challenges I face personally and the challenges we face in aggregate in getting people motivated to create a better world for all.

In Dr. Rodriguez's presentations, he reflects upon human history to identify when and why specific peoples have thrived or failed. Improvement of our circumstances over time is completely dependent upon effective human action to increase productivity. It is through human action that we have lifted ourselves from abject poverty and misery. The more people who are working productively, the more wealth comes into existence, and the better off we are in aggregate.

When human operated primarily singly or in small groups, it was likely  not particularly hard to motivate individuals toward productive behavior. Without being individually productive, people went hungry, were exposed to the elements, and likely were miserable. However, as we moved more and more toward labor specialization and working in groups, it became easier for people to not be productive and potentially get away with this. Imagine a giant galley ship with millions of people all rowing. Suppose one stops rowing. Is that a big deal? What about if 1000 stop rowing? What about 100,000? At what point does the ship stop moving? At what point does the behavior of those not rowing entice a critical mass of those still rowing to stop?

Dr. Huettel's presentations in behavioral economics are focused on what motivates people to do things, including being productive and how cooperative behavior came to be and can be effective. Unlike the simple concept of productivity, human motivation and the tools to drive human action are extremely complex since they involve motivating people who are not entirely rational. Remarkably, we will engage in behaviors which will hurt ourselves if we perceive they will hurt potential free-riders even more (Altruistic punishment). Furthermore, this is not a unique human behavior and can be found in animals such as fish.

Understanding human motivation is devilishly complicated and just when you think you know how to manage a situation with a person or persons, everything changes. While human motivations is not just about money, money is a huge human motivator.  It occurred to me that the real function of money is it simply functions as a reasonably good marker of those who engage in productive behavior. Granted it is an imperfect marker but it perhaps is the best marker we have. Is it important for people to be engaged in productive activity? I would suggest it is critical since the aggregate well being of a population is directly related to the ability of those within the population to produce goods and services needed to make the lives of people better. There is a huge moral hazard associated with the widespread ability of people to game a system which allows them access to the products of the labors of others without needing to be productive themselves.

For those who decry those of us within affluent societies that feel driven to work hard and be productive, think of the alternative. We avoid misery and abject poverty because a critical mass of the population feels obligated to some degree to engage in activities which provide value to other people. To undermine the incentives which motivate that segment of the population is to undermine the foundations of the institutions that lift people out of poverty. The default mode in the world is still life on the edge.

Sunday, April 13, 2014

Being blind to human wants

I do not watch much television but there are a few programs that capture my attention. A few years ago I got
hooked on "Deal or no deal". I was fascinated by the decisions made by contestants and their reasons for decided as they did. I saw it as a trove of data which would ultimately serve to someone's doctoral thesis in behavioral economics. Now I am fascinated by "Shark Tank" and what draws me to this is the laser focus of the sharks, the venture capitalists and how any given product or service will meet the wants of the public. Whatever you might feel about any of the sharks as people, you have to admit they are gifted in terms of seeing what the public might desire and spend their own precious treasure to acquire.

The last episode I watched highlighted a pair of inventors who developed what I thought was a remarkable
product, one that converted boiling water into electricity. I thought it was an extremely cool technology. However, most of the sharks were not so turned on to it because they thought the markets in the US would be limited. Most of them really disliked the idea of camping and thought their views were representative of the public at large. I could not help but think of my experiences in Haiti where such a device would be extremely useful and the discussion ultimately focused in on this. Mark Cuban asked about whether the inventors had considered developing world applications, which they had. Everyone on the panel thought that people in these circumstances would use this device primarily to charge small battery operated devices such as cell phones This was also the initial thought of the inventors. However, they were surprised to discover that when they inquired, their potential customers desired something else; they wanted the capacity to generate electricity to produce lighting. They were less concerned about charging their cell phones and more interested in prolonging daylight. Everyone on the panel thought they understood what their customers wanted until they asked them.

There is a lesson here for those of us to are in health care. One characteristic of the current delivery system is that our patients, our customers, baffle us by not doing what we recommend. We call this non-compliance. There are impressive numbers floated regarding the scope the problem: 20-30% of prescriptions are never filled and around half are not taken as prescribed. The knee jerk reaction among those of us within the medical fraternity (sorority) is that this behavior is a marker of some sort of  basic human character flaw which warrants remedial training. I would suggest that it may me more indicative that we are trying to sell a product which our patients for which they detect little value.

There are data which support this contention. It has been demonstrated that reducing the copays on medications increases patient compliance. This is consistent with the value theory I propose. If the interventions proposed by us cost substantially more than nothing, patients make the assessment that even at nominal cost they do not provide sufficient value to their lives to make the investment of their own resources.  The articles in the medical literature for the most part make it a given that the interventions we recommend are slam dunks and no one but fools would decline them. Of course you want a parachute when you jump out of an airplane! Duh!  I would suggest the data are not so compelling.  The truth may be substantially more nuanced. As noted in a NYT blog piece by By DANIELLE OFRI, M.D. (Orfri blog, Nov 2012):

“It’s an immense oversimplification” to reduce compliance to whether or not a patient swallows a pill, says the author, Dr. John Steiner, a researcher at Kaiser Permanente in Colorado.
To illustrate his point, he constructed a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and tabulated what it would take to be “adherent” with all medical recommendations.
Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots – on top of remembering to take the morning pills and then the evening pills each and every day.
Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.

This perspective does not even begin to touch upon the question of whether patients are even close be being convinced they derive value from any of this.  Like the sharks described above who thought they knew what wants motivated their target populations, we are often clueless as to what wants drive our patient decisions. However, unlike the sharks who generally have proven masterful in understanding human wants and have become wealthy because of this, the culture of health care delivery has historically tended to ignore what patients want and focused primarily on what we think they need. In some sense it is remarkable we get as much buy in from our patients as we do. While 20-30% of patients may not fill their prescriptions, that means that 70-80% fill them.

In order to better get our hands around these issues, let's take a hypothetical example from outside of the health care industry. Imagine that you find that your old computer is slow and runs on Windows XP, no longer supported by Microsoft. You have heard about security risks and decide to investigate whether a new machine is in order. You go to a big box retailer (Best Buy) to look into the purchase of a new computer and try to explain to the sales associate what you think you need. The salesman immediately directs you to the highest end machine they sell and also tries to sell you an extended warranty. When you balk, believing that the high end investment does not actually bring you the value you need, the salesman suggests that you are ignorant and calls you "non-compliant". He points out to you that you obviously don't understand the risks involved in buying a cheaper machine or sticking with an obsolete XP operating system. There is much at stake here with your valuable photos and financial records which all could be lost if you are not covered with an extended warranty. People lose their valuable data every day! We will just mark your Best Buy customer record with the "Non-compliant" check mark.

We in health care are involved a service industry. We need to realize that recent history has placed this service industry within a very peculiar  financial environment which has insulated many if not most of its customers from many of  the actual costs of service delivery and thus has created a perverse set of incentives and a skewed set of perspectives on the value placed by patients upon the services we deliver. However, as the cost of the medical services becomes increasingly transferred on to patients, it appears patients perhaps value the services we offer much less than we thought they would or should.  This comes as a surprise to those of us delivering the services since our impressions of value have formed by seeing demand within an environment of almost no cost to those demanding the service. Raise the price just a little and oh how the demand seems to evaporate. Perhaps we should try harder to convince patients that what we offer really does bring them value, convincing them to sped their time and resources on what we recommend. That can be viewed as education and/or marketing but the onus is on us, not on our patients. We should work hard to ask them what they they view their needs to be, where their priorities are, and what they want. We will need to be prepared for answers we do not expect or want to hear.

Sunday, April 6, 2014

Physician as craftsman

Physicians operate as craftsmen. We are organized into guilds and use the power of the state through licensing laws to keep competitors out. We train new practitioners using the apprentice model. We link our pay to directly touching our products, one at a time, whether it be in the operating room, the exam room, and less so in the lab or reading room.  We understand that people love craftsman and are suspect of things that are mass produced. We resist mass production in medicine.  However, we tend to lose sight of the fact that our standard of living and life expectancy has improved remarkably over the past 300 years because we have moved from craftsman produced goods and services to mass produced items. We can value craft items now only because mass production has made us wealthy enough to have the disposable income to acquire such luxuries.

Still we maintain medicine as a craft industry and place the most expensive craftsman (us) in the center of delivery. Can we afford to continue to do this? We have deployed increasingly complex sets of interventions and recommendations where the yield from the complexities are marginal. The increase of complexity has been
underwritten by insurance which has for the most part has insulated the consumer from the cost increases, until now. Obviously patients have liked this situation because they are insulated from costs. Deliverers of care have liked this situation because it has allowed them to deliver increasingly complex and expensive (high margin) care without the risk of sticker shock. Furthermore, this could all be delivered without disrupting the craftsman model of care, until now.

Throughout history fields controlled by craftsman have evolved away from the craft model. The major transitions and disruptive innovations were generally not driven by craftsman. It is hard to imagine that medicine will be any different. Craftsman, including physicians, are loathe to drive innovation which will disrupt their status and livelihoods. Furthermore, physicians tend to value their services to patient more than patients value them. In contrast, patients value convenience and cost more than those delivering the services. This disconnect in terms of value has been hidden due to a payment system which insulates those receiving the services from the full costs.

The time and convenience value issue is coming to the forefront. The use of various surveys of patients probing their impressions of the experience of care delivery almost invariably highlights convenience issues. It appears that patients may value convenience and cost more than they value quality. Patients can be just as happy or happier with cheap and good enough as opposed to the best.  Our responses as medical professionals historically has been like the old phone company, "We don't care because we don't have to". Addressing patient priorities has not been our priority because, unlike our patients, we value quality of the care we deliver more than convenience of delivery. What will happen when other non-craftsman parties who get into the health care delivery business have priorities which align more closely with what patients want more (cheaper, good enough, and convenient) than what we physicians believe they should desire (the best quality possible)? I believe the results are predictable.

Furthermore, the craft model of health  care delivery looks increasingly like a trap. The exploding cost of care now exerts substantial price pressures which physicians have responded to by increasing volume and through put. However, there are limits to how fast one can run the craft model. It is not particularly scalable and by insisting we touch every patients, we become bottlenecks, and expensive ones at that. The product we attempt to deliver becomes more and more divorced from what the public desires.

What is a craftsman to do? Should we remain true to our ancient craft or should we embrace new non-craftsman based care models recognizing different priorities?  If we have interventions and delivery approaches which can reach more people at lower cost and make lives better, we should strive to deploy them in ways which are affordable and scalable. However, our training programs are based upon the legacy of apprenticeship of the craftsman and guilds. Should training programs be the bastions of past, are we preparing our trainees for a world which is not likely to exist in the future with skills sets that the public is not particularly interested in using? The key question becomes, will physicians lead movements driving change, be dragged kicking and screaming into new models, or simply be bypassed and left behind?

Wednesday, April 2, 2014

What is science without replication?

Dr. Mina Bissell published a commentary in Nature in November (Reproducibility Risks) which was in response to questions raised by a study by Amgen scientists where they could only reproduce 11% of work published in high impact journals. She took what I view as a very peculiar tack on these observations. Her major concern was that the drive to improve the reproducibility of research findings could serve as a stumbling block to  promising research and researchers. She believed her concerns were justified based upon the time required and the technical difficulties associated with reproducing studies:
"People trying to repeat others' research often do not have the time, funding or resources to gain the same expertise with the experimental protocol as the original authors, who were perhaps operating under a multi-year federal grant and aiming for a high-profile publication. If a researcher spends six months, say, trying to replicate such work and reports that it is irreproducible, that can deter other scientists from pursuing a promising line of research, jeopardize the original scientists' chances of obtaining funding to continue it themselves, and potentially damage their reputations."
"Many scientists use epithelial cell lines that are exquisitely sensitive. The slightest shift in their microenvironment can alter the results — something a newcomer might not spot. It is common for even a seasoned scientist to struggle with cell lines and culture conditions, and unknowingly introduce changes that will make it seem that a study cannot be reproduced."
My question is how biologically relevant are observations if they are only reproducible under very narrow and difficult to replicate (impossible to replicate?) circumstances? Shouldn't one's reputation be somewhat dependent upon doing and reporting scientific studies which others can replicate? Substitute the term magic for science and wizard for scientist. Magic and alchemy became discredited because it was not reproducible and it was dependent upon special proprietary talents held as secrets by the purported practitioners. Where have we gone if our models begin to resemble magic tricks or at best difficult to duplicate scientific parlor tricks?

What brought this to light was the biotech company Amgen invested a huge sum of money and the product of their investment was not what they expected (Begley). The rest of us in the biomedical establishment should understand what they uncovered. Prior to their work, we had no way of measuring the quality of biomedical research work in terms of a metric which is central to research in general: reproducibility. One must assume that when they undertook this endeavor, they were not intentionally testing the reproducibility hypothesis. I can only imagine this was believed to be a given since it is so central to research activities.

To be faced with a reproducibility percentage which almost reached into single digits must have been staggering to the Amgen scientists. How can this be?  The assumption that scientific work is self correcting does not appear to be valid.  Thus, Dr. Bissell's response to this is to find all sorts of reasons that under the current circumstances with complex systems that reproducible findings are hard to generate. She misses the point. If we have arrived at a place where only one in ten studies published in the most reputable journals can be reproduced, we have an awful quality control problem in science. It is likely worse than these numbers reveal since these results come from the most reputable journals.

Given the extent of the problem highlighted by the Amgen work, one must also wonder how much of this problem may be due to scientific fraud. I came across a report of an investigation in Germany published in 2000 (Hermann and Brach) regarding two cancer scientists who operated in Germany in the 1980's and 1990's. The commission that investigated them and found rampant issues. However, little structural action has been taken to address the underlying problems. It is sad to admit but humans functioning in science will be representative of people in general. If money, fame, power are involved, some will stretch the rules and in the absence of mechanisms to identify undesirable activities, the culture will devolve into whatever it takes to be successful in the increasingly competitive funding climate.  The Wikipedia page on scientific misconduct continues to expand (WIKI).

This is simply unacceptable. The fact that any attempt to address these observations will be disruptive of current operations should be taken as a given, not as a barrier. How valuable is this multi-billion dollar enterprise if the models only work is a few hands and there are no consistent quality control tools? The arguments placed are highly reminiscent of the points put forth when the safety and quality movement came on the scene in health care delivery. Prior to the late 1990's it was difficult to track quality in health care delivery. Thus, consistent with the mantra that if you can't measure it, you cannot improve it was operational. Since there are few incentives to measure reproducibility in biomedical sciences, few focus on this. What the field values in general is productivity, whether valid and reproducible observations are made or not is of secondary value. I fear that the absence of  reproducibility feedback loops has taken us to a very undesirable place from the stand point of those investing financial resources in the research.

Dr. Bissell offers a few anecdotes from her lab to refute the concerns. When sophisticated scientists in industry spending hundreds of millions of dollars cannot duplicate your work, they might have a problem in that they burned through resources that could have been better invested elsewhere. However, if they cannot reproduce your results you have a bigger problem.  The fact that under the current system that this issue can be viewed as someone else's problem is a HUGE PROBLEM. One cannot and should not deflect the onus on someone else. Magicians and wizards can resort to secret spells and incantations. That is not science.

Sunday, March 30, 2014

Taking oaths of poverty...Not!

Those who deliver health care often express a very conflicted view of money in their profession. No one admits to being in it for the money. Yet,  I have yet to hear of any of my colleagues commit to an oath of poverty. There is a desire to live well enough, but what is enough is open to interpretation. That figure has different anchors from which various parties base their perception of what is good but not greedy.

What creates almost constant tension is the concern that the sources of the money, which drives the engines that are health care, make a difference. There are assumptions and perceptions about these sources which tend to go unquestioned, which I question. They include:

1. Money from commercial sources is unclean and corrupting.
2. Money from grants from non-profits or the state are not corrupting
3. Revenues from clinical practice are OK, unless somehow corrupted by funds from for profit entities

We have gone through various cycles of self reflection, accepting and rejecting funding partnerships with for profit entities, particularly pharmaceutical companies. In my opinion, the tensions arise because we make assumptions which simply are not true and can never be true. Institutions which deliver key services to people will always be less than perfect. The most important piece to recall is that the void left behind when key institutions fail is almost always worse than when they exist but function imperfectly.

I experience and try to direct a modestly sized operating unit which provides service to patients, training to various learners, and drives scholarly and performance improvement work. All of these endeavors require fuel, that is money. That is because those participating in these activities are almost exclusively "coin operated". Missions which provide their own margins are the easiest to sustain. Those which don't are at risk of going away, despite perceptions that they are important. Money is not everything but for activities which require the commitment of parties who require financial incentives to come to work, the economics become very uncompromising in a hurry.

Thus, what is the impact when we start to be picky about the sources of funds to support missions. I call into question the hierarchy of sanctity of fund sources as noted above. Wherever the money comes from will cloud our judgement. Yes, taking funds from commercial sources has its risks. I would argue that these risks can be mitigated by explicit transparency as to where the money comes from, how much was transferred, and where the funds went. I have seen the effects of the virtual complete cessation of industry money into medical training programs. We primarily used these funds to buy books and support small research projects. The hit occurred at the very time our other funding options became more limited. Our goals and missions are at times aligned with commercial entities such as drug companies. We should recognize this and use this alignment to maintain a differentiated source of funding.

The health delivery system and particularly academic health systems, have seen the federalization of their funding sources. I recently asked on of our finance heads what percentage of our revenues come from the federal government. They remarked that this was a very good question but they did not know off hand. I am fairly sure it is a large and growing percentage. Whether it be research grants, Medicare funds, Medicaid dollars passed through state middle men, or tuition backed by federal loans, a large percentage of key funds comes from a single source. Not such a good business model for long term sustainability in my opinion.

Furthermore, the assumption that federal or other state monies do not influence our thinking or behavior is to be questioned. These monies are by definition monies disbursed with primarily political considerations in mind. With money, there is always an underlying quid pro quo and with political monies, the payback must be something which has political value. In my opinion, the political leanings of academic health centers reflects the influence of federalization of the funding process. We have created an insular culture with few dissenting voices, which drives the expansion of state power in health care. It is unfortunate that the entire model based upon a narrowing source of funding becoming more and more sole source based is likely to prove unsustainable.

Finally, we derive huge sums of revenue from clinical activities. I am always annoyed when I read articles in clinical journals where authors claim they have not financial conflicts, yet the articles center around clinical activities which serve as their major source of revenue. Are we blind? If the intervention described in the paper focuses on a procedure which creates substantial margins to support you and your operating unit, is this not a fundamental financial COI, even you work for a non-profit entity?

If we are driven to a great degree by financial concerns (and we are), it really does not matter where the money comes from. Each source of money will create biases and blind spots, and influence our behaviors in both subtle and not so subtle ways. The effects will vary depending upon the sources but all sources provide incentives for both desirable and not so desirable behaviors. The beliefs that certain sources of funds are always substantially more corrupting than others is mistaken. Wherever the funds come from to support important missions, the rules in place with always drive certain parties to behave in less than virtuous ways, whether the monies derive from commercial or political activities. We cannot meet our missions without the financial resources unless we get buy in regarding oaths of poverty from those involved. That is not going to happen. We might as well be realistic and tap into robust and differentiated funding sources which includes both commercial and non-commercial sources to create a sustainable model.

Saturday, March 15, 2014

The struggle to provide value - Why health care is not so different

Health care delivery is complicated and expensive; increasingly even more expensive. Perhaps the biggest impact of anything change we are now seeing in the health care industry is being driven by cost and the movement of cost on to those who are directly receiving the services. Predictably, the effect of this cost transfer, primarily through increasing deductibles, is that those paying these bills are ever more acutely aware of the value proposition. Nothing will be more disruptive to volume driven health care delivery than patients pulling the emergency cord during the office visit and asking, "Do I really need this?"

What made health care delivery behave differently for many years was that these questions rarely arose because it was simply easier for all parties to avoid them. Doctors got paid more when they did more and as long as egregious harm was avoided and the perception of value delivered to patients was held, most everyone was happy. It was pretty easy to meet the bar on the latter since those needing to perceive value set the bar pretty low since they bore little of the actual financial cost.

We are now regularly seeing sticker shock. It is hard for those delivering health care to reconcile since from our perspective little has changed. Why should the perception be now that we are not delivering sufficient value to justify what we are charging since little has changed from our end. If what we are doing now does not hold up in terms of the value equation, how does that reflect on what we have been doing in the past?

This is really not so different from what has happened in a host of other industries. New goods and services in health care and other industries follow similar patterns. Expensive and new goods and services are developed and reach a small sliver of the market, generally the high end of the market. In the rest of the commercial world there are huge incentives to be the first to figure out how to take such new things and learn to deploy them widely but in order to do this, entrepreneurs must figure out how to do this at vastly lower cost. Unless they can succeed in doing this, they will fail since there are not sufficient financial resources for everyone to afford high end goods and services.

In health care, the insurance model until very recently provided little incentive to figure out how to deliver at lower cost. This is a disaster waiting to happen and not sustainable. It is quickly coming to a halt since many of the costs associated with services in health care are coming down full bore on to people with modest resources. In the short term this will take a terrible toll but in the longer term it is absolutely essential to inject the value imperative into health care delivery. The longer we insulate the broader public from the inflated prices and suboptimal resource allocation in health care, the longer it will go on and the worse the wake up call will ultimately be.

The health care industry must deliver value to the public. Otherwise, it will squander resources, serve as a barrier to the wealth creation which allows it to thrive, and impoverish those who are the most vulnerable.

Sunday, March 2, 2014

The burden of competing missions

I work at an academic medical center (AMC) and involved the classic tripartite missions of clinical service, education, and research. As noted in my recent blogs, I have become increasingly aware of the divergence between what our missions might be in an academic health center and the goals of our patients and their families. Specifically, our patient's priorities revolve around cost and convenience. It appears that these goals are at odds, particularly with our educational goals.

Our educational model is a legacy model which is not compatible with the increasingly rules based and focused factory based approaches begin adopted to increase efficiency and decrease cost. Furthermore, training requires exposure to a broad range of illness and therapeutics, which is not compatible with efficiency. In particular, health systems modeling of successful finances require they attract and cater to the least sick populations, in order to keep them happy and paying their premiums. While being of great financial values, these patients are of limited educational value.

Historically, GME and IME funds have attempted to close this funding gap, allowing for academic centers to have the resources to train and care for the sickest patient populations. The system worked reasonably well for a while. However like any subsidy, the money did not go where it might have more impact. It was all hospital based and tended to underwrite hospital functions. As the health care world moves more and more outside of the inpatient environment, how can training functions continue to exist, what should they look like, and who will pay for them?

Nothing lasts forever and there is no reason to believe that a program conceived about 50 years ago will continue in perpetuity. The question is not whether it will last forever but instead what will replace it and when, and what will the transition look like? It is unfortunate that no entity in the current system seems to want to address this issue. Existing oversight organizations such as the ACCME, LCME, and the ACGME seem to be most interested in extending their reach and operate on the assumption that the current funding structure can accommodate increasing regulatory burdens forever. They will have a scary wake up call when they discover that disruption of the current Federalized funding system will represent and existential threat to them as well as the programs they oversee.

Within academic health systems, there appear to be three distinct books of business. First, there are service lines centered around cutting edge technologies and approaches which do not exist as of yet in the community and serve as a robust training resource and source of revenue for these centers. While these used to be a major characteristic of academic health centers, these are remarkably rare. Technology which can be leveraged to generate income now diffuses into the community practices at light speed.

Second, there are services which generate healthy financial margins where AMC's must compete with the community practices. However, AMC's have difficulty competing because their structure and culture may not allow them to readily address patient desires for convenience and cost. Historically, many successful AMC's have been able to extract premium payments from commercial insurers which help offset their disadvantages. Increases in co-pays associated with commercial insurance and price transparency are undermining this revenue stream very rapidly.

Finally, academic health systems provide expertise and care for patients with very complicated disease where the relevant expertise simply does not exist in community practices. These patient populations are also necessary for fulfilling training missions and maintenance of a concentration of specialized competencies within AMC's. These concentrations serve a repositories of expertise and fulfill essential functions. They are why the sickest patients end up at AMC's for their care. Unfortunately, there is no present mechanism for AMC's to monetize these capabilities which serve both essential educational functions and meet otherwise unmet clinical needs in their communities. Those functions, no matter how essential, will disappear over time if they do not provide economic value to those delivering them.

What happens when the traditional subsidies which have underwritten training are eroded while at the same time cost pressures are increased on AMC's? Stein's Law is "If something cannot go on forever, it will stop". One f the worst aspects of our current system is that the way it is structured creates all sorts of barriers to testing new approaches to training. Regulations controlling Medicare based funding are notorious for forcing those participating into an all in or out structure. The various oversight entities such as the ACGME follow a similar model where innovative funding approaches are viewed with great prejudice. All seem to be blind to the reality that we have created increasingly complex cost structures while simultaneously creating increasingly constrained and de-differentiated funding streams. This is a very dysfunctional business model.

The end results are predictable even if the timetable of events is not. When the current funding mechanisms are disrupted, many training programs will quickly disappear. They live hand to mouth now. What will come up to replace them is an open question and will depend a great deal on what barriers will be created by current regulatory elements. What unmet needs will be created may become apparent only after a long time. Smart people will figure out how to meet human needs and profit from this, as long as they are not too constrained.