As a One Medical customer, this makes me very unhappy: even if internal controls protect my data from the rest of Amazon’s business, I struggle to believe that their interests are aligned with mine.
As a One Medical customer, the experience post IPO has been awful. Hard to get appointments and less and less MDs available with incredibly high turnover. I wouldn't say their interests are aligned with mine at all, but agree the customer data being in Amazon's hands isn't great.
That's probably an industry-wide phenomenon. One Medical IPO'd in January 2020. You know what happened after that? Covid, mass deaths, high burn out amongst medical staff, and a lot of career changes away from meeting Facebook-informed clients face to face.
this is not a problem with just One Medical - it is a huge problem in primary care everywhere.
New doctors generally don't want to go into primary care anymore - it doesn't pay nearly as much as being a specialist does, and you are expected to be available to your patients 365 days a year, 24 hours a day (at least that is what many patients think).
It is a pretty miserable business to be in right now, and not sure what is going to make it better.
> In Atlantic Canada (the four easternmost provinces) it is impossible, repeat impossible, to get a family doctor if you don't have one ..[snip].. I've heard the same occurs in Vancouver too.
I am confused. Vancouver is on the West Coast of Canada while your statement is about "four eastermost provinces". Is it then a nation-wide problem?
I've seen news articles discussing the issue occurring in Atlantic Canada, and have been told that it is also an issue in Vancouver. I do not know about elsewhere.
> and you are expected to be available to your patients 365 days a year, 24 hours a day
Boy, I wish. I've never had a doctor with any kind of special availability. I can leave a message at their office but it's not like I'll get any kind of response until later the next business day, and that will just be from an assistant.
For 24/7 needs that's what urgent care is for, or the emergency room if it's more serious.
I know a few doctors and they're not necessarily directly available to patients but have to be on-call for nurses, MAs, etc. It's not 24/7/365 but its more than I get pinged when I'm on-call.
Let's segregate customer data from medical data: The US has some (IMO) pretty strict laws about protecting PHI. One Medical isn't going to keep your data in an open public S3 bucket, and random Amazon employees aren't going to be snooping around your medical records on their intranet.
> The US has some (IMO) pretty strict laws about protecting PHI. One Medical isn't going to keep your data in an open public S3 bucket, and random Amazon employees aren't going to be snooping around your medical records on their intranet.
HIPAA provides far fewer protections than you probably think it does, and flagrant violations are frighteningly common.
Worse, HIPAA provides no private right to recourse, so even if your PHI is exposed, you're not entitled to a penny in compensation.
HHS may fine Amazon, but to Amazon, $1.5 million (the maximum cap for all violations of a provision due to negligence) might as well be the cost of doing business. And you won't receive one cent of that.
> Can you give an example about fewer protections than people think?
For starters, HIPAA doesn't actually prevent your doctor or health insurer from selling your data to a third party. It also doesn't prevent that third party from giving that data to a fourth party, who can give it to another, and so on.
What happens if one of those tertiary parties has a breach and ends up exposing your data? In theory they're supposed to report it back up the chain, but in practice it doesn't go more than one or two links, if that.
So in short:
- you have no way of enumerating the number of entities who have legal access to your health data
- you have no way of finding out when it's been illegally exposed by any of the parties who have legal access to it
- if by chance you happen to find out about an exposure[0] you have no recourse except to report it to HHS, who may apply a statutory fine, but the fine is typically minuscule compared to the size, revenue, and profit of the guilty party
- if by chance you find out about an exposure of your PHI, you are not entitled to receive any compensation
All things considered, it's easier to enumerate the very limited ways that HIPAA does actually protect you than to enumerate the protections that most people incorrectly think HIPAA provides.
[0] a real-life example is you Googling the name of your partner and stumbling upon a publicly visible Excel spreadsheet containing the name, SSN, addresses, and medical diagnoses of thousands of patients
Used to be the Joint Commision took HIPAA violations seriously. Do HIPAA violations no longer cause risk of losing Join Commision accreditation? That used to be the big sanction everyone worried about.
> Your consent to be used in research is basically baked into anything you’ve whipsaw signed at a doctor’s office.
Eh, that's not exactly true. HIPAA isn't the only (or even primary) vehicle for safeguarding patients from research, and most research is conducted under the auspices of large (usually academic) institutions that have processes to ensure informed consent, which are in turn backed by other legal statutes or contracts. Those aren't perfect, but it's not correct to say that patients provide blanket consent when they begin at a new practice, or that HIPAA is responsible.
Not to mention that there is already a better than decent chance that no matter who has your medical records, they are already being stored or backed up into one of the major cloud providers anyway.
> The US has some (IMO) pretty strict laws about protecting PHI.
But it has some pretty huge holes in it. A lot of telemedicine services aren't covered by HIPAA, for instance.
I'm not worried about Amazon keeping my data in a public bucket, nor about Amazon employees snooping in it -- but I am 100% worried about Amazon pulling some "anonymization" BS and using my data for purposes other than providing health care to me.
I don't trust Amazon with my less sensitive data as it is -- I absolutely wouldn't want Amazon anywhere near my health data.
I’m imagining a utopia now where my privacy was protected as well as my medical data is with HIPAA.
Some of my family works in medicine and there is nothing that scares the pants off of medical administration more than a HIPAA data breach. There are real penalties for it from the government and they have to be reported. People responsible get fired.
> I’m imagining a utopia now where my privacy was protected as well as my medical data is with HIPAA.
I'm imagining a utopia in which our medical data is as well protected as people think it is under HIPAA.
> Some of my family works in medicine and there is nothing that scares the pants off of medical administration more than a HIPAA data breach. There are real penalties for it from the government and they have to be reported. People responsible get fired.
The penalties are usually in the tens of thousands of dollars. That sounds like a lot, but it's really not when you consider that most breaches for which fines are levied usually affect many patients, not just one, and when you consider the annual revenue and margins of most of these responsible parties.
The fines are capped by statute at a value (about $1.5 million for all violations of a provision in a single year) that is laughably low.
Strict yes, but a company with the lobbying budget of Amazon can easily get around those laws.
The USA has demonstrated time and time again a pattern of fining corporations a minuscule amount in comparison to the damage done.
Besides, even before it comes to fines and it's in discussion in Congressional chambers, Amazon lobbyists can say to practically any senator or congressman/congresswoman: "you want to go against us for antitrust reaons? Oh well, guess we're going to have to close that Amazon warehouse in your district that creates so many jobs...and oh yeah looks like that Whole Foods in your district isn't profitable, we're going to have to close that one up too."
> Strict yes, but a company with the lobbying budget of Amazon can easily get around those laws.
They don't even need to lobby. They can just pay the fines. The fines are capped by statute at an egregiously low value, which to Amazon is chump change.
And that's just disturbing to me - that a corporation can willingly and knowingly break the law, and the money they'll make from doing so is significantly larger than the fine they'll pay.
Why is that even remotely acceptable in a democratic society?
See the big banks collective responses to regulations placed on the financial industry in the aftermath of 2008 - if the fine is significantly smaller than the potential for profits, they will do those activities and pay the fine 100% of the time. This mentality is evident in many other sectors as well, especially with publicly traded companies.
Yes, I know HIPPA fines are public. However, Amazon has enough money to not care, and to never care. You know how many labor laws Amazon has blatantly violated and not cared? If they can capture an entirely new vertical (healthcare), their share price will increase despite looming lawsuits and pesky regulations. Amazon is a multi-trillion dollar company that focuses on growth at any and all costs.
It shouldn't be, but that's how the game has been played for longer than you or I have been alive.
The fact that the penalty for many serious violations consists of fines that represent a tiny fraction of the company's worth means that breaking the law is an easy economic decision for companies. Fines are just a cost of doing business, and not even a major one.
That's really disappointing to hear. I stopped using One Medical because I moved out of the country. I loved One Medical and was thinking about moving back to it this year now that I've returned to the US. Good to know that it's not a good idea.
They were already a publicly traded corporation. Their interests have never been aligned with yours fundamentally, they've been aligned with a fiduciary duty to make profit for shareholders. Literally nothing about the profit motive has changed.
But fortunately their business model has been about providing a superior level of care for a small extra fee, and presumably Amazon is buying them for that strength. Otherwise it would be a pretty pointless acquisition.
But who knows, maybe now there'll be a discount if you have a Prime membership or something. :P
Amazon has a reputation for ruthless efficiency. Seems speculative to assume that they bought One Medical because of its high level of care and that they are able to manage the company in a way that it continues.
There are plenty of Amazon acquisitions where the service got worse post-acquisition, was relaunched as something else, or was simply shuttered.
But Amazon already did the same with Whole Foods. It continues to be premium.
There were some temporary hiccups at one point with a new backend system but that was all.
So I don't see why they wouldn't be doing the same they've done with Whole Foods, which is maintaining the high level of service, because that's the proven successful business model.
Whole Foods is absolute TRASH after Amazon bought it. The food used to be good and now it's absolute crap, less options, utter rubbish no better than keyfood. At least in NYC anyway. (multiple locations)
I don't find this true at all in my bay area location. Their fish is still the freshest in the area, including when comparing to the local fishmonger. Their produce is well above the quality and freshness of other stores except one, which they can match. Their bakery is still quite good. Variety is roughly the same. It's the same old overpriced-but-reliable Whole Foods.
The produce has changed a lot. Now, the fruits and vegetables leave a lot to be desired. If you compare the best from Whole Foods and the best from Fresh Direct, you'll see that Fresh Direct is a clear winner in most categories, but especially in produce and meat. The two used to be a lot closer in terms of quality.
Sorry, but I just don't see it. Only difference is Fresh Direct puts a produce quality rating so you know when ordering online what the quality will be.
The only store that has consistently better produce at scale than Whole Foods in NYC is Eataly, but it's more expensive and there are only two of them. Before that there was Dean & Deluca but they've long since gone out of business and their prices were astronomical -- but I swear their produce section was like a museum and the vegetables were almost works of art.
I find it funny that when you drill down, the only supposed quality decrease is in the "freshness" of produce and meat, the two things that are ultimately the most subjective. I've shopped at a lot of supermarkets for a long time, and I truly have to wonder if people are simply imagining a decrease in freshness simply because it fits a preconceived narrative that if Amazon bought it, it must have gotten worse.
Because with my own eyes and taste, I don't see it at all. And it's not like this is ancient history hard to remember -- Amazon only bought WF five and a half years ago.
> I find it funny that when you drill down, the only supposed quality decrease is in the "freshness" of produce and meat
The difference in quality has little to do with "freshness." I recently studied the difference between Whole Foods and Fresh Direct in some detail. Fresh Direct is generally 20% more expensive than Whole Foods. We were looking to cut our budget, so switching from Fresh Direct to Whole Foods was an easy choice. However, after a few weeks, it was clear that the quality just isn't as good.
Here are a few examples:
1. Fresh Direct has heritage raised chicken and pork. The chicken, in particular is amazing. It's much smaller than a typical chicken, way more flavorful, and the color of the meat is so interesting. The dark meat has a beautiful purple luster not found in the Whole Foods chicken.
2. The "Animal Wellfare Certified" meats at Whole Foods are all step 1 or step 2. Fresh Directly has many step 3 and step 4 options.
3. All of the Lancaster Co-op produce is really good. Can't find anything like it at Whole Foods.
4. We eat a lot of fruit during the summer. Certain produce at Whole Foods is just bad. Like I could not buy a good organic peach at Whole Foods. They always came rock hard and never softened.
> I find it funny that when you drill down, the only supposed quality decrease is in the "freshness" of produce and meat
I mean, these "subjective" things are basically the only thing Whole Foods has going for it. Every grocery store chain stocks "natural/organic/wellness" brands now, most at cheaper prices than Whole Foods. The quality of the produce is essentially the only reason to shop there.
Even the prepared food has changed. It's feels cheap and tastes like shit, but carries the same price. Gowanus whole foods had a whole section of moldy cold cuts not too long. If people haven't noticed what I'm talking about, its probably that they just don't remember how nice it used to be before.
Your prior should be that after Amazon acquires a company and Amazon "leaders" make their way into the corporate structure, that company will go downhill in terms of any customer-service differentiator. cf Zappos, Whole Foods, etc.
The differentiators - usually reflected in motivated staff with the freedom to solve customer problems, but also in the case of WF a focus on quality fresh food, etc - will be relentlessly driven down.
WF continues to be "premium" but it's definitely not the same chain that it was a decade ago.
Disagree. I had reasonable hopes Mackey had struck a business preserving deal. Recently discussed the homogenous thin sponge they still market at "ciabatta" with folks who go more often. They said the all bread is now outsourced and terrible.
My reasonable hopes stemmed from what HEB has done with sub-brand Central Market. While CM isn't quite as awesome as its high point, more CM goodness has rolled into regular HEB than bean-counting into CM.
> They were already a publicly traded corporation. Their interests have never been aligned with yours fundamentally, they've been aligned with a fiduciary duty to make profit for shareholders. Literally nothing about the profit motive has changed.
This is a trope that needs to stop. Public companies are not alike and the fiduciary duty is only a very high level one that can be used to justify both squeezing every customer as much as possible to losing money to support growth.
What the shareholders want matters and an acquisition changes that completely.
I didn't say it was the sole/only objective that must be pursued without any regard to anything else, which seems to be the straw man that that NYT article is arguing against.
But yes, a board of a for-profit corporation must pursue profits to their full reasonable capability. If they neglect that duty, they will be sued and replaced. This is, for example, why Twitter had no choice but to sell to Elon. Because that was most profitable to shareholders. Otherwise the board would have been taken to court and lost. That is fiduciary duty to profits.
The idea that it's a "fake rule" is also something people love to repeat. But that isn't true. A publicly traded corporation simply cannot choose to forgo profits for all time and invest in customer service instead, for example. There absolutely is a fiduciary duty to make decisions that are ultimately profitable. (But that obviously goes along with flexibility to e.g. invest more to defer profits, invest in nice offices to attract better employees, etc.)
>But yes, a board of a for-profit corporation must pursue profits to their full reasonable capability.
No this has been explicitly rejected by the court. The fiduciary duty a company has to it's board is to not screw them over. A company has the freedom to leave money on the table in order to do the right thing. Your shareholders have no grounds to sue you if you are doing something that doesn't produce 100% profit but still produces reasonable profit.
Amazon's likely buying One Medical for the same reason as most of it's acquisitions: to have an in-house team to dogfood AWS solutions. They'll care about customer experience enough to maintain a reasonable customer base, but improving the state of primary care won't be the priority.
Medical data, despite seeming like a juicy target, isn't really all that valuable atm. It requires a lot of infrastructure to move it around, and you can't do all that much with it without breaking the law. HIPAA/PHI fines can rack up really quickly and are still enforced relatively strictly. Although maybe Amazon's lobbyists are working on "fixing" that.
My guess is Amazon sees hospitals/practices starting to use more "cloud-y" services and wants to set themselves up to capture as much of that revenue as possible. The old hospital IT-fortress model leaves a lot of efficiency gains on the table and I'm sure AWS would love to be able to capture all of that.
source: I work at a "cloud-y" medical tech company
> Not everyone who who handles medical data is bound by it
This is true, but not true of anyone working at One Medical, since health care providers are bound by HIPAA. If you tell your friend you have cancer, sure, they can legally share that info. If you tell your faith healer, or your employer, they can as well.
If you tell your PCP (or your PCPs app, or their secretary), and they share that with Andy Jassy without him being cleared to handle PHI, they're in for a mountain of fines.
As much as I like being cynical about surveillance capitalism, I don't think Amazon's primary motivation here is patient data, at least in the short-to-medium term. If they wanted the data, they'd buy, like, a vitamin company or something.
> If they wanted the data, they'd buy, like, a vitamin company or something.
This is a very good point.
Nonetheless, I think that being cynical about anything Amazon is up to isn't unwarranted.
My primary personal problem with this deal is that I do my best to avoid doing business with Amazon at all, and the more tendrils they spread, the more difficult this will be.
I have been using OneMedical since 2019, Amazon Pharmacy since 2021 (a few months after they began operating), and regular Amazon since forever. Happy customer in each case. Anything could happen with this acquisition, of course, but I'm pretty optimistic.
I'm in healthcare IT, there are incredibly strict regulations about what we can and can't do with your PHI. Amazon isn't big enough to fuck with the OIG.
On a purely corporate level: Amazon’s business ethos seems in tension with the things I want from my PCP. I don’t want to be A/B tested for retention and mean time between visits in my doctor’s office.
On a more practical level: Amazon is gargantuan, and I don’t necessarily trust them to have the scoped vision necessary to run a good medical practice, rather than just a large one that fits their portfolio. This is true for any large company; Amazon is large even by large company standards.
I'd agree but I think they'll view any penalties as the cost of doing business. If they can find a way to reduce costs or raise profits by more than the penalty amount then it they'll absolutely do it.
The US has largely not shown the level of anti-trust zeal that it needs to, even among party democrats. I have no faith they will stop or shut down a company violating things.
Clinical trials are needed for medical interventions. But can't they A/B test e.g. communications or in-app experiences that try to get you to come in for insurance-covered stuff? This doesn't need to be evil -- maybe they search for messaging which gets more people in the door for vaccine boosters or regular physicals. Maybe after scheduling a kid's checkup, the app nags you to schedule your own, etc.
For the human individual person, the interests (the goal) is to care for their health; but amazon is a corporation: for them the real goal is profit, not health.
I'm saying that for the human the incentives should be all about health. the money, the costs are the "obstacle".
On the other hand, for the corporation the incentives are the profit. The health is a cost (or "obstacle").
with this 'frame' in mind I'm saying the incentives are not aligned on their own because the priorities are in conflict.
What's truly the problem here, is how healthy patients aren't 'good' customers of health-services. Then again, this is not a problem unique to Amazon, but they're getting into this 'rodeo'.
Right, but there exists enough people in the healthcare space that want an outcome driven approach as opposed to a profit driven approach. You let the parasites in and it moves the needle towards (or more towards) "profit driven".
My doctor doesn’t sell scratch-offs and cigarettes in his waiting room. The profit motive doesn’t require companies to pursue every single avenue of profit; beyond that, medical ethics explicitly forbid some avenues.
Yes. Plenty of medical providers are focused on making a profit while still emphasizing other values, rather than sacrificing them in the name of maximizing profits.
this is unnecessary, of course I know this. It's the reason Americans are now engaging in 'health tourism' a.k.a. going anywhere else in the world to get health care, specially when they know the specific procedure they need.
throwing a capitalistic-optimizing 'machine' into health services has been a huge mistake which is seemingly impossible to fix... this is how systems collapse; when the system is so resistant to fixing its 'problems' that only changing the entirety (or a significantly larger chunk) of the system fixes the problems; but the problems have to be 'life or death' (or 'do-or-die') level for this to kick in.
the biggest issue is that for a level of the system there is no problem, people die anyways. but for another level of the system (the human individual perspective) this IS a problem. if/when the system ignores a level of itself it becomes unstable like it's happening now.
You're assuming that One Medical's interests are different than Amazon's. You're probably wrong.
One Medical is there to make money. Amazon will make One Medical more efficient at making money, even if that means forcing you to be healthier.
How?
One nagging problem with healthcare is doctors believe that medicine isn't a cookie cutter problem when in fact it is. For the vast majority of conditions there are standard treatments that work. If that wasn't the case modern medicine wouldn't exist.
Every doctor can whip out some corner case and say "but what about this." Sure, that's great. But for condition A the standard treatments usually work. The trick is to know when the standard treatments aren't working and what to do.
Amazon, or any healthcare company with enough data, can look at the data and see what treatments actually work and what treatments don't. It's not a hard problem, really, but traditional health systems don't care, and to be frank, academic researchers are basically too lacking in imagination to understand how to do it or why it should be done.
Amazon at the very least will try to apply quantitative methods to the problem.
You know what's one case of a quantitative solution to a medical problem? Take a physically healthy but severely mentally ill person, and harvest their organs to transplant. It's surely gonna bring in profit and increase our GDP!
However morally abhorrent this practice may be, I do not trust Amazon to NOT do this if there aren't any laws against it, which is why I am against this acquisition. I know some people may find it debatable, but I believe healthcare should be run with a Kantian framework where every life is priceless rather than a utilitarian one.
Amazon customer service isn't what it once was, but it's still better than 99% of the industry. 30 seconds to a call with a human, instant refund, etc.. They're still one of the few large companies you can get on the phone and speak to someone with for a 5 dollar order. Try that with anything Google, Meta, ... related. Heck even in ecommerce, try that with an order online from Walmart.
I have some hope that they can do something that's better than the low, low bar that is the US healthcare system.
Edit: Thought about this some more, and I think consumers shouldn't be nearly as worried as doctors, nurses, pharma cos, and insurance companies.
Amazon is cutthroat in its dealings with stakeholders who aren't its direct customers. Amazon has no issues squeezing book publishers, vendors, and employees. They justify this as the means of getting the best price and experience for customers. Translate that to the healthcare industry and I'm not sure what to think. Some of the actors in the space could use a wake up call, but overworked nurses, GPs, etc. are not ideal.
This is a technocratic framing: I’m not trying to get a $5 refund from my doctor, or to speak with customer service. I want to speak to my doctor on the phone, to have a years-long relationship with them (so that they understand my medical history beyond whatever a DB schema supports), and so forth. It is not remotely clear to me that Amazon is equipped to provide these things.
I switch health insurance systems when I switch jobs, in most cases, causing me to switch my network of providers. I haven't had a years long relationship with any medical provider sans a specialist I pay out of pocket, if necessary, to see. Maybe the service Amazon provides won't enable what you're looking for, but what about this instead:
- Standardize health records (detailed visit summaries, all tests and lab results, all visits to referrals or specialists)
- Fast appointment times (single digit days)
- A minimum standard of service. Doctors who won't immediately rush you out the door without solving the root cause, who won't prescribe you medication that they were sold over lunch, who'll listen to your symptoms, and because the outcome is measured by Amazon's uncaring data collection machinery, they're incentivized to actually solve the issue.
- Affordable health insurance plans and prescription drugs
The above is already leagues ahead of what my friends and family have access to or deal with. For those with the means, I'm sure there will be premium offerings that may check some of the boxes you're looking for. I think there's space for Amazon's uncaring, industrial approach to do good for people and improve quality of life.
You list two things that are fundamentally incompatible:
> I think there's space for Amazon's uncaring, industrial approach to do good for people and improve quality of life.
> [I want a] minimum standard of service. Doctors who won't immediately rush you out the door without solving the root cause, who won't prescribe you medication that they were sold over lunch, who'll listen to your symptoms, and because the outcome is measured by Amazon's uncaring data collection machinery, they're incentivized to actually solve the issue.
Anyone who has actual clinical experience will tell you that an "uncaring data collection machinery" does not incentivize anyone to "actually solve the issue". Quite the opposite: the reason that the patient experience has gotten worse over the last few decades is because the industry has already been moving towards an "uncaring data collection machinery", while simultaneously squeezing providers and narrowing their already-small margins[0] and as it turns out, uncaring data collection machineries don't care about patients.
Amazon's entire modus operandi fits very well with the absolute worst[1] forces that already exist within the healthcare industry, so it's quite hard to imagine a world in which this actually works out to patients' benefit in the long run. They might sprinkle a few shiny bells and whistles on top to placate people's fear, but actual care delivery is going to suffer in pretty much every way that you list aspirationally.
[0] People sometimes treat this as a victory because they think that it'll lead to lower healthcare costs, but providers' pay actually makes up a very small fraction of healthcare spending in the US. Even if you could eliminate those costs entirely without impacting clinical care delivery or patients in any way (which is impossible), it would still translate to a 15% reduction (which wouldn't even be passed on to patients anyway, because the system incentivizes insurers to increase costs on the claims side to increase their own earnings)
[1] worst for everyone involved except shareholders
> as it turns out, uncaring data collection machineries don't care about patients.
I'm not sure this is true. The current implementation -- maybe. But the incentives, from an outsider's perspective, seem to align?
1. Healthy patients cost less in the long term. Solving for long term issues (type 2 diabetes!) vs. the immediate issue and getting someone out the door is profit seeking.
2. Patients being alive continue to pay service fees is profit seeking.
Why would Amazon not aggressively track outcomes, measure every dimension of provider care, and ruthlessly fire / downgrade low performers to maintain the above goals?
> 1. Healthy patients cost less in the long term. Solving for long term issues (type 2 diabetes!) vs. the immediate issue and getting someone out the door is profit seeking.
This is an extremely common misconception. Luckily, you've picked a really easy example to illustrate.
"Solving" type 2 diabetes is an incredibly tricky problem. It's not something that can even be measured in the short-term, let alone solved. It's also quite individualized, more so than probably any other common diagnosis except cancer. There's no magic bullet intervention, and it takes a lot of active work to build the provider-patient relationship to a point where it can identify the appropriate interventions for that patient, identify problems with those interventions, and help the patient execute on them successfully.
Because it's so individualized, and because it's so long-term, any system designed to "streamline" that is ultimately going to fail, because the curse of dimensionality will inevitably collapse away the requisite information, and the pursuit of short-term profit will inevitably cause the system to prioritize short-term interventions over long-term ones which will actually address the issue.
"Healthy patients cost less in the long term" is technically true, but there's no way of turning unhealthy patients into healthy ones that doesn't, in aggregate, cost more than the theoretical savings.
> Why would Amazon not aggressively track outcomes, measure every dimension of provider care, and ruthlessly fire / downgrade low performers to maintain the above goals?
Again, this is an incredibly technocratic approach to a field (care delivery) that requires a different approach. It works if you assume that negative outcomes are the fault of individual providers ("low performers") and that individual providers have both the agency and resources to solve arbitrary cases. In practice, that's almost never the case: there are way too many confounding factors that impact clinical outcomes, and providers are quite limited in their power compared to other players: the insurance companies, the administration of the system they work within, and most importantly, the patients themselves.
Honestly, the only way you could meaningfully "fire low performers" is to identify patients who aren't performing well and then drop them. Which is, in a way, what the health insurance system does... but we tend to consider that an antipattern.
In the long term, healthy patients cost less, yes. And bring more in by staying alive, yes. But you know what's even better? A more or less healthy patient on which you can perform lots of procedures that make money. So I (as an MD myself) very much doubt that the incentives will benefit patients, here. People always forget that the main goal of private providers is making money, not keeping people healthy...
American here -- agree with the sentiment.. but the American Medical Association guild practices, plus the weight of wealth behind the scenes, have doomed alternatives IMHO. Amazon Inc. is perfectly positioned in the minds of many to be the heartless, efficient and remote 'brain' for the ugly reality of healthcare delivery in the USA.
While digesting that unpleasant postulation, I will refer to a second order effect, and that is .. always on electronic ID with de-facto location tracking, entering into the commercial info fabric. Legislators be warned, this is going to change, and change, and change again the social fabric as real people fall into health problems and life changes, and no longer run their relationship with public information about their conditions, and that it is linked to a (profit-motive) law enforcement fines, court conditions and oversight, one at a time on a very large scale.
ahem Have you seen the scale of their Enterprise Support organization? As an AWS customer, you can be on the phone with your TAM in minutes. Maybe Amazon consumer doesn't flex that way, but it's a very limited viewpoint to say that there's no corporate DNA at Amazon that's set up for customer service.
I didn't say they lack the "DNA" for customer service. I just don't think the kinds of customer service they've optimized for are compatible with reasonable (and beneficial, in terms of patient outcomes) expectations in the world of primary care medicine.
Amazon philosophy of growth and medical care are totally incompatible.
This is one of the reasons that capital profits should be taxes way higher. Letting one company accumulate such power in such a short period of time makes society unstable.
I hope the best to the American citizens that will suffer thru this situation.
Why would anyone? They aren't the biggest player in eCommerce, cloud computing, grocery, or warehousing. As a customer I'm usually quite happy with the service they provide. I recently bought some heavy items from them that would have cost more than $300 in shipping from the manufacturer, but Amazon delivered the items for free as I am a prime member. Whole Foods has been a fantastic value since Amazon took over and high quality produce is much cheaper than it was prior. I'm not here to say Bezos walks on water, but as far as big companies go, Amazon is probably the best to interact with as a customer.
There are quite a number, but our primary mechanism for sharing ideas and information are incredibly pro-conglomerate (most large media organizations are the result of decades of mergers). Those in power heavily studied the anti-trust actions of the early 1900s and worked to prevent them from happening again and threatening their bottom line. Quite ingenious if you ask me, that's why you see dozens of people in this very thread touting why a mega corp buying a medical provider is actually a good thing.
I think Amazon is tired of paying a small fortune in healthcare costs which have to be renegotiated every few years and administered by some moronic organization like Cigna.
Maybe they can do better? Fee for service is kind of insane. Urgent care strep throat $250 + meds makes no sense. It should be $50 total or less.
In what world should strep throat cost less than $50.
1. You interact with a receptionist. They use commercial software to track your visit, find an appropriate medical professional for your condition, and fit you into a schedule/queue.
2. You see a medical professional, often a nurse, that checks your vitals and updates your chart. This professional will often take a swab of the infected area.
3. The swab is sent to a lab, where medical grade equipment and a trained technician analysis the sample.
4. You see a medical professional with the prescription pad. Usually an MD or NP. They are responsible for the diagnosis. Strep infection could be a symptom of a larger problem. People without a bacterial infection need to be treated, but shouldn't be given antibiotics. This professional needs to carefully listen to the patient and clearly explain their condition, and what to expect from treatment.
5. You see clerk at checkout. Your entire bill is reviewed by your insurance company.
6. You see a pharmacy tech, a pharmacist oversees your prescription being filled, a medical grade product is provided. Lots of liability at this step. Lots of security and shrinkage concerns for the business.
Keep in mind that throughout this entire process staff is held to higher education, background, and training standards than the general population, all software is built for HIPPA and costs more than standard enterprise software, all equipment is built to a very high standard, all offices are more sanitary than average businesses, and many of the trades are seeing long term labor shortages. Throughout the process you'll probably take an hour of professional time.
Last week I went to an urgent care clinic to get treated for strep throat. Many of the steps did not occur as you describe. Here is what happened.
1. I signed in using an automated terminal. A tablet which scanned my ID and insurance card. I sit down in the waiting room. A few minutes later a nurse comes to get me.
2. The nurse takes my temperature and swabs my throat for a rapid test which is then done in front of me. The nurse leaves the room while the test is reacting. The interaction takes about five minutes.
3. A NP came in to look at the test and my throat. The only interaction I had with the NP was when they asked me if I thought I had strep to which I replied "yes". The NP diagnosed me with strep and wrote me a script for amoxicillin in less than five minutes.
4. I left the urgent care clinic without seeing the clerk at checkout. The entire visit including waiting to see a medical professional took less than 30 minutes.
5. Ten minutes later I pick up my course of antibiotics at a pharmacy four blocks away. The price of the medicine was free with insurance and $15 dollars without.
Strep tests cost $35 dollars retail. The price to visit the clinic was $200 dollars ($165 sans the price of test). The per hour cost of medical care was $990 dollars.
One easy way: you can telehealth for say $50 and do a rapid strep test which is like a covid test and does not require a lab to process it. Then you get the meds from a pharmacy sure. If your rapid strep is negative then it's probably viral. 99% of the time the urgent care says go see your primary care physician in a few days if symptoms don't improve with over the counter meds.
> One easy way: you can telehealth for say $50 and do a rapid strep test which is like a covid test and does not require a lab to process it.
The sensitivity of rapid strep tests is already low (and the cost/risk of untreated strep quite high), to the point where standard-of-care already dictates that negative rapid results be followed up with a lab culture. Not everyone follows that in all circumstances, but it is considered standard of care.
The real-world accuracy of OTC rapid strep tests performed at home by untrained non-clinicians is even lower.
There are cases in which a strep diagnosis is warranted without all of the above, but the picture you're painting is overly optimistic in terms of cost, and measurably degrades quality of care for patients compared to the status quo.
98% is the specificity in the link you cited, not the sensitivity, which would be the relevant statistic. That's also a consumer-facing marketing page for an urgent care clinic that just cites "sources", so you should probably take anything you read there with a grain of salt. It's essentially an advertisement.
But furthermore, we're not talking about the tests performed in a clinic by a clinician. We're talking about OTC tests performed at home by an untrained non-clinician.
> Ok so 90% sensitivity.. Anyway, it seems backup culture is rare and also problematic.
This is the danger of Googling around for information without any contextual domain knowledge.
- You're quoting a statistic from an op-ed (op-eds are not fact-checked, let alone peer-reviewed)
- You're misquoting the statistic as provided by the op-ed (that op-ed is written about a test with 95% specificity, as claimed by the author)
- You're quoting an op-ed written by a witness called to testify in the defense of a physician who was sued for not following the documented standard-of-care - hardly an impartial source
- You're quoting an op-ed written about a single case (n=1). Furthermore, it is chosen not even as a medical case study but rather because the legal case is of financial interest to the author
- The op-ed is nearly fifteen years old - and, as it turns out, the prevalence and risk of rheumatic fever is radically different in 2023 than it was in 2008, for the worse.
- Even if you discount all of the above, the op-ed as taken at face value is written about a case in which a patient didn't get a backup culture drawn and ended up requiring two heart valve replacements (!) after a false negative on the rapid strep test. Regardless of whether or not the doctor is legally liable, it's not a good argument that rapid tests are sufficient.
If you go about looking for information to support your argument, it's often likely that you'll be able to find something that on the surface seems to support your case. But if you don't have the necessary domain knowledge to evaluate the trustworthiness of the source, the accuracy of the claim, or even its relevance to the matter at hand, that can lead you astray.
A rapid covid test is ~$10. Penicillin is ~$10. That leaves $30 for the telehealth.
That's doable. The thing I don't like about this approach is that I'm not sure how it works on the margins. A rapid covid test has a lower accuracy than a strep swap processed in a lab. What do the people with very sick throats but not strep do? How does it catch people that have a more fundamental health issue? Are there common pitfalls that the system might snag on, like individuals not carefully reading dialog boxes and quickly incorrectly clicking that they do not have a antibiotic allergy.
I'm privileged, but my personal bias is to pay more for higher quality health care instead of paying less for lower quality healthcare.
I spent a good portion of my career in the insurance space, and got to the point I just won't work in that industry anymore. Not only because I think benefits coordination companies like you mention are awful, but also because of the sheer amount of bloat I've seen in that industry. Most major cities have literal towers of offices just filled with insurance workers, many of whom do almost nothing for their salary. I personally know one developer at a large one that hasn't talked to his manager in months, and hasn't done any coding at work for almost as long because he has no tasks to complete, and was told "we're waiting on this project to be approved". He collects a paycheck and doesn't even go into the office. He is one of ten on his team. I think Insurance and banking may be the last of the big corporations you can still get lost in.
So yeah, maybe Amazon can do better at least on the administration side.
One Medical doesn't replace health insurance; you still need coverage for ER, hospitalization, prescriptions, etc. You won't get a discount on all that for having a One Medical subscription, either.
I'm pretty sick of this stuff. As if a multi-conglomerate will have no want to abuse the access to new data and push medical access in directions it shouldn't be going. Amazon just bought iRobot. So now they have microphones and cameras in your home, they know what you eat, buy, and watch, and now they get your medical information.
I honestly don't have any hopes anymore. The U.S.'s democratic process and regulation entities are corporate captured. We're owned and controlled by institutional corporate shareholders.
The perception of a singular power of "Government" is an illusion. Government in reality should be seen as more of an ecosystem, with numerous centers of power of various sizes and areas of influence. When a part of government is captured it means that individuals with power within that substructure have little ability to push back against larger external forces acting upon the structure itself. To override that would involve large numbers of people within the structure coordinating against their individual interest, or power from outside that substructure with the ability to apply a countervailing force.
> Are you saying that a captured government is still in charge?
I'm saying that people in government has to decide to be captured, when it extracts free money from its populace with the promise that it will remain impartial.
> That’s … not how capture works.
This is never a useful thing to say in terms of furthering the conversation. I appreciate it may have felt good, though.
It felt like I as having to explain things to someone who was being thick for the simple purpose of being thick.
Corporations have purchased our government and therefore the government is, in my opinion, not in charge. Sure they enact violence as all nation states do- often on behalf of those corporations.
Neither of those two actors are good for the people, for the working class.
If you can’t see how big this problem actually is - start by reading “The Jungle” and realizing nothing has changed for the better for us workers, in a very long time.
Blessings not from corporate kindness, by the way.
The only thing a corporation can do, especially at Amazon’s size, is evil for the worker and community. They are built to expand into infinity, consuming all for shareholder profit.
I know it's easier said than done, but if this is something you're passionate about, why not start your own "whatever you think sucks as a public company" as a not for profit ?
> Why don't you start X to compete with a trillion dollar behemoth Y?
Because if they think they can make a profit, they have a trillion dollar that they will freely leverage to strangle the living air out of your company. Weak US anti-trust laws won't do anything until there is a "significant, provable harm to the consumer".
The general lesson here is more capitalism won't solve the issues of unchecked capitalism, you will have to get the legislative system to intervene to make sure you can have fair competition in the market.
There's a scene in the hospital in that movie where a roomba-like machine is just moving back and forth saying "your floor is now clean". Broken tech devices has become something I constantly see now. We have all this junk and 4-5 year old IoT toys not working, fridges with blank screens that no one cares about.. and it keeps getting worse.
That and, my experience at the doctor now feels quite similar. "Says here you're retarded"
There's a dirt road connecting two neighborhoods in my area that google thinks is the most direct way to get across town. Unless you have a true off road 4x4 with a lifted suspension capable of climbing a 15% grade, you're going to have a bad day going in reverse when you realize it's not a real road.
It's gotten so bad that there is an actual sign that says "GPS IS WRONG THIS IS NOT THE WAY" at the end of the last paved part.
I just mean it fails constantly. Doesn't load routes. Doesn't load search history / autocomplete. Generally unresponsive. Acts like it's waiting on a response, but it's not network issues, because as soon as I restart the app, it's responsive again.
Funny as someone who 'quantum leaped' forward five years (aka prison) Google Maps is about the only thing that seems to be way and not intentionally turned to garbage like Amazon/Spotify. Why can't I report I've already read a book on Audible (I have already read everything it's recommending me)? Why can't I rate what I liked/didn't to get better recommendations? Why can't I sort by price (I got a $5 credit)? When can't I sort by running time descending?
I went back to good old Pandora and it's been so nice to have an algorithm that feeds me something I actually want.
>How does a bookstore go from being a bookstore that now controls the internet's infrastructure and now my healthcare?
Despite my sneering comment, Amazon was never supposed to be a "bookstore"
Bezos's goal was to be the largest intermediary for all commerce worldwide.
This was the quote: "To be Earth’s most customer-centric company, where customers can find and discover anything they might want to buy online, and endeavors to offer its customers the lowest possible prices"
How does a bookstore go from being a bookstore that now controls the internet's infrastructure and now my healthcare?
I don't know but money isn't the answer. Back then, in 1980's Germany book wholesellers Koch, Neff & Oetinger and Lichtenbrink pioneered robotic storage, and for very much the same reasons as Amazon. They were logistics giants that would deliver your book overnight, but they did not go on do dominate the world.
If our society and bureaucratic process has let the Amazon situation get this bad, what makes anyone think it's not simply going to continue to get worse at the same (logarithmic) pace? The oligarchs aren't going to do anything they're not forced to, and right now, they're the ones forcing the hand of the system.
This was idea of Todd Combs, an investing manager of Berkshire Hathaway. It failed before (Buffet BRK, Dimon JPM & Bezos AMZN venture called Haven went bust a while ago), but I think Bezos just keeps trying...
> Medical records shall be retained in their original or legally reproduced form for a period of at least six years from the date of discharge or three years after the patient's age of majority (18 years), whichever is longer, or at least six years after death.
How do you get the 10 docs you've visited in the last decade to delete all the info they have on you? I'm not sure, but I'd bet on it being harder than with One Medical.
I noticed One Medical is actually already a publicly traded company under ONEM. I'd think this is quite a bit different, than if Amazon bought a nonprofit hospital/health system like Sutter Health, or Allegheny Health Network, or even the clinic across your street that you naturally assume is a nonprofit.
Whole Foods and OneMedical represent a strategy of locking up wealthy households into the broader Amazon ecosystem. It’s iMessage, but for your bad knee.
Buying Whole Foods was a way to buy a freezer and small warehouse with the grocery budget of the top ~3% of US Households attached. OneMedical is a way to do the same. I expect they’ll try to roll up Summit or another group next.
> ...represent a strategy of locking up wealthy households into the broader Amazon ecosystem.
I find this an odd but interesting approach, because I associate Amazon as being a bargain, low quality sort of brand. It's a good service, but it's definitely not premium. In some cases I'd say it borders on tacky and tasteless. This is not just about the product catalog too, it's site/app quality, Fire and Alexa devices, selling ads on Kindle lock screens, being completely shameless about service quality issues, AWS shipping services 2 years before they're actually any good, and so on.
Whole Foods probably isn't like this yet, although I haven't been in since pre-acquisition because there are only a few in the UK, and I don't know anything about OneMedical, but if Amazon's brand permeates into these, either visibly or invisibly, I can't imagine it going well.
I mentioned this in another thread…I’m waiting for this to become the “company town” of tech. Employees make money, forced to spend it at the company store. Is Amazon in housing yet?
What a truly devastating outcome. Amazon has no idea how to run healthcare, and they will apply their "squeeze the customer, squeeze the provider" ethos to it. I'm so sorry for all the employees and patients at one medical.
too bad this country can't seem to leave essential services like health care in the hands of medical specialists instead of capitalists. no matter how Amazon tries to spin this one out, it's unlikely to end well:
"By taking a large portion of healthy, well-educated patients who require less-complex care out of the usual primary care system, tech companies such as Amazon will leave primary care, a specialty essential to the future of health in the U.S. that is already on life support, even more desolate."
>>If urgent care can reduce unnecessary strain on their thin ranks, so much the better.
You are not completely wrong, but it is not that simple - the problem most PCPs have is that 'doc in a box' places tend to soak up all the quick and easy visits, that pay just as much as the long and complicated ones that can takes hours for a typical PCP to resolve - but they often pay the same - so urgent care clinics see you, look at your throat, write you a prescription and send you on the way - "treat'em and street'em"
Meanwhile the 82 year old 400lb diabetic, pre-dementia patient on 12 different medicines with 7 different things they want to talk about during the visit, takes a doctor and team of nurses and medical assistants a hugely disproportionate amount of time to diagnose and treat - and they can't bill all that much more than the doc-in-the-box got for writing a script for a sore throat.
In other words, these places are skimming all the profitable and easy to resolve cases, and the PCP now only has complicated patients that proportionally pay less, further eroding the finances of most primary care facilities, which then means they can't pay as much, so then they have an even harder time attracting talent.
It is also difficult to ask a PCP to see 16-20 complicated cases in a typical day - they need a few easy ones thrown in that they can quickly resolve and move on. Nobody can go 100% all day long on hard problems.
I was referred to a “dermatologist” recently that turned out to be a PA with a background in nutrition. She had virtually no experience with actual dermatology. I was forced to wait over an hour after my appointment was set to begin, and my insurance was billed $500 for a 15-minute visit. She did not improve my situation one iota, so that was a complete waste of time and money.
Our health system is failing spectacularly at every level.
the overwhelming amount of things that patients come into a dr's office with do not required an actual MD to diagnose and treat - NP's and PA's do just fine in most cases.
Heck, even regular nurses with a few years experience could probably look at your sore throat, check your blood sugars and adjust your meds.
Everybody thinks whatever they have wrong with them is something unique and special that requires a full blown MD - usually it is not.
If I need a transplant, I am going to want a full blown MD to do it - for most run of the mill things, I am happy to see a NP or PA.
Yes, PCPs are in short supply. Much of this is artificial due to the limits accrediting organizations have placed on the number of new doctors per year.
1. The numbers on Amazon's quarterly reports are huge. They are playing in the big leagues.
2. Everyone with money remembers when they were just a book store and the dotcom bubble burst. The narrative that they can go into a market and dominate it in a few years is a strong one everyone has a lot of belief in.
3. They are one of the leaders in using technology to upgrade traditional business lines. Every industry still experiences Fear of Missing Out on the latest technology change. Imagine how great of a position Sears Catalog would have been in if they could have held their strength for another five or ten years. They had brand name recognition, supplier relationships, warehousing, distribution, and physical locations for returns.
4. When a tech company enters a market there is a higher level of risk accepted than private equity. The private equity firms usually pick more sure bets than this.
