If you hear a health claim sounds too good to be true..

We all have things we believe without evidence. We particularly have things we believe without good evidence. I am not even talking about religious beliefs, which are, by definition, acts of faith, but what we can call lay beliefs about the world. One area in which this is both important and widely variable is health and medicine. There is a tremendous amount of information out there, and much of it is correct, and much is not, and sometimes some correct stuff seems, on the surface, to contradict other correct stuff. If that is true, what is a person to do?

One option is to learn about things in detail, understand the scientific method, understand statistics, and understand how “truth” evolves and changes with new discoveries. Or, alternatively, to know that there are people who do know and understand these things, who have spent years and decades learning about them, being trained in the subtleties of science and research, and listen to what they say. For decades, say roughly from WWII, this is how our public health developed. We didn’t just trust scientists, we trusted science. We could see the progression of scientific knowledge, and how it positively impacted ourselves, our communities, and our nation and world.

You don’t have to be a statistician and understand all the intricacies to understand, for example, the basics of probability. When something is more likely than something else, that doesn’t mean it will always happen. When you throw a pair of dice, it is more likely to come up 7 than any other single number (6 of the 36 possibilities – 1 in 6 -- are 7). This does not mean it will always be 7, or usually be 7, or even be 7 a majority of the time, but (given enough throws) it will be 7 more often than any other number. If you understand this, you are on your way to interpreting scientific data. If you don’t, don’t shoot craps.

In medicine, a diagnostic test or treatment that works only 1/6 times is not likely to be used, so the probability that it will give an accurate diagnosis or a successful treatment is going to be much higher. But almost never 100%. 99% is very good; 1% is a small chance, and if you had a 1% chance of getting 7 and crapping out, or getting a wrong answer on a test, you’d go for it. But if something is done a million times, 1% is 10,000. You, or a loved one, could be one of the 10,000 in whom a test is inaccurate, a treatment fails, or even a side effect kills you. That is terrible for you, but doesn’t increase the likelihood of it happening to the next person. If you throw dice, the odds of a certain combination are the same every single time. Even if someone, say, rolls 11 six times in a row it doesn’t change the probability (1/36) of getting an 11 the next time. There is no such thing as “hot dice” or a “hot shooter”. If you don’t understand that, don’t play craps.

Enough of probability now. The main point is that because something bad sometimes happens with a test or treatment doesn’t make it bad. Some of the issues in health that are most controversial now, like vaccines, are phenomenally and overwhelmingly good. Most of the bad things attributed to it are completely made up (not that the bad thing happened to someone, but that it was the result of the vaccine), and the others are very rare, far more rare than the bad things happening to the unvaccinated.

While truth does evolve and change with new discoveries, those changes are usually logical and stepwise. We know about something, and new information increases our knowledge. It rarely completely contradicts everything we know; it theoretically could and there have been some discoveries that did, but if a claim seems to it is very unlikely. It is usually internet spam, promulgated by people who think you are a sucker and may pay them for something that magically solves a problem. If you have a health problem, this is almost never the way to go. Sure, pharmaceutical companies are scum-sucking parasites who would kill their mothers, not to mention you, to make a buck, but that doesn’t mean the medications that they make are bad, ineffective, or more dangerous than what you can buy over the internet because somebody says it works. The FDA (at least historically, before it became decimated) required rigorous testing of medications before they are released to the public, while the miracle cures you see on the internet have not. In addition, the doses are standardized and consistent. You can know what you are getting, and if you cut the dose in half or double it, that is what you are doing. With unregulated drugs, you don’t know.

Yes, there are many natural substances that can help, and indeed many prescription and regulated drugs have their origin in them. But even though aspirin may have originated from willow bark, how much willow bark is the right dose for you? From what age tree? Growing in what conditions? In what season? What about next time? Or your next door neighbor? Or your kids? A good rule of thumb is the old saying: If something seems too good to be true, it probably is. “Magical” cures on the internet never are. Another old saying, attributed to P.T. Barnum, is “a sucker is born every minute”. No one wants to be that sucker, but people are remarkably inconsistent about when they will be judicious and when they will swallow the Kool-Aid whole.

If someone you hate and think is stupid tells you something that sounds ridiculous and unbelievable, you probably won’t believe them. But what if it is a friend? If what they say is something that you already think might be true? Looking things up on the internet (sometimes called “doing your research”) is actually not a bad way to start. You usually find accurate information. This is really different from reading something sent to you or spammed out by bloggers (like me) or “influencers”; if someone is “reaching out” to you, it is basically marketing. Think of the difference between you calling your bank to find something out about your account and getting a call from someone that says that they are your bank!

How does this relate to social justice? Are there not believers and non-believers in data and science in both majority and minority groups, among the young and old, among the rich and the poor, among liberals and conservatives? Sure, but the impact is different among these different groups. Many people are not only acting on their own fringe and unscientific views, but pushing and promulgating them to others. And, as always and as in almost everything, it is the poorest, least empowered, least educated, most marginalized, those with the thinnest safety net, who suffer the most. We may occasionally read of someone who has been hoist on their own petard, refused vaccination and died of the disease, followed a wacko diet or taken unregulated medication who gets ill or dies from it, but when the society or government rejects science in favor of public health policies based on fringe beliefs, it is the least well off who are most often harmed.

Remember, there may be magic in the movies, but there is not real magic in the world. If something sounds to good to be true…

The EMR, and AI: Are they good? Pose risks? Both?

When I worked with residents in the hospital, the electronic medical record, EMR, was relatively new. We were fortunate to work in a hospital that invested heavily in a good, well-regarded EMR, and spent quite a bit on training the doctors to use it. In the end, almost all the “stakeholders” agreed on which one was best, and the hospital bought it, and had us trained. Good for them.

The EMR wasn’t perfect though. In addition, the hospital didn’t buy all the parts. EMRs come in modules, some necessary, some elective, especially back then. It was clear that the hospital had prioritized the modules for billing, and especially for maximizing billing. Also, anything that the subspecialists who earned the hospital lots of money wanted. Other modules, particularly those that would enhance primary care, were more rudimentary or absent. Some of the things that many of us thought would be easily facilitated by a computerized database and looked forward to having were not available. Surely, once everyone is loaded into the computer, it should be simple to print out a list of all the patients with diabetes assigned to a particular doctor! That would really help us to track them, contact them, make sure they didn’t fall through any cracks. Whoops, sorry, we didn’t buy that module. The maximization of potential billing, on the other hand, was not only there but required many different screens to be filled out, effectively transferring work to physicians from someone else.* And it was inconsistent in how it treated health risks. For example, tobacco use had a who series of questions, including information the patient themselves probably forgot about how much, when, etc., but there was only one on whether they drank alcohol.

There were many things that the EMR did make easier, though, including writing long notes in the chart, since people didn’t have to write by hand. Like the Word® program I am using, and most other computer programs, cut-and-paste became easy and routine. Residents’ notes got longer because they could cut-and-paste yesterday’s note and (hopefully) update it. But sometimes they might forget the update part; it could be embarrassing if yesterday’s note said “surgery tomorrow” and it still said it in today’s note, even though the surgery had occurred that morning! The EMR also facilitated making notes longer by importing all the lab results and radiology reports. This is important information, but it is also available elsewhere (i.e., in the lab and radiology sections). A simple “Radiology exams normal” or whatever they showed would have been much better than cutting and pasting the whole report, as well as briefer. Better because it would have required the resident to read it, make an assessment (“it’s normal”, or “it shows a tumor”) and write that. It would have required thinking. Not to say that they didn’t think, but a summary in their own words would have demonstrated that in a way that cut-and-paste couldn’t.

But the biggest problem with the EMR is the amount of time that it takes to complete, especially in outpatient clinic settings, and especially for primary care clinicians who usually have a wider variety of issues to address and less money to hire others (scribes, sometimes nurses or even NPs or PAs) to do their documentation for them. It is not uncommon for primary care physicians to spend more time documenting in the EMR, frequently at home at night**, than seeing the patient! And in the inpatient setting, hospitals hire nurses to comb charts looking for ways to “upcode”, to charge more.*** (A part of the ongoing contest between providers and insurers to see who can hit the other up for more (except when they have been vertically integrated, more common in outpatient settings, see Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare, May 21, 2026). And potentially costing the patient more, if the insurer refuses to pay it all.

And now we have AI. Or AI is having us. The debate on AI, on whether it will create a great new world or a “Brave New World” à la Huxley, rages on, now with the Pope getting involved with a new 42,000 word encyclical. AI is happening, will continue to happen, and will continue to have effects, many untoward, and some of those resolving – but not necessarily in ways that are good for people. And there are many different people, not just in the US but in the world. Recent commentaries have suggested the benefit would be greatest for the well-off and well-educated (well, almost all things do), although what seem to be “regular” people are using it to bolster their “home brewed lawsuits” and clogging up courts (good or bad?)

I know a lot of doctors who are thrilled about AI, and see it as a vehicle for reversing, or at least slowing, the constant drain on their time that comes from more documentation being required for billing, for insurers, and even for government regulations, in some ways a counter-weight to the EMR. They have apps that record the entire encounter, and then AI drafts a progress note that covers all the essential information in the conversation for both clinical and legal/billing purposes. Then the clinician reviews, augments, and corrects the AI-generated note. Hopefully. That is a danger. AI (as well as clinicians, it should be noted) can make mistakes, and provide incorrect information. With people, we know who to blame. However, recent experiences with friends and family encounters with the health care system suggests that once something gets into the medical record, especially a digital one (indeed, all digital data collection), it is there forever and efforts to correct it do not always take.

And, back to the residents copying their notes rather than creating original ones, it is comparable (if more high-stakes than) to students using AI to write their papers. It allows the appearance of creation and completion without the thinking required to learn to do the job right. Of course, AI advocates argue that AI learns to think more reliably than do people. Maybe this is not a scary idea. A recent opinion piece in the New York Times by Dr. Helen Ouyang suggests that AI (ChatGPT, in this case) gives good, well-researched medical information, and, more important, is accessible to answer questions when the doctor isn’t. The author notes that ”Of course, as a doctor, I know when to question the chatbot and when to ignore it. Many other patients don’t.” That’s right, and that’s a concern. Most of us who have used AI know that it isn’t always right, but if it’s a topic we don’t know about, we don’t know.

The other thing that Dr. Ouyang liked about ChatGPT was, ironically, its personality, since “I had always assumed the ‘human side’ of medicine was the part A.I. couldn’t touch.” The AI was unflaggingly positive, upbeat and encouraging, and never got irritated about repeated or “stupid” questions. People miss this when dealing with – people. While some doctors, like other people, are not, by nature, always warm, positive or supportive, the circumstances in which they work, the pressure from their employers (see several previous pieces, recently Why is it so hard to get medical care? And what should we do about it?, March 15, 2026, and The problem with the US healthcare 'system': THE INSATIABLE PURSUIT OF EVER MORE MONEY BY CORPORATIONS AND WALL ST., Feb 25, 2026). We should also remember, that while being nice, and friendly, and supportive is usually good, it is also a strategy for gaining your trust that has been misused by bad actors throughout history. And AI never gets tired of doing it, never wants to go home, never misses its kids, and doesn’t have to worry about spending as much time completing the EMR as it did seeing you! (see Does AI communicate better than real doctors? If so, why is that?, Nov 20, 2025).

So, I guess that the jury is not in on AI, or its most effective and reliable and accurate utilization. When it is, it will probably be too late to change it.

  

*This is only one example of work that has been transferred to the primary user. I have long made my own travel arrangements, and like it because I know what I want, but it takes a lot of my time.

**Another example of work transferred to the clinician, at the expense of their family.

***See this piece for a clear example of widespread and profound upcoding: https://healthcareuncovered.substack.com/p/government-watchdog-agency-finds

Vertical Integration saves money. And CVS and its competitors use that to line their pockets, not provide healthcare

I have several times referred to the concept of “vertical integration” in the health care/health insurance/pharmaceutical industry, most recently on March 28, 2026, Everything is becoming more unaffordable, but health care may lead this list!. These posts often reference the posts of former insurance executive-turned-whistleblower Wendell Potter on his substack “Health Care Un-Covered”, including “With CVS’s Vertical Empire Under Threat in Tennessee, the Company Threatens to Leave”, which discusses the fact that CVS, most widely known as large pharmacy chain, also owns the Pharmaceutical Benefit Manager (PBM) Caremark. PBMs are add-on middlemen that negotiate better rates for insurance companies with pharmacies. CVS owns pharmacies, a lot of them. This may seem like conflict of interest (COI), but that is apparently a quaintly outdated concept in this era of mega-corporations.

Actually, the PBM-pharmacy COI is only a part of the CVS megalopoly. They also own one of the nation’s largest health insurers, Aetna, so they have both ends and the middleman! And, to round it out, they own a large primary care provider group (Oak St. Health) and long-term care company (Signify Health) and urgent care provider (Minute Clinic). Just read the AI summary if you Google “Companies CVS owns”, but if you want it, the comprehensive list by the SEC is here. This is what vertical integration is; you buy from yourself, and sell to yourself, set the prices (usually in a way that minimizes tax liability), and make a lot of money. The structure is not hard to understand, but it maximizes the conflict of interest. (For a discussion of why this is conflict of interest and not “potential” conflict of interest, see this blog post from August 20 2010, The AAFP, Coca-Cola, and Ethics: Serving the public interest? . In brief, COI exists when a decider has interests in both parties, and a decision one way would help their other interest. The conflict exists whatever the decision is actually made. A judge hearing a case in which one party is a company in which they own a great deal of stock has a conflict of interest; it doesn’t require waiting to see how they rule.)

To be clear, CVS is far from the only major player in the “healthcare industry” (quotes on purpose, and emphasis on “industry”) that is vertically integrated. The largest health insurance company in the US, UnitedHealth, also owns a PBM, (OptumRx), a primary care group (Optum) and a whole host of other companies (SEC listing here). So does CIGNA (their PBM is ExpressScripts). So, there is competition within the “healthcare” sector; it is an oligopoly (few companies) not a complete monopoly. But oligopolies don’t really compete in the way classic capitalist theory would have it; rather, they tend to set prices and divide up the market so they all do well (although they would prefer the other companies to go out of business, the existence of a few tends to forestall any governmental intervention that might occur with a true monopoly).

Is vertical integration bad? A major argument in favor of it is that it can, and often does, increase efficiency. If you own everything, from insurer to care delivery system to pharmacy, and all the other players in between, you can minimize the obstruction from a piece that is owned by someone else. Things can move more smoothly. Costs can be reduced significantly. These are the arguments most commonly put forward, to the public, by vertically integrated corporations that control a huge market sector, oligopolies as well as monopolies.

It is also the argument put forward to stockholders, particularly large stockholders like private equity firms. Especially the “reduced costs” part. This is very attractive to stockholders. It could also be attractive to those ostensibly served by the “healthcare” industry, those people needing – healthcare. After all, they are heavily burdened by the cost of their healthcare, which constantly goes up. This includes the portion that they are responsible for in the form of premiums, deductibles, copayments and “cost sharing” (meaning insurance only pays a part of the bill and you’re on the hook for the rest). Another recent Potter piece, The Bill That Never Ends, summarizes the situation and addresses the fact that deductibles reset every year, so people are constantly behind the 8-ball and can never pay it off. It reminds me of the compound interest that keeps former students in debt for decades even though they may have paid off far more than the original loan! It is an example of how our laws are set up to benefit large businesses, not regular people.

Which, of course, brings us to the issue of efficiency, and lower costs. To what use is this efficiency, this lower cost, put? Cui bono? There is an argument that such efficiency could decrease the overall cost of health care to the nation, as well as to the individuals who require care, which has actually been promulgated for decades by academics and others. There are fewer of them these days, as it has been demonstrated repeatedly that such an idea is frightfully naïve. Yes, money is saved, but it is all used for greater salaries and bonuses for management and greater profits for shareholders. If it were being used to lower premiums, decrease deductibles, lower the cost of drugs, or increase the availability and affordability of health care, we would have seen it. We have not. Too bad.

A weak, but possibly useful, analogy is to a family. The adults (usually) generate the income, and certainly choose how to spend it. This can be mainly to provide food and housing, education for children, health care (to the extent that it is available) and other benefits for the family. Or it could be spent on relatively transient pleasure for the adults – alcohol, tobacco and other drugs, gambling, etc. Most of us feel that the first is better, a “good” thing, and the second is not good, is selfish, and even reprehensible. Apparently, such moral judgement is not applied to corporations, certainly not, in this case, those involved in “healthcare”.

I keep putting “healthcare” in quotes when applied to the industry. This is because it is not an industry that is at any significant level dedicated to providing healthcare to our people; when it does, this is a byproduct. It is an industry that is dedicated to extracting the most dollars possible from the rest of the economy and putting them in their own pockets. While this is, of course, the goal of most of our industries, it seems worse that “healthcare”, perhaps because of the veneer that come from ostensibly doing something good, seems to be particularly effective at it.

A single payer health insurance system only addresses coverage. A national health service, such as in Britain, is a more comprehensive manifestation of vertical integration. It doesn’t always work well, mostly because it is starved of funds as a political act to demonstrate that the public sector does not run efficiently or effectively, thus an argument to privatize it, which has to some degree been done in the UK. And, like almost all efforts to privatize formerly public services, the cost goes way up, the service does not improve or gets worse, and the money that could have been used to benefit the people is lining the pockets of ganevem. This does not seem like a good use of benefits of efficiency and decreased cost arising from vertical integration to me.

Maybe we can do something about it! Imagine if the phrase “healthcare” industry didn’t have to be in quotes!

 

For more (or maybe just more terse):

“The health insurance company gets a cut, the pharmacy benefit manager gets a cut, the drug manufacturer gets a cut, and the patient…gets screwed!” Rep Alexandria Ocasio-Cortez, interviewing CVSHealth CEO David Joyner at a congressional hearing.

Also “Federal rules require the insurer to spend a certain percent on care. But, when you own the care, when the insurer owns the pharmacy, owns the PBM, owns the drug manufacturer, you also own the health care cost.”

The whole clip is not that long and makes the point about vertical integration very clear, including 1000% markups on some drugs! Thank you, AOC!  If you have time to do nothing else, watch this video!

https://ocasio-cortez.house.gov/media/press-releases/icymi-ocasio-cortez-calls-out-cvs-healths-corporate-strategy-monopolize 

Aging, suffering, and the inevitability of death: Let's keep it real, and ignore the quacks

My friend Paul Taylor, longtime journalist and former executive at the Pew Trusts, has just published a new book called “This Is Getting Old: Two Boomers and Their Generation at Dusk”. It has two main topics. The first is an often-disturbing analysis of the impact of the “Boomer generation” as a whole, focused on their (our) massive accumulation of money, fighting for society’s resources to be directed to us, and shockingly, away from those who need it most, children. There are clearly many different indviduals in this generation, as well as subgroups (since boomers were born 1946 to 1965, the usual characterizations of us in our youth, activism in the late 1960s, obviously are only about the older part of that cohort). He makes the point that not only did this generation, as many before, get more conservative as they aged, but that only a portion of them were ever progressive. And the contrast between their generosity to their own children and grandchildren, and their parsimony toward most of society’s children is, at least coincidentally (as he states it), or definitely (as I think) about the color, race, and ethnicity of the majority of today’s children. Did I say this was shameful? If not, I do!

The other focus of the book is the aging of his, their, and our generation, focusing particularly on one couple (a terrific, impressive, warm and active couple), but also full of data on what is happening to all of us. Which is the same thing that happened to everyone before us, getting old and eventually dying. We may be dying older, and dying of different things, and (many of us) having more healthy and productive years before we die, but we all die. And for many of us, perhaps most of us, as all through history, that dying will be preceded by a period – which can be short or be many years – of suffering, of being sick, in pain, losing our mental faculties, or all of these. Guaranteed. While billionaires are being quite successful in avoiding (at least for themselves) the other of that famous pair, taxes, avoiding death is, even for them, only a science fiction cryogenic dream for them that has not yet happened. Thank goodness. If there are any people that the future does NOT need preserved for them to deal with, it is the billionaires most assiduously working on it!

So, we need to remember not only the inevitability of death, but the suffering that so often precedes it. We boomers have been watched it in our parents, our older relatives, and, sadly, many of our peers. It is well to remember the myth of Tithonus, who was granted eternal life by Zeus, but not eternal youth. He continued to age, alive and living sicker and more decrepit. A more modern self-deception: a few decades ago, I was the only physician in a health policy class. Each week one student had to make a presentation to the class on a particular topic. The student who addressed the issue of “long term care” did present data, but then added that in their opinion the need for long-term care would decrease because people were taking better care of themselves, exercising and eating better and not smoking. I pointed out that this would obviously increase the need for long-term care, as people would less often die young from heart attacks and more often live older and older (if not eternally, like Tithonus) with more and more care needs. I suspect I even said something like “if you want to decrease the need for long term care, have people smoke, drink, eat poorly, not exercise and drop dead in the 40s and 50s”.

But that student, and others, were young. Somehow, they conflated living a more healthful lifestyle, and having better health in the near and medium term, with not ever confronting getting old, sick, and dying. That is purely wishful thinking. While living more healthfully is a good idea, it cannot prevent the inevitable. And yet, many people, even today, believe this that somehow they can and (more venally and evilly) are selling it to others. Some of these ideas are commonly associated with folks like Secretary of Health and Human Services Robert F. Kennedy, Jr. (how painful to associate that name and that title!) and the MAHA (Make America Healthy Again) movement. Like the MAGA (Make America Great Again) of Donald Trump, the key point is the “again”. In the case of MAGA, it depends on what your definition of “great” is – probably America was if it means slavery, racism, subjugation of women, and constant wars, with military budgets making up the biggest part of public spending, the funding of which comes disproportionately from those with lower incomes.

In terms of MAHA, while there may be a bit less subjective flexibility about defining “healthy” than “great”, there is definite disagreement about the road to health. For example, a recent study by the Edelman Trust Barometer produced the table below. About a quarter to a third
of Americans believe each of these falsehoods, and 70% believe at least one, with a whole bunch of folks who “don’t know”. Edelman calls these claims “false or unproven”, which is generous. To a greater or lesser degree, they are all false. The most dangerous are the claims about vaccines, which are good, and to a large degree the reason that boomers and others are likely to live as long as they are. As a t-shirt I have seen correctly asserts “Vaccines cause adults”!

 

 

Unpasteurized (ie, raw) milk has in fact caused lots of deaths because of bacterial contamination. Testimonials from dairy farmers who drink it all the time are not valid for urbanites who are consuming it days after milking, when the bacteria in it that would have been killed by pasteurization has had time to multiply, The other false claims may not cause death, but sure can cause suffering; I suffered a lot of dental cavities as a kid before our water was fluoridated. Fluoride is definitely helpful to dental health (excessive amounts can cause unsightly, but NOT dangerous, mottling of teeth). Avoiding acetaminophen in pregnancy can cause pain. And on animal protein: it is not more healthful than plant protein, it is in fact, generally less healthful. As is animal fat (e.g, tallow, lard). 

These false claims are relatively easy to refute, although it is not easy to convince people who believe them that they are wrong; these are two different things. But what of the amazing plethora of other magical health claims, today’s equivalents of snake oil (in promises for great health, not to mention quackery). Early in his book, Taylor writes 

Don’t pick up this book expecting to find the magic formula for staying forever young. I ain’t got one. You’re better off cruising TikTok, where a bustling industry of anti-aging influencers serves up a bottomless banquet of science and quackery. They treat aging as a curable condition, death an avoidable fate. 

Sigh. It would be wonderful if these nostrums could keep you healthy and keep you from dying. But they don’t. That doesn’t keep them from being a “bustling” (and profitable!) industry.

Three points:

1) Natural is not necessarily better or safer. That is a fallacy. Anything that actually has biologic effects can have the ones you want, and the ones you don’t (side effects). If it doesn’t have any biologic effect, it’s not helping either.

2) Don’t be a sucker. Yes, Big Pharma is evil, but there is much better data on whether and how its products work than those of the MAHA-hood.

3) If it sounds to good to be true, it probably is.