Does AI communicate better than real doctors? If so, why is that?

The New York Times recently ran an article titled “Empathetic, Available, Cheap: When A.I. Offers What Doctors Don’t”, which should be very concerning to the medical profession as it emphasizes three things that they are often not. But probably won’t concern the real decision makers in healthcare – the corporate owners, “health systems”, insurance companies, and private equity. After all, their concern is solely making money, and they are doing just fine, thank you.

The article indicates that AI seems to be responsive to and nice to people, and seems to show respect, concern, and empathy; “seems to” is important, because these are computer programs, not people, and they don’t have any feelings. Nonetheless, people feel better when they are addressed with respect, concern, and compassion. Even if it is programmed and not real. The truth is that doctors and other actual people do not always do so, for a variety of reasons. And they don’t even have the chance to if the patient cannot contact them, which is so common as to be routine these days

For many years, I told medical students that, while they had worked very hard to master the language of medicine, learning idioms, jargon, eponyms, and acronyms so they could fit in and impress their seniors, residents and attending physicians, regular people would not understand them if they spoke like that. They had to be able to translate that back into their first language, English (or whatever their vernacular was). This is an important skill, for without it people (“patients”) won’t understand what you are saying, and won’t know what is going on with them. And that is important. It takes effort, and it takes intentionality – you must want the person to understand what you are saying. That’s is true even if what you are telling them is bad news, something that will make them upset or unhappy.

I thought about this after a recent conversation with a couple of current medical students. I made the points above, about the importance of communicating in a way people can understand, and observed that, in fact, often people did not understand. This was based on, among other things, the number of times I had to try to explain to my patients, as a family doctor, what their specialist was saying. And the number of times I had to try to figure out, as a family member or friend, what my family member or friend’s doctor had been telling them that led them come away with what seemed to be an incorrect understanding of the situation. I have even said “If you assume that no one ever understands anything their doctor tells them, you will be correct a distressing percent of the time”.

The students agreed, but when they gave examples from their experience, I became more concerned.

A surgeon I worked with was unable to get all of the cancer out, but when telling the patient used all kinds of technical and unfamiliar terms, like ‘clean margins’. It was like they were trying to not lie, but to obfuscate what they were saying by talking in words and phrases that were technically true but not meaningful to the patient. I was left, after the surgeon had gone, to try to respond to the patient who asked me ‘What did they just say?’”

Obviously, this should not be the job of the medical student, but of the surgeon. And while it is tempting to say, “Well, they’re surgeons; communication is not their strength” (and while, as a family doctor, I like to think we are better at it), most or all doctors are guilty of this sometimes. (It is also true that it is even harder when you have to acknowledge that the bad news may, in fact, be the result of something you did wrong, but this is a separate area.)

I have recently had experience with close family members who had complications during procedures. One, during an endoscopy, had their blood oxygen level drop and had to have a breathing treatment afterwards, receiving a new diagnosis of asthma. This was upsetting, but at least they were told everything. Another, in a much more concerning episode, had major lung surgery. After the surgery, they had terrible, persistent pain which was not adequately treated. Several months later, visiting another doctor (not the surgeon), they were told that their oxygen level had also dropped severely, as a result of having a pneumothorax, a serious, potentially dangerous condition where air gets into the chest cavity and can partially collapse the lung. More relevant, it can be terribly painful. This might explain why the nurses, following their pain-management algorithms, did not give the patient sufficient pain medication. It is still not clear if they were told their patient had a pneumothorax, but it is definitely clear that the patient, my family member, was not told. They should, of course, have been.

There are a lot of potential problems with AI providing people medical information, some of which are discussed in theTimes article. For one thing, it could be wrong. It doesn’t really know you, and part of the reason that you are consulting the medical AI (or real clinician) is that you don’t actually know either exactly what is wrong with you, or how to put it in terms that will get you the correct answer to your question even if the AI is capable of getting the correct answer. Of course, sadly, the same can be true of real doctors, especially when you don’t actually speak to them; the article leads with the story of a person who wanted advice on how to increase the protein in their diet, and received generic – and unhelpful – answers from the physician on line (presumably a “patient portal”). For all we know, they could have been AI produced.

It would be much better – some of us would say essential – for doctors to communicate fully and honestly with their patients, using language that they can understand, even when the news is not good. And for them to be there, being, well, patient, while their patient tries to formulate questions, and answer them. But there are a lot of reasons that they don’t, or can’t.

A part of it may be that they are poor communicators, or uninterested in having their patients understand everything, especially if it could be embarrassing or take a lot of time. But AI doesn’t have that problem. It is not paid by the patient, and it has no set number of people it has to see in a given amount of time the way that real clinicians do. These actual clinicians often work in hamster-wheel conditions (time spent not only seeing patients but having to do electronic charting aimed at maximizing profit via upcoding as much as possible) which are not the fault of the doctor, but of their employers who are interested in “throughput” to make as much money as possible. Saliently, procedures are relatively well reimbursed but spending the time necessary to talk to a person to be sure that they completely understand what is going on is not. Of course, this is also part of the reason that there are fewer students entering primary care and more are entering better-paid procedure-based specialties.

Having a health care system that valued, and paid for, communication would be good. It would have to start with a system designed to maximize the health of our people, not corporate profit. Yes, there would still be some doctors who communicated poorly, and even made poor medical decisions, but those could be dealt with as individuals, rather than having them intrinsically encouraged by the system.

Doctors could and should do better, and maybe there is a place for AI. But there is no place for profit in healthcare.

"Health Care Un-covered": Covering the abuses and heartlessness of the health insurance industry is a big job!

The former health insurance executive turned whistleblower Wendell Potter provides outstanding service on his substack “Health Care un-Covered” by revealing abuses within the insurance and greater healthcare industry (well, abuses to him and to me; SOP to the companies!). Recently, Trudy Lieberman, a past president of the Association of Health Care Journalists posted there “Deny, Defend, Depose”, words made famous by being inscribed on the bullets used to kill UnitedHealthcare CEO Brian Thompson. She discusses early meetings in the 1990s when health insurance coverage was migrating from covering “major medical” to “managed care”, where the company paid for – and sometimes controlled directly – all the care you received. Managed care, as a concept if not a term, existed way back in the 1950s, when “consumer cooperatives” like HIP in New York, Ross-Loos in Los Angeles, Group Health in Seattle were established to reduce the cost of healthcare by eliminating the middleman – the insurance company – and could either provide more care to members for the same money, or similar care for less money. When, first under Nixon and then Reagan, this concept was expanded, many people (like me) were fine with it because of our positive experience with the consumer cooperative version.

Under the new version, however, a different type of managed care emerged which, rather than excluding the insurance companies, was owned by the insurance companies, often even employing the physicians and other clinicians who provided care. Thus, a third option emerged: rather than either saving consumers money or providing them with more care, these companies could provide less care and pocket the savings! She writes

New perils came with that new age of health coverage. In the quest to save money while ostensibly improving quality, there was always a chance that the managed care entities and the doctors they employed or contracted with – by then called managed care providers – could clamp down too hard and refuse to pay for treatments, leaving some people to suffer medically.

And this is what happened and continues to happen. UnitedHealth is not the only company to profit handsomely (an understatement) from this setup, but it is the largest. The three words in the title (and on the bullets) summarize the strategies used – deny claims for healthcare, defend any challenges in court (these costs being less than the profits) and depose patients, making their lives miserable.

When these changes were being instituted, there were many in the policy arena who advocated for them as a means of cost control, citing the “overuse” of healthcare by Americans as the main reason for the high cost of our health system compared to that of other countries, which needed reining in by supposedly responsible bureaucrats. They were wrong then, and they are wronger now, when it is clear that the cost to the system of people “overusing” healthcare (whatever that means) is miniscule compared to the amount of money being taken out of the rest of the economy in terms of profits for health insurance companies, and to some degree to providers (e.g., hospital systems). The cost of US “healthcare” compared to other countries has risen, although the amount of actual healthcare we get has not, has gone down, demonstrated by the lower health status and increasing mortality rate of Americans.

In a post written by Potter he describes one of the main ways that UnitedHealthcare (and others) siphons money from the public sector, Medicare, into its pockets by not only the “3Ds”.

UnitedHealth has taken a unique approach to Medicare Advantage: directly employing thousands of doctors and arming them with software that generates diagnosis checklists before they even see patients.

This is a tactic to enhance the strategy of upcoding, ensuring that they get more money by documenting every possible problem a person might have, even if not relevant to the reason that they are being seen. In Medicare Advantage (managed care for Medicare patients, in which UnitedHealth is the largest player) this is even more insidious; in MA plans Medicare pays the insurers not for the care provided but by capitation, paying more for sicker patients. Thus, documenting every potential sickness makes them more money. Of course, the theory is that sicker people cost more, and so the insurers need more money for them. That would be good, but UnitedHealth and other insurers have figured out how to get more money to go in their coffers, however, not to the care of patients, by often using extraneous diagnoses that do not increase the amount of services rendered or the care people receive.

In a related documentation of abuse by players (insurers, providers, drug companies) in the “health sector”, Becker’s Hospital Review reports on the Shkreli Awards given out by the Lown Institute. Named after Martin Shkreli, the Turing Pharmaceuticals CEO who in 2015 “acquired a 62-year-old drug called Daraprim and, overnight, increased the price from about $13.50 per pill to $750” (discussed by me in Drug prices and corporate greed: there may be limits to our gullibility, Sept 27, 2015).  I suggested that there were limits because “in 2017, he was convicted in federal court on two counts of securities fraud and one count of conspiring to commit securities fraud, resulting in a 2018 sentence of seven years in prison. In 2022, a federal judge ordered Mr. Shkreli to repay $64 million for hiking the price of Daraprim and imposed a permanent ban on his executive roles in public companies and a lifetime ban from the pharmaceutical industry. He was released early from prison that same year.”

But that was then. Based on the activities described for the recipients of this year’s Shkreli Awards, including UnitedHealthcare, which came in #2, Shkreli himself was a piker. BTW, the #1 spot went to Former Steward Health Care CEO Ralph de la Torre, MD.* So I guess the idea that there are limits to our gullibility, or to the greed of these people and corporations, and the willingness of “regulators” to tolerate or even enable it, was optimistic.

However, a positive is that the Consumer Financial Protection Bureau (CFPB) has finalized a rule that would bar medical debt from appearing on Americans' credit reports. Potter observes that

“This progress did not happen in a vacuum. Addressing the medical debt crisis has been a growing priority for policymakers, patients and organizations like Be A Hero, Undue Medical Debt and the Lower Out-of-Pockets (LOOP NOW) Coalition, which I lead.

My team and I, through LOOP NOW, had the honor of helping facilitate a White House event in which Vice President Harris and CFPB Director Rohit Chopra laid out the administration’s plans to address the crisis. That event wasn’t just about policies — it was about amplifying the stories of people like Lindsay, a single mother saddled with $50,000 in medical debt after her insurer denied coverage for her child’s life-saving brain surgery.”

Potter notes that “This single action could wipe $49 billion in debt from the credit reports of 15 million people, offering relief to individuals and families that have had their financial futures derailed by the unforgiving realities of our health care system. If you’ve ever struggled with medical debt—or know someone who has—this is a moment worth celebrating.”

And indeed it is. Until the new Trump administration reverses it, as they probably will, along with abolishing the CFPB altogether.

 

*”Lown Institute awarded Dr. de la Torre the top spot for bad behavior in 2024, which was the demise of Dallas-based Steward Health Care. The for-profit chain was on a buying spree in recent years. Four days into 2024, hospital landlord Medical Properties Trust reported Steward was $50 million behind on its rent. When The Boston Globe published local reporting on the state of affairs at Steward's Massachusetts hospitals, lawmakers and officials started to pay closer attention and the house of cards began falling apart. By May, Steward reported $9 billion in debt and put all of its hospitals up for sale. Dr. de la Torre resigned in September, days after the full Senate voted unanimously to hold him in contempt after he did not comply with a Senate subpoena.”

Scamming Medicare: It's the providers and insurers, not the patients!

I have often written about universal health care and favored a single-payer system, or, in its current incarnation, Medicare for All. I still do and will have some more to say about it in a bit, but wanted to begin by providing some recent examples of the outrageous abuses of our non-system of health care. More important, abuses of the people who are supposed to be receiving health care. Actually, it is not so much that these are examples of new practices, but rather that there have been important recent articles exposing them.

In “Where the frauds are all legal” on December 7, 2019 in the NY Times, Elisabeth Rosenthal, an opinion writer, physician, and editor of Kaiser Health News, describes exactly that. Dr. Rosenthal has often written on the same theme, notably in a wonderful book that I have recommended before, “An American sickness: how healthcare became big business and how you can take it back”, but this recent article was precipitated by the experience of her husband following a serious bicycle accident. Dr. Rosenthal describes a number of scams (and they are scams, even if they are legal) perpetrated by the hospital, and gives them cute and memorable names; it is good enough to summarize here.

1.      Medical Swag, such as charging $319 for a plastic brace that was in place for an hour (and you may or may not get to keep it!) and other such goodies, “…like the sling you can buy at Walgreens for $15 but for which you or your insurer get a bill for $120 after it is given to you at urgent care.”

2.      The Cover Charge. This was the $7143.99 “trauma activation fee” charged by the hospital. This was in addition to whatever else was charged by physicians, for x-rays, labs and medical equipment. ‘Trauma activation fees have been allowed since 2002, after 9/11, when the Trauma Center Association of America, an industry group, convinced regulators that they needed to be compensated for maintaining a state of “readiness.”’ But, she asks, ‘Wait. Isn’t the purpose of an E.R. to be “ready”? Isn’t that why the doctors’ services and scans are billed at higher rates when they are performed in an emergency department?’ Note: Dr. Rosenthal in an emergency physician.

3.      Imposter billing. This is when the physician bills for a service that s/he didn’t provide directly, such as when it was done by a resident or PA or NP. Sometimes the physician is on site, sometimes not. But they are billed at the full physician rates. Cool beans. This is what allows some doctors to see a panel of patients in clinic while they are in the operating room at the same time!

4.      The Drive-By. Charging for full examinations (which are documented as full examinations after just a few questions – or even a phone call). Sometimes only a few questions are all that is appropriate, but you can’t – or shouldn’t – be able to bill for a physical examination!

5.      The Enforced Upgrade. Meeting someone in the ER, even for a minor problem, because the office is closed (in the specific case, the clinic the doctors used was open only 2 hours 45 minutes two days a week), causes much, much higher charges.

What is sometimes more amazing to me is that the insurer paid for all these things. Part of the reason is that they have no way of knowing if these upcharges were medically necessary. Sometimes (as pointed out in Rosenthal’s book) it is because they just pass the charges on by raising their premium rates. Of course, insurers don’t pay the full charges – they pay a significant discount. Only uninsured people are expected to pay the full charge!

So these are pretty outrageous, but mostly (as the title points out) legal, if outrageous. Not, however, necessarily legal would be the overcharges and payments from Medicare to certain insurers documented in a report from the DHHS Office of the Inspector General, and covered by the Times in “Federal Watchdog Questions Billions of Dollars Paid to Private Medicare Plans” by Reed Abelson, December 12, 2019. This is a different sort of scam, perpetrated by Medicare Advantage plans. To start with, Medicare Advantage plans are something of a scam to begin with. Why? Well, on the surface, “all” they do is to essentially provide Medicare patients with the benefits of an managed care plan – indeed, often you may an additional premium on top of Medicare to the insurer and you have wrap-around HMO-type coverage. This can be really good for you as a consumer; you can get covered for vision, hearing, prescription drugs (without the need for an additional Part D plan), and copays. What makes it at its essence a scam is that the Medicare Advantage plans get higher payments for a variety of reasons than does traditional Medicare.

One reason is that they tend to enroll lower-risk patients, who cost less to care for. To some degree this is because they have the disadvantages of HMOs as well as the advantages; limited physician and hospital networks and limited portability if you are out of the geographical service area. But most of it is from the way that they are marketed. It is to these insurers’ financial advantage if as many of the high-utilizing, high-cost, older, and sicker Medicare patients are in traditional Medicare, and the ones who are younger, less-sick, and lower-utilizers – thus lower cost – are in their plans. They work hard to make this happen, When the Trump administration pushes Medicare Advantage, as when Center for Medicare and Medicaid Services (CMS) administrator Seema Verma says “What works in the Medicare program is Medicare Advantage — because plans are competing on the basis of cost and quality, driving toward value and increasing choice to beneficiaries,” it is true – but, as with any other for-profit product, it markets its advantages to those most likely to make it money.

Then there are the probably-illegal actions found in this report. Primarily, these result from “up-coding”, having administrative personnel comb the entire medical records to find things that they claim allow them to bill for higher-complexity in patients who have more diagnoses, even when the person providing the care did not address those issues. Hospitals use reviewers to upcode all the time, and sometimes it may be legitimate, in cases in which the care was provided but not completely documented. This “data-mining” approach to upcoding, however, is not. And this is not all. The Times article also notes  that ‘An earlier report from the inspector general’s office also raised concerns about Medicare Advantage, concluding last year that plans were inappropriately denying medical claims as a way to increase profits.’ The amount involved is not chump change; an additional $6.7 Billion in payments in 2017.

So no good either way, “legal” scams by providers (read mainly “hospitals”) or probably illegal scams by insurers. Both illegitimately take our money (whether paid as taxes, premiums, co-pays, etc.) and funnel it toward profit. Would a single payer, Medicare-for-All program prevent this? Yes, although it would have to be the “Improved and Expanded” Medicare called for by the current bills in the House (HR 1384) and Senate (S1129). From the patient point of view everything is covered. From the provider point of view, they would not be able to game the system by upcoding and other techniques. From the insurer point of view, they would not make so much profit.

For too long, healthcare in the US has been a struggle between insurers (who think they pay the providers too much) and providers (who think that they don’t pay enough). The interests of the actual people, patients, taxpayers, rate-payers, are lost in this struggle, crushed by the tectonic plates of those big industries. Many politicians and pundits say we can’t go against them. I say we have to. As Jim Hightower says “Who’s afraid of Medicare for All: Not ordinary Democrats or independents — just insurance companies, lobbyists, and old-line politicians”.

Time to make them put our interests first!