TEDMED Blog

Global surrogacy: When making babies is no fun. Op-ed by Leslie Morgan Steiner

The content, views and opinions expressed in this blog post are those of the author(s) and do not imply endorsement by TEDMED. By inviting guest bloggers, TEDMED hopes to share a variety of perspectives that provoke and engage our community in discussion and debate.


Leslie Morgan Steiner at TEDMED 2014

Leslie Morgan Steiner at TEDMED 2014: The inconceivable costs of baby-making

As a mother and writer on women’s issues, I believe nothing is more intimate an issue for every woman—actually, every human being—than the desire to have a child.

Now, my children were all conceived and born naturally. They enjoy full robust health. But I discovered that infertility—the myriad variations of disease and biological abnormality that cause specific men and women to be unable to create children together—strikes randomly. Anyone can be infertile. Infertility is surprisingly common; the inability to have children afflicts 10-12% of the human population.

There is no surefire way to prove you are fertile in advance, for example you cannot use a blood test to screen newborns or teenagers for the inability to have children as one might for hemophilia or celiac disease. Part of infertility’s cruelty is the surprise of its assault. You rarely learn you are infertile until you try, and fail, to have a baby.

When I found all of this out, I wondered: what would I have done if I were infertile?

That was when I stumbled upon the seemingly strange new solution of surrogacy—paying another woman to carry a baby for you. Surrogacy has actually always been a solution to the age-old problem of infertility. In fact, surrogacy (via concubine) is mentioned over 20 times in the Old Testament.

Today, the global medical community, funded by generations of desperate infertile women, has figured out exciting—and disturbing—new ways to create babies no matter the obstacles. The medical term is Gestational Surrogacy (GS). A new-and-improved version of an ancient solution to childlessness.

Today, thanks to in vitro fertilization (IVF) and other advances in assisted reproductive technology, babies can be created with sperm from one source, an egg from another, and a uterus from yet another. In England today, women who are carriers of rare mitochondrial disease can actually use their DNA in a healthy donor egg cell to bypass the defective mitochondria, thereby creating an IVF scenario with three biological sources. Surrogates today are not biologically or genetically connected to the babies they gestate. This simplifies many ethical, legal, and parenting issues.

And creates new ones.

Modern surrogacy is transforming humans’ centuries-old definition of motherhood.

Today a newborn can have two mothers or two fathers, or no mother, or no father. A baby can actually have zero legal parents, as in a few isolated cases where a gestational surrogate carried a baby created with donor egg and sperm, and a clinic mix-up blocked authorities from tracking down and proving any legal parent.

Today anyone—a 25-year-old with uterine fibroids, a 40-year-old woman with a cancerous uterus, two married gay men, a nun—can have a baby, their biological baby, via surrogate.

As long as they can afford it, because surrogacy in the U.S. can cost $100,000 or more.

Gestational surrogacy has become better known in recent years due to international celebrities such as musician Elton John, comedian Jimmy Fallon, and actresses Nicole Kidman, Elizabeth Banks and Sarah Jessica Parker who have all had babies via U.S. gestational surrogates.

But the rise of GS is important for normal people too.

Like Gerry and Rhonda Wile, a nurse and firefighter from Arizona, who shared their story with me for my book The Baby Chase.

Gerry and Rhonda met and married in their late 20s. Gerry was already a father, but he’d had a vasectomy, which he didn’t tell Rhonda about for six years (but that’s another story).

As for Rhonda, for her entire life she had an extremely rare, undiagnosed medical condition that allowed her to get pregnant easily—and she did—but the same condition caused her to miscarry 100% of these pregnancies.

Prior to 20th century medical technology, Rhonda would have gotten pregnant and miscarried dozens of times throughout her reproductive years—as often as 3-4 times a year—for decades, without ever understanding what was wrong with her biologically. For too many centuries, infertility was a lifelong, mystifying curse. A perennial loss that often left sufferers, women in particular, feeling rejected by their husbands, families, communities, and even by God.

So what did the Wiles do?

What would you do?

Today there are several options for the world’s infertile. Treatment, adoption, accepting that you will live your life without children. But for the Wiles, there was only one solution. Surrogacy meant the Wiles could create the family they dreamed of using Gerry’s sperm, Rhonda’s eggs (or what turned out to be eggs from a donor), and an unrelated gestational carrier.

Gestational surrogacy is an exciting, awe-inspiring new medical innovation that makes it possible for infertile couples like Gerry and Rhonda, and millions of other people, to have babies and become parents.

Leslie and the Wiles family

Leslie and the Wiles family

Surrogacy today heralds the end of infertility, the death of an affliction that has plagued humans since the beginning of time. However, surrogacy in the United States is financially out of reach to most people. This is why some people, like Gerry and Rhonda Wile, travel to other countries to find affordable, legal surrogates to create their babies.

The final surprise about surrogacy is that it’s personal. It’s human. It’s about you and me and the people we love.

What if you had to travel 8,000 miles to have your baby—and risk not being able to bring her back with you?

Or had to choose between being openly gay and having your own biological offspring?

Or your health insurance said you were too old, or too religious, or not religious enough to qualify for infertility reimbursement?

Or your God said no, you can’t treat your disease…you must live your life without the children you’ve dreamt of having since you were a child yourself.

Imagine the betrayal you would feel if your country, your political leaders, your neighbors, your God, refused you a baby, merely because the treatment for your disease made people uncomfortable.

Would this make you want—or deserve—a baby any less?

In her TEDMED 2014 talk, Leslie Morgan Steiner, journalist and bestselling author, brought the audience along on her journey to learn the truth about a successful gestational surrogacy industry on the far side of the world–and how it could provide a model to help solve several social problems in the US.

 

Wonder what “Breaking Through” looks like? Find out at TEDMED 2015!


With less than six months to go until TEDMED 2015, we’re thrilled to announce the eight sessions that will take center stage this November 18-20 in Palm Springs, California. If you are planning on joining us, secure your spot today!

RegisterButton copyAt TEDMED 2015, we will focus on breaking through the status quo and celebrating the typical, the atypical and the spaces in between as we come together to shape a healthier world.

The mythology of a “breakthrough” tells the story of a lone genius and one magical, “aha” moment. But, let’s not mistake a good story for the truth. In reality, we all have breakthrough potential and the least likely way to unlock that potential is to toil away in social or intellectual solitude. Instead, we break through in new combinations and we collect the building blocks of our future breakthroughs every day, in every new interaction, in every new insight, one improvement at a time.

The year’s program is not about once-in-a-generation breakthroughs or cures. Instead, it’s about the steady, daily process of “breaking through” and driving continuous progress toward a healthier future – “breaking through” our established routines, “breaking through” our usual habits of mind, and “breaking through” our perceived environmental limits.

It has been said that the greatest form of courage is the long-haul, persistent determination to do a little better each day, and that the best way to make quantum leaps is to prepare the ground with steady, ongoing progress.

In this spirit we share the eight sessions that will make up the TEDMED 2015 stage program:


Human Explorations
Delve into intensely human experiences, including sexual myths and realities; the indomitable human spirit; how we identify with our genomic data; emerging technologies that edit our DNA; the tortured psyche; maximizing human potential; and a musical celebration of heart and soul.
Learn more…

Mind Matters
Explore the secrets and wonders of the brain, from the amazing wisdom of the cerebral cortex, to the mind’s invisible wounds and dysfunctions; from the latest neuroscience, to the vast remaining mysteries of our most inscrutable organ.
Learn more…

Catalyzing Great Science
Risk-taking researchers reveal new ways to disrupt the scientific paradigm, break through barriers between academia and industry, link seemingly unrelated fields, and meet demand from patient activists.
Learn more…

Back to Basics
Creating a culture of health often depends on factors that reach far beyond health care. Explore solutions with wise and determined change-makers who stand – and fight – at the front lines of innovation.
Learn more…

Food Fix
Craving a forbidden intellectual sweet, or desiring insights into the impact of food on health? Check out this tempting menu. “Chefs” include a conscientious food capitalist; an urban food anthropologist; a geneticist who is re-engineering meat and dairy; a global food rights activist; and other multi-disciplinary thinkers who are reshaping what and how we eat.
Learn more…

Techno-Utopia
Brimming with shiny techno-optimism, this session features novel ways we are creating technologies with wide applications to health and medicine. Behold a sensor innovator’s quest to make medical care less invasive; a geneticist’s journey to make artificial DNA base pairs replicate in nature; and a daring pursuit to discover new uses for old drugs with machine learning.
Learn more…

Who Cares for Health Care?
Physician, heal thyself … and while you’re at it, how about healing your field? Every cure starts with accurate diagnosis, so this series of cautionary tales reveals surprising perspectives and under-appreciated challenges facing our health care system.
Learn more…

Out There
This session lives “in the wild” and on edges so newly discovered they feel eerily sci-fi. Explore our changing environment and so-called fringe science that is going mainstream. Speakers highlight some exciting, promising and even heart-wrenching ways to engage with the unexpected and seemingly foreign.
Learn more…


Ready to meet the speakers who will be featured in these sessions? With 60+ speakers and performers confirmed and the 2015 program finalized, we’re excited to start sharing our speaker line-up, beginning next week. Then, each week from now through early August we will unveil the speakers – stay tuned!

Special thanks again to both our Editorial Advisory Board and our Research Scholars for sharing their knowledge and experience with the TEDMED team as we designed this year’s program. We could not have created such a powerful program without their contributions!

We hope to see you in Palm Springs in November. If you have any questions, please reach out to Melanie at Admissions@TEDMED.com.

 

2015’s Research Scholars: Another Peek into What Makes a Great TEDMED Talk

Earlier this year, we shared details around some of the critical elements that support TEDMED’s editorial process. Specifically, we shared our core values, code of ethics, speaker selection process and the addition of TEDMED’s inaugural Editorial Advisory Board (EAB). As we explained, our EAB members advise TEDMED on topics, themes and speakers that should be considered when creating our annual stage program.

Now, as we prepare to announce this year’s program and speaker line-up, we want to give you a peek into another significant group that contributes to our editorial process: the TEDMED 2015 Research Scholars.

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When TEDMED curates the talks that are being considered for the stage each year, topics range literally from A (autoimmune disease) to Z (zona pellucida). To assist us with reviewing and researching the deep science behind potential topics, themes and speakers, TEDMED relies on outside feedback from our Research Scholars who are a diverse group of carefully selected experts.

Our Scholars are equipped with the professional training, objective knowledge and institutional credibility required to give TEDMED a wealth of insights, informed perspectives and thoughtful suggestions for further queries and investigation. TEDMED assembles Research Scholars from across the biomedical spectrum: university faculty, post-docs, grad students, public health professionals, entrepreneurs, science journalists and medical students from leading institutions and associations.

It’s no mystery why our Scholars break away from their busy schedules to volunteer their time in support of TEDMED’s mission. Each is a person of extraordinarily generous spirit; and, each is passionate about making a difference in health and medicine. We are proud to count the TEDMED Research Scholars as valued members of the TEDMED community…and we thank them for their outstanding contributions.

Without further ado…we are honored to recognize the Research Scholars for TEDMED 2015. See the full list here.

Stay informed as details around TEDMED 2015 continue to be shared. Follow us on Twitter and Facebook, and consider registering today for TEDMED 2015 in Palm Springs, November 18-20, at the beautiful historic La Quinta Resort! We’ll begin announcing details of the program next week.

Stop bypassing the dangers of anorexia – Q&A with Cathy Ladman

“My job is to understand and accept myself, my imperfect self.” - Cathy Ladman, TEDMED 2014 [Photo by Brett Hartman]

“My job is to understand and accept myself, my imperfect self.” – Cathy Ladman, TEDMED 2014 [Photo by Brett Hartman]

 

At TEDMED 2014, Cathy Ladman – a comedian famous for poking fun at her personal neuroses – shared the internal dialogue of someone struggling to cope and understand her eating disorder. Her talk, funny in the “I don’t know if I should be laughing” kind of way, focused on anorexia, which has the highest death rate of any mental illness. We got in touch with Cathy to learn more about her talk and experience at TEDMED.

Why does this talk matter now? What impact do you hope the talk will have?

I have thought, for a very long time, that there has to be a real, honest wake-up call in our society regarding the obsession with being thin. There are people dying from anorexia, and our society turns away from these facts because they are inconvenient. These facts get in the way of the, most often, ridiculous female body standard, and that’s what sells magazines, movies, TV shows, etc. I hope that people will see how grave this is, and how we have the power to stop perpetuating it.

After watching this talk, what actions do you want your viewers to take?

Be honest with yourself and others. Find your self-worth in things other than your body and your looks. Speak out when you see TV shows, films or any public media glorifying skinny.

Which TEDMED 2014 talks or performances left the biggest impression on you? Why?

Sigrid Fry-Revere’s “What can Iran teach us about the kidney shortage?” – I never knew of the donor system that exists in Iran. This talk was fascinating, and made a lot of sense to me. I was partly surprised by my response. I would have guessed that I would not be on the side of selling organs, but I see that, handled this way, it’s a sound idea.

Rosie King’s “How autism freed me to be myself”- Rosie was terrific, vibrant, hopeful, brave, completely real, and spoke with no artifice. I loved her!

Abraham Verghese’s “A linguistic prescription for ailing communication”  - Abraham is a gentle, intelligent man, whose love of words echoes my own. The more we know language, the more we create language, the better we can communicate with each other and, hence, understand each other.

Carl Hart’s “Let quit abusing drug users” – This was such a terrific presentation of a perspective that I hadn’t known before, and makes complete sense. His theories could help to change the cycle of drug addiction and poverty.

Acrobaticalist Ninja Theater – Q&A with NANDA

NANDA is a high-energy troupe of comic actors who delight in calculated chaos, kung-faux fighting, and irreverent pop-culture parodies. Their TEDMED 2014 performance literally turned everything upside down (including themselves!) with a mishmash of traditional theater, vaudeville, and circus – all while utilizing dance, juggling and acrobatics. NANDA’s contribution to TEDMED went beyond their performance, as they also led TEDMED speakers through relaxation and voice exercises before their sessions.

NANDA’s performers are Misha Fradin, Chen Pollina, Kiyota Sage, and Tomoki Sage. We got in touch with them to learn more about their time at TEDMED.

Turning it upside down at TEDMED. [Jerod Harris]

Turning it upside down at TEDMED. [Jerod Harris]

 

What motivated NANDA to perform at TEDMED?

We were motivated to connect, share and learn with and from the TEDMED community.  Plus, its always fun to visit San Francisco!

What impact do you want your performance to have?

We hope our performance inspires people to enjoy life to the fullest!

Which TEDMED 2014 talks or performances left the biggest impression on you?

Jeffrey Iliff’s “One more reason to get a good night’s sleep” – Jeffrey inspired me to understand my sleep behavior more, allowing me a better understanding of my self and body. As an acrobat and juggler, my physical and mental health are both very important to me (Misha Fradin).

Kitra Cahana’s “My father, locked in his body but soaring free” – Kitra’s talk was emotional and powerful, there were multiple times I found myself on the edge of my seat as the story was beautifully woven. It inspired my own healing process and compassion around traumatic experiences from my own life (Misha Fradin).

Amy McGuire’s “There is no genome for the human spirit” – Amy’s genetic research made me think about the human race and how we’ll be battling our health problems in the future. I am a huge fan of genome sequencing as I have had family members that may still be alive if there had been affordable tech to do this. The fact that this is becoming a reality is phenomenal, and will drastically change the direction of all medicine (Misha Fradin).

What is the legacy NANDA wants to leave?

We share a vision of living in a global community that values and demonstrates support, imagination, and intercultural collaboration. It is our mission to be an instrument in the success of this vision.

What’s next for the group?

The next step for NANDA is to have as much fun in life as is humanly possible.

Apart from Desire – Q&A with Heather Raffo

Actor, playwright, and librettist Heather Raffo performed a powerful excerpt from her one-woman show, 9 Parts of Desire. We reached out to learn more about her inspirations, aspirations and ambition.

Heather Raffo performs on the TEDMED stage. [Sandy Huffaker]

Heather Raffo performs on the TEDMED stage. [Sandy Huffaker]

 

What motivated you to perform at TEDMED?

As an artist with Iraqi and American heritage, I most wanted to launch a conversation about how we recover from war: how we survive as individuals, families, cultures and countries.

My work grapples with an ever shifting identity of what it means to be Iraqi or American and how trauma changes one’s sense of self.   I was thrilled to have an opportunity to talk and learn from such diverse and profound thinkers and health care professionals about how they relate trauma and loss to survival and healing.

Why does this performance matter now? What impact do you hope the performance will have?

A few months ago I had a revelatory conversation with a US Military General. He reminded me that the effects of the wars in Afghanistan and Iraq have only begun to surface for our veterans. For Iraqis, the civilian population has experienced multiple traumas over multiple decades, the sense of belonging that once held that society together is shifting rapidly as it is throughout the Middle East.

The work I do tackles some of the most difficult conversations our nation has yet to have.   It also tackles taboos rarely addressed in Middle Eastern society.  It broadens the lens through which many view the Iraq war, and helps offer a complex understanding of those affected by violence.

What kind of meaningful or surprising connections did you make at TEDMED?  

I connected with so many extraordinary individuals at TEDMED.   But perhaps most moving, were the conversations I had with war veterans who sought me out after my performances. They were thankful that hard truths were used to break open subjects they feel have not been discussed openly. TEDMED was a unique environment to have those difficult conversations about devastating human experiences and the universal will to live.

What is the legacy you want to leave?

I’ve spent the last decades of my life devoted to bridging my Eastern and Western cultures – bringing the worst of war into a sacred artistic experience. The legacy I am working to bring about is a movement that uplifts the feminine experience, that addresses our relationship to violence and that integrates the Middle Eastern voice into the American theatrical canon.

What’s next for you?

I’m working on an adaptation of Ibsen’s A Doll’s House set in a Arab American family.  What is particularly thrilling about this work is that my writing is being done from an embedded position within Middle Eastern American communities.  The first mounted workshop will be at Georgetown’s Davis Performing Arts Center in December 2015.

I’m launching my Places of Pilgrimage monologue series on the web.  Middle Eastern women telling their stories in their own words! It is based on a writing workshop I developed for universities and community centers both in America and internationally.

My opera Fallujah, inspired by the life of US Marine Christian Ellis, will have its world premiere at Long Beach Opera in January of 2016. The opera is composed by Tobin Stokes.

Once these three projects are up and running, links will be available on my website heatherraffo.com.

A new vision for the future of telemedicine: Q&A with Elliot Swart

In his TEDMED talk, Elliot Swart directed our focus to telemedicine and its potential to not only replace but improve upon current diagnostic procedures.  We reached out to learn more about how he is shaping the future of telemedicine.

Elliot Swart takes the TEDMED stage. [Kevosk Djansezian]

Elliot Swart takes the TEDMED stage. [Kevosk Djansezian]

 

What advice would you give to other aspiring innovators and entrepreneurs?

One piece of advice I took to heart is set out to solve a problem that you truly understand. And even once you have a problem, don’t quit your day job until you have a real idea of how to solve it and why your solution is different. The most unhappy entrepreneurs I know are the ones who decided to be entrepreneurs before they had a problem to solve.

Now, I’m not suggesting you should wait around until lightning strikes. My favorite TED talk of all time is “How to start a movement” by Derek Silvers.  The gift I took away from that talk is that it takes a lot of people to truly accomplish something, and that being the second, third, or even tenth person to join is as important of a role as the person who starts it. There are hundreds of amazing startups and early stage companies solving meaningful problems. Go out and find one!

What has been your main source of inspiration that drives you to innovate?

My company, 3Derm, makes a teledermatology solution to help get melanoma patients seen sooner. In my work I’ve come across a number of people who will tell me about their friends or family who have died from skin cancer. I like cool technology as much as the next guy, but what really drives me is the number of lives we’ll save if we succeed.

Why does your talk matter now? What do you hope people learn from your talk?

Telemedicine is still seen as the second best alternative – standard practice only if the patient is extremely remote or has no other options. But, slowly, we’ve seen people start to turn the corner and realize that telemedicine can be used to lower costs and increase convenience in almost any population. By developing telemedicine systems for different specialties, we are essentially distilling the diagnostic process into the necessary information, making medicine more quantitative and easier to standardize.

My company has spent four years creating a telemedicine sense for dermatology. There are many other specialties that will require years of university research and commercialization. I hope my talk can convince people of telemedicine’s potential as a standard of care and the importance of pursuing this research.

Now is the time to face the truth about drug use – Q&A with Carl Hart

In his TEDMED talk, Carl Hart offered a highly provocative but evidence based view of drug addiction and its links with crime. Carl speaks from personal experience; he grew up in a poor neighborhood in Miami, where he himself engaged in petty crime and drug use. Today, Carl is an Associate Professor of Psychiatry and Psychology at Columbia University, and a self-professed advocate for social justice and science.  

"I was unprepared for what I would learn as I went about making my contribution to the study of the neurobiology of addiction." - Carl Hart, TEDMED 2014 [Photo: Kevosk Djansezian]

“I was unprepared for what I would learn as I went about making my contribution to the study of the neurobiology of addiction.” – Carl Hart, TEDMED 2014 [Photo: Kevosk Djansezian]

 

We reached out to Carl to learn more about why his talk is particularly timely today. Here was his response:

Today – May 19 –  would have been Malcolm X’s 90th birthday, had he not been assassinated fifty years ago. Malcolm X’s influence on human rights, social justice activists, and me is increasingly apparent as society becomes more concerned about issues of over-policing in certain communities. My TEDMED talk, “Let’s quit abusing drug users,” is particularly important today because it illustrates the detrimental impact of aggressive selective drug law enforcement on communities of color.

In recent months, the issue of hostile, militarized policing has been pushed to the national forefront in response to the killing of the black, unarmed teenager, Michael Brown, by a white police officer in Ferguson, MO. Similar types of killings have occurred too often under the guise of the war on drugs. Eric Garner, Ramarley Graham, Kathryn Johnston, Trayvon Martin, and Tarika Wilson are just a few examples. In all of these cases, authorities suspected that the deceased individual was either intoxicated from or selling an illicit substance. This talk shows that dangers of drugs have been exaggerated, and that this has helped to created an environment where unjustified police killings are more likely to occur.

The importance of my talk is even further enhanced because too many people misattribute societal ills to drug problems. For example, the majority of people who use drugs – 80-90% – don’t have a drug problem. They are responsible members of our society. They are employed; they pay their taxes; they take care of their families; and in some cases, they even become President of the United States. Our three most recent Presidents all reported using illegal drugs when they were younger. In my talk, I clearly show that the real problems faced by society are not drugs but are poverty, unemployment, ignorance and the dismissal of science that surrounds drugs.

In my TEDMED talk, I also present intriguing results from my own research, during which we brought crack users into the laboratory and offered them $5 cash, or a hit of crack worth more than $5. We repeated this many times with each person over several days in the laboratory.  The drug users chose the drug about half of the time, and the $5 the other half. Even a nominal amount of money was enough to deter them from taking the drug at least half of the time. These findings are inconsistent with the notion that crack users display the insane, “anything for a hit” behavior that I had been previously taught. They also demonstrate how attractive alternatives, such as viable economic opportunities, can go a long way in decreasing societal problems, including drug abuse.

Watch Carl’s TEDMED 2014 talk, “Let’s quit abusing drug users,” here:

 

Can Consumers Change the Business of Health Insurance? – Hangout Participants Address Remaining Questions

On April 30, a multi-disciplinary panel of experts joined us for a Great Challenges live online event to examine health insurance’s shift from a business-to-business industry to a business-to-consumer one. Moderated by USA TODAY’­s healthcare policy reporter, Jayne O’Donnell, the group discussed what is working, what’s not, and what it all means for businesses, for consumers – and ultimately – for healthcare costs. If you were unable to join us, check out the recast below:

We had so many important questions that our participants were unfortunately unable to adequately address each during our one-hour event. We gathered our unanswered questions and posed them to our participants so that they could continue the conversation off-air. Here’s what Jennifer Sclar and Abir Sen had to say:

How does a person’s gender, race, age, or socioeconomic status affect the likelihood that they will take on the consumer role in insurance purchasing?

Jennifer: The likelihood that people will have to take on the consumer role in insurance purchasing will largely be dictated by forces beyond their control.  It is a role that people will increasingly be forced into, either because of the insurance mandate or because their employer is moving to a defined contribution model and away from a defined benefit model.  However, there are enormous differences among groups in terms of where they will shop for insurance, how they will shop for insurance, and how successful they will be in terms of procuring the best product for the best price.  There are issues and differences among groups that we know about and that we can use to try to maximize engagement across the board.

With respect to gender, we know that the overwhelming majority of health decisions are made by women.  Women are far more likely to select an insurance plan for their family, make doctor’s appointments and treatment decisions for themselves and their families (including their children and their parents), and deal with insurance company billing and eligibility issues.  With respect to race and ethnicity, we know that the States and the federal government have been far less successful in their efforts to reach out to minorities, and Hispanics in particular, than other uninsured groups, and this is a serious problem that needs to be addressed.  With respect to socioeconomic status, we know that the ability to pay for insurance, even when it is heavily subsidized, is a huge barrier to entry for many uninsured groups.  And, finally, we know that the older and sicker you are, the more likely you will be to sign up for insurance and that the long-term health of any insurance marketplace will depend on the ratio of older/sicker enrollees to young invincibles.  Successful strategies to address the particular barriers to entry for each group will be imperative to the success of the ACA, as well as the long-term trend toward the consumerization of health care.

What impact will more patients taking control of their insurance purchases and having “skin in the game” have on healthcare costs?

Jennifer: Complicated plan design and increased cost sharing will lead to demand for greater price transparency and clearer billing practices.  Patients will demand to know what they are being charged for, and the underlying costs.  This will likely lead to greater competition and lower prices for routine care, but could result in higher prices for more complicated procedures.

Abir: That’s difficult to answer without accounting for all the other variables — the overall health of the population, the advances that are being made in medical technology, and whether the advances increase or decrease overall cost, to name a few. If all of those variables are held constant, I would expect that consumers having more skin in the game would reduce healthcare costs due to the consumer making better decisions (such as getting generic substitutions over brand name drugs where possible, going to urgent care versus ER, and getting more preventive care).

Several of you have products that allow for plan comparisons. But what resources exist for people to learn basic concepts of health insurance?

Jennifer: Most plan comparison tools offer consumers basic definitions of key insurance concepts.  The problem for most consumers, including those who are highly educated, is that they are not really interested in learning about health insurance.  Most consumers just want to know that they will have the coverage they want, when they need it.  Health insurance is a very complicated financial product.  Clear Health Analytics tries to strike a balance between the few who will want to have a deeper understanding of insurance, and the majority who want to know what they are buying (e.g. Will my doctor be in network? Are my meds covered? Can I see a mental health professional?), and what it will cost.  We offer more in-depth information in pop-up boxes, which allows the screen to remain relatively clean and uncluttered.  Consumers can also visit healthcare.gov and the State Based Marketplaces to learn more about health insurance; they can also consult a navigator, assister or an insurance broker.

Abir: A well-designed product will obviate the need for people to understand the nits and nats of health insurance. In 2015, you don’t need to be able to code in order to use a computer. In the 1970’s, you did. The computer industry developed user interfaces that allowed the layperson to use their product quite easily. With the advent of consumerization, a similar evolution will happen in healthcare. Now, the interface may not be solely internet-based — it may incorporate human components through phone, chat and even in-person meetings. We don’t know exactly what that looks like yet. We do know that a user-friendly interface must and will develop.

With patients rather than businesses as consumers, insurance companies will likely need to change the way they do business. What will that look like?

Abir: As individuals become more accountable for their health care costs, they are also going to start holding the entities that provide them healthcare services more accountable. This includes insurers, providers, administrators, and so on. The pressure from consumers and the dynamic of competition will force everyone to up their game or risk losing the consumer’s business! All of this will have a positive impact on product design and customer service. Insurance companies will need to create products that people actually want to buy. Providers will have to incorporate technology to improve the consumer experience. As everybody focuses on making the consumer happy, we will truly get a consumer-centric system.

As an aside, we need to stop thinking about and referring to consumers in the healthcare industry as “patients.” It’s like calling everyone who purchases auto insurance an “accident victim.” This distinction is important because the way we think about consumers needs to incorporate both those who are actually sick and accessing healthcare, but also those who aren’t and are truly just buying insurance.

A few insurance companies (such as Florida Blue) have opened brick and mortar stores to sell plans and provide customer service in-person. Is this a trend you see taking off? Why or why not?  

Jennifer: This will be interesting to watch.  The medical loss ratio provisions of the ACA have made brokerage commissions increasingly unaffordable for insurance companies.  Commissions are characterized as administrative overhead, which means they must come out of the 15-20% of premium dollars that insurance companies are permitted to spend on administrative expenses.  Insurance companies are looking for creative ways to cut administrative costs, and brokerage commissions are an easy target. Moreover, many insurance companies are eager to get into the private marketplace space.  The marketplace will change many long-standing arrangements in the health insurance industry, including those among insurance companies and brokers, and those among brokers and consumers.

Abir: There is a reason why airlines don’t have brick and mortar retail stores. When people buy plane tickets, they usually want to compare across various airlines and see which one is cheapest and/or most convenient. Likewise, in a consumer driven market, individuals will want to compare across several insurance companies and find a plan that suits them the best. It doesn’t make sense for them to go to a store where they can only get plans from one insurer, being sold by that very insurer.

Each insurance policy has unique coverage constraints, co-pays, agreements with pharmacies, etc. How would you counsel a health insurance consumer to be a savvy shopper when it comes to doctors, hospitals and pharmacies so that they’re paying the least but still getting excellent care?

Jennifer: This is where access to data and innovative technology can really help consumers.  Clear Health Analytics, as well as others, have created – and will continue to create – cutting-edge technologies that can help consumers evaluate costs, availability of preferred doctors, facilities and prescriptions.  One of the major changes that the ACA brought was the elimination of underwriting for health insurance.  This makes health insurance ripe for a major change in the way it is distributed.  Brokers are no longer evaluating consumers for risk – it is merely a matter of matching the right consumer with the right policy, and that is a task that is uniquely suited for an amazing technology platform.  Beyond the insurance purchasing decision, Clear Health Analytics wants to help consumers use their insurance by offering information on treatment options, costs, outcomes, and quality.

Abir: 
I would advise them to get an advisor who is independent, who doesn’t work for their employer, who doesn’t work for their insurance company, and has no financial conflict. Come to Gravie.com – we are open for business!

 

Op-ed: The primary nature of access to care, by Danielle Ofri

The content, views and opinions expressed in this blog post are those of the author(s) and do not imply endorsement by TEDMED. By inviting guest bloggers, TEDMED hopes to share a variety of perspectives that provoke and engage our community in discussion and debate.

Daniel Ofri speaks on the TEDMED stage. [Photo: Sandy Huffaker]

Daniel Ofri opens up about medical errors on the TEDMED stage. [Photo: Sandy Huffaker]

 

“Doctor, it’s taken so long to get this appointment with you.” This is the opening line of so many medical visits these days, and I find myself constantly apologizing to my patients for the delay. Even though both the patients and I know that it’s a systemic issue, it’s still front and center in our personal interaction. They are frustrated that they can’t get a timely appointment, and I’m aggravated because too many medical issues pile up in the interim, making the visits we do have massively overburdened.

The difficulty with access to medical care has been extensively highlighted at the VA hospital system, but is endemic to our entire medical system, even for patients with good insurance plans. Since the Affordable Care Act, some 10 million more Americans now have health insurance. This is an impressive achievement that should be celebrated, but of course insurance is only the first step in improving overall health. Now, these 10 million Americans must find doctors. A survey of 20,000 doctors from the nonprofit Physicians Foundation reports that fewer than a fifth of American doctors are able to take additional patients. More than 80% of doctors are over-extended or at capacity.

What does this mean for American medicine? One possibility is that the Affordable Care Act has placed us on an unsustainable path, something we hear frequently from those who oppose Obamacare. But this only holds water if the prior status quo—allowing a significant swath of America to remain outside the healthcare system—is considered acceptable. Luckily, we are slowly coming around to the ethical conclusion that the rest of the world has already made, that health care is something that all people deserve. Political realities may have forced awkward contortions in our health-care reform, accommodating multitudes of private insurance plans rather than offering a public option—concrete progress has nevertheless been made. So now the health care system must adapt. It can no longer survive on the expediencies of ignoring 15% of our population—it needs to start thinking about caring for all Americans.

A first step is considering how we allocate our existing clinical resources. The Physicians Foundation survey reported that doctors spend 20% of their time doing non-clinical paperwork. If you visualize that statistic carved out from the total number of doctors, it’s equivalent to about 170,000 doctors whose stethoscopes are sitting idle. This is a mind-boggling waste. To not be able to get an appointment with your doctor because she is spending a fifth of each day doing paperwork would sound ludicrous if it weren’t so dangerous. But patients and their serious medical conditions are getting short shrift as their doctors and nurses drown in metastasizing paperwork. Freeing up doctors’ time to see patients—a true measure of efficiency!—could make a real difference in the access problem. Amputating off even half the paperwork would be the equivalent of 85,000 new doctors available for patients.

A second step is to start planning ahead for healthcare that fits the needs of our patients, now that we are getting serious about taking care of all patients. For that, we need to delve a little more deeply into the access issue. Other countries have access issues also, but their long waiting lists relate primarily to specialties and procedures. What is uniquely American about our access problem is that it is particularly difficult to get primary care. Our inability to provide basic medical care for all Americans is what torpedoes the net efficacy of our medical system. Despite our superior technological advancements, we rank dead last in overall health outcomes compared with other developed countries. There is no secret about how to improve this—it’s tending to the basics. Research shows that the more primary care patients receive, the healthier they are and the longer they live. But the American system is not set up for this. Going forward, the only way to have a significant impact on our nation’s health is by improving access to primary care. Expanding training slots in family medicine, internal medicine, geriatrics, gynecology, and pediatrics is a necessary step, because the sheer growth of the American population means that we will need at least 20,000 more primary care doctors, if not more. But alongside increasing the pipeline of primary care doctors, we have to rethink the way we value and reimburse medical care.

It is an embarrassing truth that in the United States access to medical care relates to how lucrative that care is. It’s much faster and easier to get expensive tests and procedures than to take care of your general health. The fee-for-service system has consistently weighted procedure-based services (surgeries, endoscopies, MRIs) as having more “value” than cognitive-based services (treating diabetes, asthma, or heart failure). This absurd and patently profit-driven assessment means that we end up with more procedures and higher bills but poorer health and ultimately less access to basic medical care. Newer payment systems—bundled payments, pay-for-performance, accountable care—have the potential to jigger the balance somewhat. But our fundamental hierarchy remains completely backwards. Until we reverse this and make primary care, well, primary, getting an appointment with your general doctor in the United States will be the Achilles’ heel of medicine. Unless, of course, that heel needs a botox injection.

Danielle Ofri is an internist at Bellevue Hospital, an associate professor of medicine at NYU, and editor of The Bellevue Literary Review. Her most recent book is What Doctors Feel: How Emotions Affect the Practice of Medicine. In her TEDMED 2014 talk, she makes a powerful against-the-grain case that one of the things medical professionals are most resistant to doing would lead to dramatic improvements in care and undoubtedly save many lives.