As a One Medical customer, this makes me very unhappy: even if internal controls protect my data from the rest of Amazon’s business, I struggle to believe that their interests are aligned with mine.
Fuck Amazon, though.
New doctors generally don't want to go into primary care anymore - it doesn't pay nearly as much as being a specialist does, and you are expected to be available to your patients 365 days a year, 24 hours a day (at least that is what many patients think).
It is a pretty miserable business to be in right now, and not sure what is going to make it better.
>New doctors generally don't want to go into primary care anymore
An amazingly high portion of Canadians don't have a family doctor <https://www.ctvnews.ca/health/despite-more-doctors-many-cana...>. In Atlantic Canada (the four easternmost provinces) it is impossible, repeat impossible, to get a family doctor if you don't have one <https://web.archive.org/web/20190226051406/https://www.thete...>. It's one thing to have shortages in rural areas—that happens in the US too—but Halifax?!? I've heard the same occurs in Vancouver too.
I am confused. Vancouver is on the West Coast of Canada while your statement is about "four eastermost provinces". Is it then a nation-wide problem?
Boy, I wish. I've never had a doctor with any kind of special availability. I can leave a message at their office but it's not like I'll get any kind of response until later the next business day, and that will just be from an assistant.
For 24/7 needs that's what urgent care is for, or the emergency room if it's more serious.
HIPAA provides far fewer protections than you probably think it does, and flagrant violations are frighteningly common.
Worse, HIPAA provides no private right to recourse, so even if your PHI is exposed, you're not entitled to a penny in compensation.
HHS may fine Amazon, but to Amazon, $1.5 million (the maximum cap for all violations of a provision due to negligence) might as well be the cost of doing business. And you won't receive one cent of that.
For starters, HIPAA doesn't actually prevent your doctor or health insurer from selling your data to a third party. It also doesn't prevent that third party from giving that data to a fourth party, who can give it to another, and so on.
What happens if one of those tertiary parties has a breach and ends up exposing your data? In theory they're supposed to report it back up the chain, but in practice it doesn't go more than one or two links, if that.
So in short:
- you have no way of enumerating the number of entities who have legal access to your health data
- you have no way of finding out when it's been illegally exposed by any of the parties who have legal access to it
- if by chance you happen to find out about an exposure[0] you have no recourse except to report it to HHS, who may apply a statutory fine, but the fine is typically minuscule compared to the size, revenue, and profit of the guilty party
- if by chance you find out about an exposure of your PHI, you are not entitled to receive any compensation
All things considered, it's easier to enumerate the very limited ways that HIPAA does actually protect you than to enumerate the protections that most people incorrectly think HIPAA provides.
[0] a real-life example is you Googling the name of your partner and stumbling upon a publicly visible Excel spreadsheet containing the name, SSN, addresses, and medical diagnoses of thousands of patients
[1] see above
https://www.ada.org/resources/practice/legal-and-regulatory/...
Eh, that's not exactly true. HIPAA isn't the only (or even primary) vehicle for safeguarding patients from research, and most research is conducted under the auspices of large (usually academic) institutions that have processes to ensure informed consent, which are in turn backed by other legal statutes or contracts. Those aren't perfect, but it's not correct to say that patients provide blanket consent when they begin at a new practice, or that HIPAA is responsible.
But it has some pretty huge holes in it. A lot of telemedicine services aren't covered by HIPAA, for instance.
I'm not worried about Amazon keeping my data in a public bucket, nor about Amazon employees snooping in it -- but I am 100% worried about Amazon pulling some "anonymization" BS and using my data for purposes other than providing health care to me.
I don't trust Amazon with my less sensitive data as it is -- I absolutely wouldn't want Amazon anywhere near my health data.
Some of my family works in medicine and there is nothing that scares the pants off of medical administration more than a HIPAA data breach. There are real penalties for it from the government and they have to be reported. People responsible get fired.
I'm imagining a utopia in which our medical data is as well protected as people think it is under HIPAA.
> Some of my family works in medicine and there is nothing that scares the pants off of medical administration more than a HIPAA data breach. There are real penalties for it from the government and they have to be reported. People responsible get fired.
The penalties are usually in the tens of thousands of dollars. That sounds like a lot, but it's really not when you consider that most breaches for which fines are levied usually affect many patients, not just one, and when you consider the annual revenue and margins of most of these responsible parties.
The fines are capped by statute at a value (about $1.5 million for all violations of a provision in a single year) that is laughably low.
Except your searching for medical conditions on google or amazon is not protected. They know.
The USA has demonstrated time and time again a pattern of fining corporations a minuscule amount in comparison to the damage done.
Besides, even before it comes to fines and it's in discussion in Congressional chambers, Amazon lobbyists can say to practically any senator or congressman/congresswoman: "you want to go against us for antitrust reaons? Oh well, guess we're going to have to close that Amazon warehouse in your district that creates so many jobs...and oh yeah looks like that Whole Foods in your district isn't profitable, we're going to have to close that one up too."
They don't even need to lobby. They can just pay the fines. The fines are capped by statute at an egregiously low value, which to Amazon is chump change.
Why is that even remotely acceptable in a democratic society?
Amazon isn't actually doing this, and it isn't actually acceptable.
HIPPA fines are public, if they did this even once everyone would know.
See the big banks collective responses to regulations placed on the financial industry in the aftermath of 2008 - if the fine is significantly smaller than the potential for profits, they will do those activities and pay the fine 100% of the time. This mentality is evident in many other sectors as well, especially with publicly traded companies.
Yes, I know HIPPA fines are public. However, Amazon has enough money to not care, and to never care. You know how many labor laws Amazon has blatantly violated and not cared? If they can capture an entirely new vertical (healthcare), their share price will increase despite looming lawsuits and pesky regulations. Amazon is a multi-trillion dollar company that focuses on growth at any and all costs.
You wrote a whole paragraph about something that never actually happened, and that shows no sign of happening.
And you wrote it as if it actually happened. It's quite astonishing to read.
The fact that the penalty for many serious violations consists of fines that represent a tiny fraction of the company's worth means that breaking the law is an easy economic decision for companies. Fines are just a cost of doing business, and not even a major one.
But fortunately their business model has been about providing a superior level of care for a small extra fee, and presumably Amazon is buying them for that strength. Otherwise it would be a pretty pointless acquisition.
But who knows, maybe now there'll be a discount if you have a Prime membership or something. :P
There are plenty of Amazon acquisitions where the service got worse post-acquisition, was relaunched as something else, or was simply shuttered.
There were some temporary hiccups at one point with a new backend system but that was all.
So I don't see why they wouldn't be doing the same they've done with Whole Foods, which is maintaining the high level of service, because that's the proven successful business model.
True in Wyoming and the Bay Area, too. Produce and fish aren’t as fresh as competitors. It’s cheaper. But not premium.
The food is the same. Nothing has changed that I can tell.
Same hot/cold bar. Same produce. Same meat and fish. Same in house brands. Same pizza. Same bakery.
Main differences are just a lot more self checkout and areas for Amazon returns. And Prime discounts of course.
What food do you think got worse?
The only store that has consistently better produce at scale than Whole Foods in NYC is Eataly, but it's more expensive and there are only two of them. Before that there was Dean & Deluca but they've long since gone out of business and their prices were astronomical -- but I swear their produce section was like a museum and the vegetables were almost works of art.
I find it funny that when you drill down, the only supposed quality decrease is in the "freshness" of produce and meat, the two things that are ultimately the most subjective. I've shopped at a lot of supermarkets for a long time, and I truly have to wonder if people are simply imagining a decrease in freshness simply because it fits a preconceived narrative that if Amazon bought it, it must have gotten worse.
Because with my own eyes and taste, I don't see it at all. And it's not like this is ancient history hard to remember -- Amazon only bought WF five and a half years ago.
The difference in quality has little to do with "freshness." I recently studied the difference between Whole Foods and Fresh Direct in some detail. Fresh Direct is generally 20% more expensive than Whole Foods. We were looking to cut our budget, so switching from Fresh Direct to Whole Foods was an easy choice. However, after a few weeks, it was clear that the quality just isn't as good.
Here are a few examples:
1. Fresh Direct has heritage raised chicken and pork. The chicken, in particular is amazing. It's much smaller than a typical chicken, way more flavorful, and the color of the meat is so interesting. The dark meat has a beautiful purple luster not found in the Whole Foods chicken.
2. The "Animal Wellfare Certified" meats at Whole Foods are all step 1 or step 2. Fresh Directly has many step 3 and step 4 options.
3. All of the Lancaster Co-op produce is really good. Can't find anything like it at Whole Foods.
4. We eat a lot of fruit during the summer. Certain produce at Whole Foods is just bad. Like I could not buy a good organic peach at Whole Foods. They always came rock hard and never softened.
I mean, these "subjective" things are basically the only thing Whole Foods has going for it. Every grocery store chain stocks "natural/organic/wellness" brands now, most at cheaper prices than Whole Foods. The quality of the produce is essentially the only reason to shop there.
The differentiators - usually reflected in motivated staff with the freedom to solve customer problems, but also in the case of WF a focus on quality fresh food, etc - will be relentlessly driven down.
WF continues to be "premium" but it's definitely not the same chain that it was a decade ago.
My reasonable hopes stemmed from what HEB has done with sub-brand Central Market. While CM isn't quite as awesome as its high point, more CM goodness has rolled into regular HEB than bean-counting into CM.
It does? Not in my area. I've never been a Whole Foods customer, but my friends who were have universally said that it has become much worse.
This is a trope that needs to stop. Public companies are not alike and the fiduciary duty is only a very high level one that can be used to justify both squeezing every customer as much as possible to losing money to support growth.
What the shareholders want matters and an acquisition changes that completely.
This is a fake rule that people love to repeat. It isn't true.
E.g., but feel free to google it yourself -- there are a multitude of articles on the subject: https://www.nytimes.com/roomfordebate/2015/04/16/what-are-co...
But yes, a board of a for-profit corporation must pursue profits to their full reasonable capability. If they neglect that duty, they will be sued and replaced. This is, for example, why Twitter had no choice but to sell to Elon. Because that was most profitable to shareholders. Otherwise the board would have been taken to court and lost. That is fiduciary duty to profits.
The idea that it's a "fake rule" is also something people love to repeat. But that isn't true. A publicly traded corporation simply cannot choose to forgo profits for all time and invest in customer service instead, for example. There absolutely is a fiduciary duty to make decisions that are ultimately profitable. (But that obviously goes along with flexibility to e.g. invest more to defer profits, invest in nice offices to attract better employees, etc.)
No this has been explicitly rejected by the court. The fiduciary duty a company has to it's board is to not screw them over. A company has the freedom to leave money on the table in order to do the right thing. Your shareholders have no grounds to sue you if you are doing something that doesn't produce 100% profit but still produces reasonable profit.
My guess is Amazon sees hospitals/practices starting to use more "cloud-y" services and wants to set themselves up to capture as much of that revenue as possible. The old hospital IT-fortress model leaves a lot of efficiency gains on the table and I'm sure AWS would love to be able to capture all of that.
source: I work at a "cloud-y" medical tech company
That all depends. There are serious limits to where HIPAA applies. Not everyone who who handles medical data is bound by it, for starters.
This is true, but not true of anyone working at One Medical, since health care providers are bound by HIPAA. If you tell your friend you have cancer, sure, they can legally share that info. If you tell your faith healer, or your employer, they can as well.
If you tell your PCP (or your PCPs app, or their secretary), and they share that with Andy Jassy without him being cleared to handle PHI, they're in for a mountain of fines.
As much as I like being cynical about surveillance capitalism, I don't think Amazon's primary motivation here is patient data, at least in the short-to-medium term. If they wanted the data, they'd buy, like, a vitamin company or something.
This is a very good point.
Nonetheless, I think that being cynical about anything Amazon is up to isn't unwarranted.
My primary personal problem with this deal is that I do my best to avoid doing business with Amazon at all, and the more tendrils they spread, the more difficult this will be.
100%. I still don’t think having the 21st century standard-bearer for anticompetitive practices move into healthcare is a good thing by any means.
On a more practical level: Amazon is gargantuan, and I don’t necessarily trust them to have the scoped vision necessary to run a good medical practice, rather than just a large one that fits their portfolio. This is true for any large company; Amazon is large even by large company standards.
They'll have to be a bit careful with regulation here if they do try it. Clinical trials are where you do that sort of thing.
For the human individual person, the interests (the goal) is to care for their health; but amazon is a corporation: for them the real goal is profit, not health.
I'm saying that for the human the incentives should be all about health. the money, the costs are the "obstacle".
On the other hand, for the corporation the incentives are the profit. The health is a cost (or "obstacle").
with this 'frame' in mind I'm saying the incentives are not aligned on their own because the priorities are in conflict.
What's truly the problem here, is how healthy patients aren't 'good' customers of health-services. Then again, this is not a problem unique to Amazon, but they're getting into this 'rodeo'.
throwing a capitalistic-optimizing 'machine' into health services has been a huge mistake which is seemingly impossible to fix... this is how systems collapse; when the system is so resistant to fixing its 'problems' that only changing the entirety (or a significantly larger chunk) of the system fixes the problems; but the problems have to be 'life or death' (or 'do-or-die') level for this to kick in.
the biggest issue is that for a level of the system there is no problem, people die anyways. but for another level of the system (the human individual perspective) this IS a problem. if/when the system ignores a level of itself it becomes unstable like it's happening now.
One Medical is there to make money. Amazon will make One Medical more efficient at making money, even if that means forcing you to be healthier.
How?
One nagging problem with healthcare is doctors believe that medicine isn't a cookie cutter problem when in fact it is. For the vast majority of conditions there are standard treatments that work. If that wasn't the case modern medicine wouldn't exist.
Every doctor can whip out some corner case and say "but what about this." Sure, that's great. But for condition A the standard treatments usually work. The trick is to know when the standard treatments aren't working and what to do.
Amazon, or any healthcare company with enough data, can look at the data and see what treatments actually work and what treatments don't. It's not a hard problem, really, but traditional health systems don't care, and to be frank, academic researchers are basically too lacking in imagination to understand how to do it or why it should be done.
Amazon at the very least will try to apply quantitative methods to the problem.
However morally abhorrent this practice may be, I do not trust Amazon to NOT do this if there aren't any laws against it, which is why I am against this acquisition. I know some people may find it debatable, but I believe healthcare should be run with a Kantian framework where every life is priceless rather than a utilitarian one.
I have some hope that they can do something that's better than the low, low bar that is the US healthcare system.
Edit: Thought about this some more, and I think consumers shouldn't be nearly as worried as doctors, nurses, pharma cos, and insurance companies.
Amazon is cutthroat in its dealings with stakeholders who aren't its direct customers. Amazon has no issues squeezing book publishers, vendors, and employees. They justify this as the means of getting the best price and experience for customers. Translate that to the healthcare industry and I'm not sure what to think. Some of the actors in the space could use a wake up call, but overworked nurses, GPs, etc. are not ideal.
- Standardize health records (detailed visit summaries, all tests and lab results, all visits to referrals or specialists)
- Fast appointment times (single digit days)
- A minimum standard of service. Doctors who won't immediately rush you out the door without solving the root cause, who won't prescribe you medication that they were sold over lunch, who'll listen to your symptoms, and because the outcome is measured by Amazon's uncaring data collection machinery, they're incentivized to actually solve the issue.
- Affordable health insurance plans and prescription drugs
The above is already leagues ahead of what my friends and family have access to or deal with. For those with the means, I'm sure there will be premium offerings that may check some of the boxes you're looking for. I think there's space for Amazon's uncaring, industrial approach to do good for people and improve quality of life.
> I think there's space for Amazon's uncaring, industrial approach to do good for people and improve quality of life.
> [I want a] minimum standard of service. Doctors who won't immediately rush you out the door without solving the root cause, who won't prescribe you medication that they were sold over lunch, who'll listen to your symptoms, and because the outcome is measured by Amazon's uncaring data collection machinery, they're incentivized to actually solve the issue.
Anyone who has actual clinical experience will tell you that an "uncaring data collection machinery" does not incentivize anyone to "actually solve the issue". Quite the opposite: the reason that the patient experience has gotten worse over the last few decades is because the industry has already been moving towards an "uncaring data collection machinery", while simultaneously squeezing providers and narrowing their already-small margins[0] and as it turns out, uncaring data collection machineries don't care about patients.
Amazon's entire modus operandi fits very well with the absolute worst[1] forces that already exist within the healthcare industry, so it's quite hard to imagine a world in which this actually works out to patients' benefit in the long run. They might sprinkle a few shiny bells and whistles on top to placate people's fear, but actual care delivery is going to suffer in pretty much every way that you list aspirationally.
[0] People sometimes treat this as a victory because they think that it'll lead to lower healthcare costs, but providers' pay actually makes up a very small fraction of healthcare spending in the US. Even if you could eliminate those costs entirely without impacting clinical care delivery or patients in any way (which is impossible), it would still translate to a 15% reduction (which wouldn't even be passed on to patients anyway, because the system incentivizes insurers to increase costs on the claims side to increase their own earnings)
[1] worst for everyone involved except shareholders
I'm not sure this is true. The current implementation -- maybe. But the incentives, from an outsider's perspective, seem to align?
1. Healthy patients cost less in the long term. Solving for long term issues (type 2 diabetes!) vs. the immediate issue and getting someone out the door is profit seeking.
2. Patients being alive continue to pay service fees is profit seeking.
Why would Amazon not aggressively track outcomes, measure every dimension of provider care, and ruthlessly fire / downgrade low performers to maintain the above goals?
This is an extremely common misconception. Luckily, you've picked a really easy example to illustrate.
"Solving" type 2 diabetes is an incredibly tricky problem. It's not something that can even be measured in the short-term, let alone solved. It's also quite individualized, more so than probably any other common diagnosis except cancer. There's no magic bullet intervention, and it takes a lot of active work to build the provider-patient relationship to a point where it can identify the appropriate interventions for that patient, identify problems with those interventions, and help the patient execute on them successfully.
Because it's so individualized, and because it's so long-term, any system designed to "streamline" that is ultimately going to fail, because the curse of dimensionality will inevitably collapse away the requisite information, and the pursuit of short-term profit will inevitably cause the system to prioritize short-term interventions over long-term ones which will actually address the issue.
"Healthy patients cost less in the long term" is technically true, but there's no way of turning unhealthy patients into healthy ones that doesn't, in aggregate, cost more than the theoretical savings.
> Why would Amazon not aggressively track outcomes, measure every dimension of provider care, and ruthlessly fire / downgrade low performers to maintain the above goals?
Again, this is an incredibly technocratic approach to a field (care delivery) that requires a different approach. It works if you assume that negative outcomes are the fault of individual providers ("low performers") and that individual providers have both the agency and resources to solve arbitrary cases. In practice, that's almost never the case: there are way too many confounding factors that impact clinical outcomes, and providers are quite limited in their power compared to other players: the insurance companies, the administration of the system they work within, and most importantly, the patients themselves.
Honestly, the only way you could meaningfully "fire low performers" is to identify patients who aren't performing well and then drop them. Which is, in a way, what the health insurance system does... but we tend to consider that an antipattern.
While digesting that unpleasant postulation, I will refer to a second order effect, and that is .. always on electronic ID with de-facto location tracking, entering into the commercial info fabric. Legislators be warned, this is going to change, and change, and change again the social fabric as real people fall into health problems and life changes, and no longer run their relationship with public information about their conditions, and that it is linked to a (profit-motive) law enforcement fines, court conditions and oversight, one at a time on a very large scale.
Your experience with Amazon's customer service and my experience with it are completely opposite.