Last week, I read an article entitled: Employers Shift Rising Health Care Costs Onto Millions of Workers. While the majority of Americans—157 million—get healthcare from their employers, the article explains that “Many people are also paying thousands of dollars in medical expenses when they get sick, because companies have increased the plans’ deductibles to offset increases in premiums.”
A separate sobering study from last week reported that more than one in a quarter of Americans are facing medical debt, with one in six having more than $5,000 in medical debt. A particularly sad anecdote—though I suppose not entirely surprising for the American healthcare system—was from a young woman in Nebraska: “[One] patient, Maggie Williams, 28, a mother in Omaha, said she ended up with more than $20,000 in hospital bills she couldn’t pay after she required treatment last year for a high-risk pregnancy. She had qualified for Medicaid but lost eligibility, she said, after her husband’s income rose. While she was able to obtain coverage through his policy, she said, she still had the five-figure bill.”
With this all as the backdrop, the narrative is ripe for the claim that the efficiency of A.I. may save the doctor-patient relationship, the insurance industry—or even that one day, A.I. may even replace doctors and auto-diagnose or prescribe to patients who are desperate for quick and cheap care.
I spoke with Vamsi Varra, M.D., a dermatologist and machine learning scientist based in the Bay Area who has mixed feelings about the use of A.I. in medicine. He says that people who believe that A.I. will replace doctors “are deluding” themselves. Yet he reiterated that the issues in the healthcare system remain significant, including burnout of clinicians, and the top-down pressures from monied interests forcing the consolidation of practicing doctors—as well as an emphasis on patient volume rather than proper care. Dr. Varra is concerned that with A.I., the powers-that-be will use it as a tool to further consolidate power rather than as a remedy to solve many woes of the medical system.
This year, Dr. Varra started his own telehealth platform, in an attempt to ethically and asynchronously communicate with more patients without corporate medicine pressuring him to do so. Dr. Varra doesn’t use A.I. with his platform, mostly because patients have so little trust in its results.
“Patients don’t trust the quality of the A.I.—or what companies are going to do with the data they put into A.I. applications,” Dr. Varra told me. “I don’t trust it either.”
However, Dr. Varra has seen some interesting use cases for A.I. in dermatology, including a public research model that was trained, using predictive A.I., on over a hundred thousand images of benign and malignant skin lesions. Each image was meticulously labeled by a human dermatologist—allowing the model to learn and associate the pixels in the images with the association of being benign or malignant. While this model was confined to the research setting, Dr. Varra can see other potential A.I. use cases reaching real-world clinical deployment—including the automation of prescription acne topicals, because the risk of the wrong topical for retinoid acne is ostensibly non-existent.
Outside of dermatology, Dr. Varra posits that A.I. can be a helpful tool in getting certain test results for patients faster. For example, getting a blood cell count via blood smear can be very tedious when done manually; today this task is fully automated. He also points to the benefit of “ambient scribes” in taking notes and thereby preventing doctor burnout. However, this is not a panacea either: a recent study from the University of Edinburgh found “patients could be less likely to share personal information such as substance abuse history if they knew the conversation was being processed by AI.” Beyond that, there are many questions that arise as to where and how that data is being hosted and stored.
With the recent Elizabeth Holmes-Nathan Fielder film as a backdrop to our conversation, Dr. Varra is also concerned about the potential for A.I. hype in healthcare. To that end, Dr. Varra is actually in the midst of aiding the Utah Office of Artificial Intelligence Policy in reviewing an approved proposal for a pilot to automate acne prescriptions in Utah. It initially speaks of humans being involved in the validation process; however the documentation for the pilot—launched by Nolla Health and focused on assessing acne from patients’ photos—cites seemingly non-existent papers, which Dr. Varra thinks might be A.I. hallucinations.
Utah’s pilot program is not limited to dermatology, either: another pilot from Expect Fitness will offer “virtual pelvic floor therapy for women in the state to help with urinary incontinence, pelvic pain and postpartum pelvic floor problems.” Dr. Varra has since communicated his findings to the Utah Office of A.I. Policy. The office stated they communicated Dr. Varra’s findings to Nolla Health, who in turn sent the Utah office errata which will be updated on the office’s website.
Perhaps the one use case where some people—even skeptics—can see use for A.I. is in drug discovery, development, or novel treatment within healthcare. Some of that has been born out: last year, A.I. helped a doctor in Philadelphia repurpose drugs for conditions including rare and aggressive cancers, fatal inflammatory disorders and complex neurological conditions.
But drug development is of course different from A.I. being used in the actual administration of care via scheduling, for instance. A WIRED report describes the challenges nurses at HCA Healthcare face with Palantir’s automated scheduling system—including inexperienced nurses being scheduled at the same time, leading to the one experienced nurse being taken away from a critically ill patient to train the less experienced nurses. The same report speaks to mass burnout among nurses, and how they are unable to contest their schedules locally with their hospitals—instead having to reckon with HCA headquarters, the largest hospital chain in the United States.
One doctor reported to The Atlantic that “his hospital had enlisted A.I. to draft messages to patients on his behalf—sometimes producing output for his review that he described as ‘completely absurd.’”
And generally, the healthcare industry is prime for power consolidation, as it is increasingly becoming vertically integrated. Insurance companies like Aetna are owned by pharmacies like CVS—which also has its own pharmacy benefit manager (PBM), CVS Caremark, to negotiate opaque drug rebates with pharmaceutical manufacturers. Insurance companies like Cigna own specialty pharmacies, and gargantuan hospital systems own doctors offices. Many parties are often engaged in self-dealing circles—in cahoots with big pharma companies—that unnecessarily raise the prices of drugs for patients.
Astra Taylor, the activist and author of End Times Fascism, points out that A.I. may actually be costing the healthcare system more, because hospitals are deploying A.I. to overbill private insurers, and private insurers deploying A.I. to combat the hospital billing, leading to a war of the bots. Taylor says that this has cost Americans over $1 billion in excess healthcare spending.
So while some argue A.I. potentially could be used, in certain realms—to make things better for patients—in reality, it may actually be used as an excuse for cost-cutting and enriching just a few—namely the hospital, pharmacy, and insurance executives (and the makers of the A.I. products). To that point, the intrusion of A.I. into the healthcare system mirrors its enablement of power consolidation in literally every industry, including entertainment and media.
While Dr. Varra may disagree with someone like Astra Taylor on the unequivocal badness of A.I., he still believes the healthcare system needs a desperate overhaul. “When you look at the amount of independent physicians now versus a decade ago, you realize that we have an extreme consolidation of healthcare,” Dr. Varra told me. “Every single aspect of healthcare is very monopolized and consolidated; incentives don’t align with what patients or providers want. Beyond a few exceptions, strategies will be implemented for the sake of profit.”
What else we’re reading…
Anthropic’s IPO prospectus describes a future “age of miracles,” replicating fantastical salvation language that others have used to describe A.I. and its benefits. (Of note and relation to this piece: Anthropic CEO Dario Amodei has claimed that Anthropic has the potential to “cure all diseases.”)
Former Yahoo CEO Marissa Mayer is getting heat for declaring that she had to ask her A.I., “Dazzle,” to help her think of three traits to describe her daughter.
This is a very cool chart from a Brown student mapping where data workers manually annotating A.I. are based.
Microsoft is offering a voluntary buyout to 60,000 employees—a whopping 27% of their workforce. It mirrors predictions that knowledge workers may see more voluntary buyouts from corporations as white-collar labor is devalued.