Corpo-Normalization of Hospitals Without Walls
We must stop this trending healthcare “innovation” before it’s too late.
I’m sharing a quick essay I wrote about a catchy health care scheme that is not getting the scrutiny it deserves right now. This public-private initiative is a doozy and spells bad news for America’s already violent and awful approach to health equity. This is a recommended read for anyone who was a fan of the piece I shared in October, called The Vengeful Specter of Cuts to Medicare Advantage.
In other news, Death Panel just released a truly fantastic episode this morning that I am really proud of and want to plug. We were joined by friend of the show and social epidemiologist, Abby Cartus, whose specialty is peri-natal mortality, to discuss the recent updates on Texas’ draconian abortion ban, SB8.
The episode—which as you can see, comes highly recommended—is currently for Patreon subscribers only. It’s worth the sub. This episode is comprehensive and hilarious, we dig into the oral arguments heard last week at the Supreme Court and one study that shows the law already reduced abortions by 49.8%, and wonder just what, exactly, it would take to get anyone to do anything about it. Here’s an extended preview.
[Image description: Meme, the background image is a vintage sci-fi illustration of a robot carrying a limp human man wearing a tight white shirt and red track pants through a futuristic tunnel that looks like it’s something out of a Hito Steyerl installation. Behind is another robot and behind that robot is a yellow road leading to a futuristic-looking city under a bright blue and cloudy sky. On the robot is text which reads “Medicare for All” and on the man is text which reads “You”]
The Corpo-Normalization of Hospitals Without Walls:We must stop this trending healthcare “innovation” before it’s too late.
On October 14th, 2021, a new advocacy effort called The Advanced Care at Home Coalition was launched to lobby for increased access to acute-level care and recovery services provided not in a hospital or rehabilitation facility, but in the patient’s home. The Advanced Care at Home Coalition (ACHC) is founded and funded by a slew of major health industry players including Mayo Clinic, Kaiser Permanente, Johns Hopkins Medicine, University of Michigan Medicine, and University of North Carolina Health.
This group argues that society has progressed to the point that the hospital has become obsolete, pointing towards a decentralized “way of the future” approach which has become a common strategy in for-profit healthcare groups in the last decade. The initiative is also supported and seemingly driven by a “hospital without walls” company called Medically Home, which is a platform to enable “health systems to safely admit patients to their own homes rather than the hospital for acute and restorative care.”
Kaiser-backed ACHC is not the only astroturf organization that’s popped up around this issue, in March of 2021 the Moving Health Home Coalition (MHHC), backed by Amazon Care, Intermountain Healthcare, and Ascension was founded to lobby regulators and agency administrators on the value of CMS funded “hospital without walls” care initiatives. Amazon-backed MHHC’s first effort centered on a push to make significant changes to Medicare reimbursement rates, with one of their key issues being to urge CMS to pay the same rate for in-home acute care as the 2022 Medicare Physician Fee Schedule for a primary care office visit.
Home-recovery acute care services have been a booming sector for venture capital money, with a slew of recent investments, partnerships, and acquisitions in this space being reported over the last year. While these narratives pop up regularly in industry trade blogs like Fierce Healthcare, I have seen little penetration of this coverage into news cycles beyond the specialist press, which is why I wanted to draw people’s attention to the growing corpo-normalization of “hospitals without walls.”
[Image description: Meme, the background image is a vintage sci-fi illustration of a large skull-headed bat beast in the center of the picture bearing down chasing a man in a business suit in the foreground through a barren orange wasted landscape. On the monster is text reading “Medicare for All” on the man in the suit it reads “hospitals without walls”]
These corporations urge that their “tech-enabled strategy” limits strain on already COVID-burdened hospital systems, drives better outcomes because of the positive vibes of recovering in your own home, and (yep, you guessed it!) reduces costs. National Nurses United (NNU) wrote in a statement that they were “horrified...by [these] recent attempts to redefine what constitutes a hospital and what counts as nursing care.” The nurses’ union, which has supported the Single Payer cause for decades now, wrote:
“Not only does this program endanger the imminent safety and lives of patients, it completely undermines the central role registered nurses play in the hands-on care that patients need to safely heal and recover. … We reject Kaiser’s assertion that iPads, cameras, monitors and the occasional visit by likely lesser-skilled and unlicensed personnel are in any way comparable to the skilled, expert nursing care and social-emotional support we [registered nurses] provide every moment of every shift,”
As Fierce Healthcare reports, in NNU’s statement they argued that “the primary driver for these programs is not to improve patient care or satisfaction but the ‘relevatory idea’ that they will be able to shift hospital overhead costs onto the patient by sending them home.” In response, both provider platforms like Medically Home and their astroturf shields like Kaiser-backed ACHC or Amazon-backed MHHC, argue that standards of care are not compromised by the patient’s locale.
In reply to NNU’s appropriate outrage, Kaiser defended its partnership with Medically Home, saying, “Regardless of whether the patients are receiving care in the comfort of their own home or in a hospital, we hold ourselves to the same high standard of care. The program empowers multidisciplinary care teams to provide the right care at the right time meeting our patients where they want to be." That is certainly the impression that one might come away with after watching one of the many television appearances promoting these advocacy efforts.
The picture painted in this TODAY Show spot is certainly an idyllic depiction of what in-home services and supports and in-home long term care (LTC) should look like—but the important distinction is that what is being shown is explicitly not LTC. It is acute care, provided in-home. This segment paints so compelling a picture of these tech-driven initiatives that I almost didn’t include it for fear that it would be too convincing against the argument I want to make here, so please keep in mind when watching that this is acute-hospital in-patient care, normally billed to CMS for care provided in a physical hospital, in the home. A “hospital without walls” not long term care or in-home services and supports. Kaiser-backed ACHC publically insists that its advocacy is for services that are only intended for short-term care encounters, primarily as a way to help elders “prevent or recover from an illness, injury or hospital stay.”
TODAY Show anchor, Vicky Nguyen, leads the segment by stating that, “It’s pretty incredible, doctors we spoke with say patients recover faster, and hospitals can save up to 30% in costs which then can lead to lower healthcare prices for us, as consumers.” The priorities here are not just heavily implied but rather, barely disguised capitalist desires under the banner of improving patient health, healing, and happiness. Its worth noting that the “doctors we spoke with” refers to doctors who work either for home-health tech platforms like Medically Home—including the doctor who designed their care coordination framework—or who are working on behalf of these companies as doctors being observed in ongoing studies paid for by these same corpo-backed advocacy groups.
The patient depicted in this video has a large and spacious home, with room for medical equipment. The platform even installs an old-school landline phone that connects directly to the Mayo care team at their centralized care hub. The “care hub” itself is bleak and looks suspiciously like if a 9/11 dispatcher was outfitted with a dystopic surveillance system like healthcare Batman spying on the elderly and disabled people of Gotham. Not all patients have access to a living space that can accommodate this setup.
Beyond that, it quickly becomes clear that many of the cost-savings from the hospital will come from the unpaid labor of the patient’s family who may be unable or unwilling to provide that care. It seems laughable that Kaiser could in any way insist that standards of care are maintained when for the vast majority of the day a patient is not receiving one on one care in person from Kaiser’s staff, but instead is interfacing with Kaiser staff remotely and being provided with in-person care by their family or whoever else might reside with them in their home unless on a rare occasion a visiting care team member is there. Seems like a dangerous breach of duty to call them “standard morning rounds” when the team is not seeing the patient in person.
I suppose if the patient were wealthy enough, they could hire in-home nursing or long term care to compliment the acute-remote-in-home services in order to remove the labor expected from the family onto yet another corporation’s payroll, but that supposes that all patients will be from a particular class position and capable of bearing that expense of care labor on behalf of the hospital. Because that is just one of many of the overhead costs that hospitals like Kaiser are asking patients to bear, in order for the privilege to potentially pay less in notoriously-consistent and transparent itemized hospital prices down the line. It sounds like a bad deal if you ask me. A really bad deal.
[Image description: Meme, the background image is a vintage sci-fi illustration of a green hairless lion-like creature standing on top of a blue rock jutting out of a foreground of blue sand. Buried in the blue sand is a skeleton in a spacesuit with a cracked helmet. The crack in the helmet reveals a skull that reflects the green and blue hues of the desert alien landscape. In the background are a series of blue mountains and an orange sky. On the lion is text reading “Medicare for All” and on the dead astronaut is text reading “public/private health finance innovation” with scare quotes around the word “innovation”]
So where does this horrible, extractive, exploitative, and hyper-capitalist healthcare innovation come from? None other than a McKinsey alum, with generous funding from venture capital funding. Rami Karjian, the CEO of Medically Home worked for McKinsey for over a decade and has significant experience “improving patient flow” across hospital systems—whatever that means, I’m not entirely sure. I would love to hear your thoughts on this in the comments. Karjian eventually went on to lead McKinsey’s Asian Operations team before jumping ship to get involved as the president of a reverse-logistics company called Flextronics.
Since 2015, Karjian has focused his efforts on virtual “hospital without walls” technology services like Medically Home. Karjian’s general ideology is summed up well in an interview he did to celebrate raising $80 million dollars for Medically Home for some spammy-sounding podcast on a blog from a company called Pantera Advisors which seems to be like an inspirational blog for people who want to be entrepreneurs:
Rami Karjian: [...] The core idea of the company is it treats patients in their homes with all of the care and the services that they would have received in the hospital. It’s a mix of telemedical care with an iPad, and a phone, and devices and in-person care with nurses and others going into the home. But the key point is, these are patients who otherwise would be in the hospital. Our very first patient, Chuck, that we had all worked so hard to set everything up to care for – when we admitted Chuck into the program, Pippa, our Chief Medical Officer, who is still with us from back then, was explaining to us what the patient was like, and she was saying, “Look, he’s legally blind. He can’t hear. He’s very old, and he’s been in and out of hospitals six times in the last 18 months.” We thought that’s quite a patient to start in – very, very sick, high acuity. I remember a phone call that my partner Raphael made to our customer CEO, Steve, and the reaction was from Steve was like, “Wow. That patient sounds like he’s really sick. Are you sure he doesn’t need to be in a hospital?” Raphael, without missing a beat, said, “Well, he is in a hospital. He’s in our virtual hospital.” That adrenaline of the first patient and such a hard first patient was really something, and it set the course for our company because now, we’re known as the high-acuity, very, very sick patients’ hospital-in-the-home people.
Alejandro: In terms of explaining a little bit more on the business model, how do you guys make money there?
Rami Karjian: Our business model actually shifted, and it was one of the big learnings for us to be open to where the market could go. When we started, our business model was, we would provide all the care to patients and their families, like Chuck. What we learned was, the need in the market was to have somebody who could enable really high-acuity, high-quality safe care on behalf of other health systems which would deliver it themselves. So, we switched from a care delivery company to a platform that enabled other health systems to deliver the care. So, the core business model is, we enable our customers, large health systems, who want to provide safer, better care to their patients, and we essentially charge them for virtual beds. So, say that a hospital may build a new tower that might have 50 new beds in it, we help our customers build new virtual towers on top of their existing hospitals, and then we charge them per bed.
Alejandro: That’s amazing...
Here you can see Karjian teasing out where Medically Home actually makes its profit, which lays bare their reliance on the shouldering of overhead costs on patients, especially labor costs, in exchange for what would normally be one bed in a physical hospital.
Karjian states that they had initially planned to provide the staff themselves, but clearly there was a realization that the labor costs were too high there, and so they shifted strategy towards the platform model, carving out a tidy little niche for their corpo-parasitism. NNU’s accusation that this partnership is only to the benefit of the hospital systems is not an exaggeration, the business model of Medically Home was not only designed to do this but re-designed, with a fully tailored overhaul to reorient their business towards this model, when the first one didn’t pan out.
I regret having to use the term “business model,” because to call it simply a business model is distancing and dullens our capacity to comprehend precisely how the surplus profit is actually extracted in this capitalist market relation. How exactly is the sausage made, where does the surplus actually come from? Who does the surplus come from?
Building on that line of inquiry, one has to wonder next, how much the multitude of medical equipment, on 24/7, has added to the patient’s overall electricity bill? How many more hours will caregivers be expected to labor for free? (Labor for free not “for” their kin but “for” the hospital...) What abuse and neglect could reasonably occur in this model of care which would be of no issue in a brick and mortar hospital? What issues of privacy this raises? What is the cost of that privacy? Is there data generated? Can that data be sold? Can that labor cost to compile the profile and administer the care be reclaimed? Resold? Where does the surplus come from? Who does the surplus come from? How does the surplus get made?
This process of inquiry reveals what Marta Russell called “the money model of disability”—which I argue should not be limited to the realm of disability politics. This method of extraction is the fundamental vibe of racial capitalism. Artie and I argue this in our forthcoming book Health Communism, and Da’Shaun L. Harrison argues similarly in their new book Belly of the Beast: The politics of anti-fatness as anti-Blackness. To bring in Harrison’s sharp critique of these extractive forces as a mechanism of anti-Blackness, I’d like to bring in this point from their book about how this violent relation behaves contingently at the intersection of white supremacy and American diet culture:
For anti-Blackness and anti-fatness to be legitimate subjugating and objectifying structures, their existence had to be predicated on a Thing unobtainable by Black fat subjects. That Thing is health. In other words, to legitimize race, sex, and class statuses, health had a job to do. That job was to ensure that the Black—which is, too, the fat—was always fixed to be something that Black fat subjects could not be. This leads to the birth of the medical-industrial complex—an institution built and sustained by race scientists and eugenicists dedicated to the continued Death of Black fat subjects. Said again: to be Black and fat is to always live as Dead, and “health” ensures that… Health, in name and in action, has always existed to abuse, to dominate, and to subjugate. The medical industry, the health care industry, and the diet industry all exist to maintain a culture intended to “discipline” those whose bodies refuse to—and, for many, simply cannot—conform to the standards of health.
This criticism of the deadly racism of American health culture might at first seem unrelated but is in fact an important complication to this policy landscape which “hospital without walls” advocates seem desperate to avoid discussion of.
For example, if we were to take these entrepreneurs at their word, then this benefit which “has such better outcomes” than in-hospital care would be largely inaccessible to people already categorically underserved by the American healthcare system due to the imposed inequity of access to care along racial lines. It would also disadvantage all those in rural areas, or those simply with poor internet access, and of course, anyone who doesn’t live in spacious housing or have a stable and reliable electric grid.
Categorically these initiatives are also anti-fat because in-hospital care provides access to robust diagnostics equipment with adaptive exam equipment, which much research has shown comes at a premium when bought at the consumer level (a reason why many private medical practices are inaccessible in clear and flagrant violation of the ADA). The policy preferences being pushed by the lobbying efforts of Kaiser-backed ACHC and Amazon-backed MHHC are then intended only for white, wealthy Americans with large homes and loving biological families with free-time.
NNU raised concerns about this initiative’s capacity to heighten racial and class disparities in care outcomes as well, arguing that the programs have a clear bias towards those with better housing, resources, and social networks. Furthermore, I would add that it has a clear bias towards those who can afford to upgrade their homes with even the most simple modifications like indoor or outdoor ramps to make the home accessible, an expense that many disabled and elderly people are unable to afford.
This is not a population that capitalism has ensured has a few thousand dollars just lying around to throw at making medicalized renovations to their homes in lieu of an inpatient stay for acute care at the hospital. Again, yes some patients would prefer this, and I get that, and this is what LTC should be like, but with cash-benefits towards the repairs and accessibility upgrades. That aside, taking this corpo-care infrastructure as it is now, in the world, under American capitalism, “hospitals without walls” are an unreasonable way for a hospital to save money, this practice cannot be allowed to continue let alone expand. Certainly not as a public-private hybrid.
It’s absurd to argue that this is for the benefit of anyone other than those who profit off these austerity regimes of care. Also worth noting is that this all comes amidst the context of an upcoming strike planned by nurses at Kaiser Permanente Health System for November 15th, 2021. On November 4th unions representing more than 30,000 workers notified the health system of their intention to strike over Kaiser’s plan to cut wages for new employees by up to 36 percent and cap raises for its current workers at 1 percent.
[Image description: Meme, the background image is a vintage sci-fi illustration of a Death-like creature holding a ray gun who is zapping two people in the foreground. The people are quickly dematerializing into skeletons surrounded by a green glow, the right person is already just a skeleton, the left person is all skeleton up until his head. Behind them, bright orange flames are blazing with orange lightning and a bright orange glowing moon. On the Death figure is text reading “Medicare for All” and on the human figures, it reads a collection of the following companies' names listed from top to bottom and left to right: Kaiser, Mayo Clinic, Amazon Care, UNC Health, Cigna, Aetna, United, Johns Hopkins, Anthem, Humana, Blue Cross Blue Shield]
Health finance issues are always labor issues, and what might seem at face to be harmless lobbying for simple rule changes at CMS can have catastrophic consequences for both workers and patients. Fractured as our care system is, it is still a system, albeit one which is designed to self-cannibalize in order to extract maximum profit. This model is only sustainable under a capitalist society which places lower economic valuations on the lives impacted by these so-called “healthcare innovations” by “smart consultants turned entrepreneurs.” The price we pay for their success is not only unjust but unnecessary, even inefficient.
This is also one of the many millions of reasons why we must pass Medicare for All with robust in-home services and supports, fully funded long term care could look as comprehensive as this care, if done from a perspective of desired care outcome—but none of this is possible unless we sever care from profit and make a commitment to providing not just the medicalized determinants of health, but the social and structural ones too like housing, food, clean air, water, and the abolition of the carceral industrial complex.
There is no room for reform, there is no time to wait. Again to return to the work of Da’Shaun L. Harrison from their new book Belly of the Beast—these socioeconomic political structures do not need reform, they don’t need entrepreneurial curiosity and disruption; “they need total destruction. If we go back to the beginning, if we pull up the roots, unless the social institutions...are destroyed, we can only ever return back to the place we left.”
 The list of healthcare partners behind The Advanced Care at Home Coalition (ACHC) also includes; CristianaCare, Adventist Health, Geisinger Health, Integris, Novant Health, ProMedica, Sharp Rees-Stealy Medical Group, and Unity Point Health.
 Source: Medically Home Group Twitter bio (accessed 11/09/2021) @medically_home: “Medically Home's hospital-at-home enables health systems to safely admit patients to their own homes rather than the hospital for acute and restorative care.”