ZERO GRACE/ZERO MALICE

Amazon's purchase of One Medical could speed up American healthcare

The U.S. healthcare industry is a 7-ton seal bleeding at sea. Predators are circling. Unearned margin: price increases relative to inflation without quality improvements. Amazon is the 11-foot megalodon with 7-inch teeth. Amazon is no longer circling... but attacking.

In 2020 dollars, per capita U.S. healthcare spending increased from $2,968 in 1980 to $12,531. The result is a massive industry with 13% of the nation's workers and a fifth of GDP.

Doctor No

In 40 years, healthcare has made progress. From 73.7 in 1980 to 78.8 in 2019, life expectancy rose (before Covid knocked it back down a bit). Pharmacological therapies have revolutionized, and genetic research is paying off. The financial return, improvement split by cost increases, is terrible. No country has expense rises like the U.S., and no one spends as much per capita as we do. Developed countries have longer life expectancies, healthier populations, and less economic hardship.

Two-thirds of U.S. personal bankruptcies are due to medical expenses and/or missed work. Mom or Dad getting cancer could bankrupt many middle-class American families. 40% of American adults delayed or skipped needed care due to cost. Every healthcare improvement seems to have a downside. Same pharmacological revolution that helped millions caused opioid epidemic. Our results are poor in many areas: The U.S. has a high infant mortality rate.

Healthcare is the second-worst retail industry in the country. Gas stations are #1. Imagine walking into a Best Buy to buy a TV and a Blue Shirt associate requests you fill out the same 14 pages of paperwork you filled out yesterday. Then you wait in a crowded room until they call you, 20 minutes after the scheduled appointment you were asked to arrive early for, to see the one person in the store who can talk to you about TVs, who has 10 minutes for you. The average emergency room wait time in New York is 6 hours and 10 minutes.

If it's bad for the customer, it's worse for the business. Physicians spend 27% of their time helping patients; 49% on EHRs. Documentation, order entry, billing, and inbox management. Spend a decade getting an M.D., then become a bureaucrat.

No industry better illustrates scale diseconomies. If we got the same return on healthcare spending as other countries, we'd all live to 100. We could spend less, live longer and healthier, and pay off the national debt in 15 years. U.S. healthcare is the worst ever.

What now? Competition is at the heart of capitalism, the worst system of its kind.

Priority Time

Amazon is buying One Medical for $3.9 billion. I think this deal will liberate society. Two years in, I think One Medical is great. When I got Covid, I pressed the One Medical symbol on my phone; a nurse practitioner prescribed Paxlovid and told me which pharmacies had it in stock.

Amazon enables the company's vision. One Medical's stock is down to $10 from $40 at the start of 2021. Last year, it lost $250 million and needs cash (Amazon has $60 billion). ONEM must grow. The service has 736,000 members. Half of U.S. households have Amazon Prime. Finally, delivery. One Medical is a digital health/physical office hybrid, but you must pick up medication at the pharmacy. Upgrade your Paxlovid delivery time after a remote consultation. Amazon's core competency means it'll happen. Healthcare speed and convenience will feel alien.

It's been a long, winding road to disruption. Amazon, JPMorgan, and Berkshire Hathaway formed Haven four years ago to provide better healthcare for their 1.5 million employees. It rocked healthcare stocks the morning of the press release, but folded in 2021.

Amazon Care is an employee-focused service. Home-delivered virtual health services and nurses. It's doing well, expanding nationwide, and providing healthcare for other companies. Hilton is Amazon Care's biggest customer. The acquisition of One Medical will bring 66 million Prime households capital, domain expertise, and billing infrastructure. Imagine:

"Alexa, I'm hot and my back hurts."

"Connecting you to a Prime doctor now."

Want to vs. Have to

I predicted Amazon entering healthcare years ago. Why? For the same reason Apple is getting into auto. Amazon's P/E is 56, double Walmart's. The corporation must add $250 billion in revenue over the next five years to retain its share price. White-label clothes or smart home products won't generate as much revenue. It must enter a huge market without scale, operational competence, and data skills.

Current Situation

Healthcare reform benefits both consumers and investors. In 2015, healthcare services had S&P 500-average multiples. The market is losing faith in public healthcare businesses' growth. Healthcare services have lower EV/EBITDA multiples than the S&P 500.

Amazon isn't the only prey-hunter. Walmart and Alibaba are starting pharmacies. Uber is developing medical transportation. Private markets invested $29 billion in telehealth last year, up 95% from 2020.

The pandemic accelerated telehealth, the immediate unlock. After the first positive Covid case in the U.S., services that had to be delivered in person shifted to Zoom... We lived. We grew. Video house calls continued after in-person visits were allowed. McKinsey estimates telehealth visits are 38 times pre-pandemic levels. Doctors adopted the technology, regulators loosened restrictions, and patients saved time. We're far from remote surgery, but many patient visits are unnecessary. A study of 40 million patients during lockdown found that for chronic disease patients, online visits didn't affect outcomes. This method of care will only improve.

Amazon's disruption will be significant and will inspire a flood of capital, startups, and consumer brands. Mark Cuban launched a pharmacy that eliminates middlemen in January. Outcome? A 90-day supply of acid-reflux medication costs $17. Medicare could have saved $3.6 billion by buying generic drugs from Cuban's pharmacy. Other apex predators will look at different limbs of the carcass for food. Nike could enter healthcare via orthopedics, acupuncture, and chiropractic. LVMH, L'Oréal, and Estée Lauder may launch global plastic surgery brands. Hilton and Four Seasons may open hospitals. Lennar and Pulte could build "Active Living" communities that Nana would leave feet first, avoiding the expense and tragedy of dying among strangers.

Risks

Privacy matters: HIV status is different from credit card and billing address. Most customers (60%) feel fine sharing personal health data via virtual technologies, though. Unavoidable. 85% of doctors believe data-sharing and interoperability will become the norm. Amazon is the most trusted tech company for handling personal data. Not Meta: Amazon.

What about antitrust, then?

Amazon should be required to spin off AWS and/or Amazon Fulfillment and banned from promoting its own products. It should be allowed to acquire hospitals. One Medical's $3.9 billion acquisition is a drop in the bucket compared to UnitedHealth's $498 billion market valuation.

Antitrust enforcement shouldn't assume some people/firms are good/bad. It should recognize that competition is good and focus on making markets more competitive in each deal. The FTC should force asset divestitures in e-commerce, digital marketing, and social media. These companies can also promote competition in a social ill.

U.S. healthcare makes us fat, depressed, and broke. Competition has produced massive value and prosperity across most of our economy.

Dear Amazon … bring it.

Homeownership isn't the only life pattern.

Want to irritate people?

My party trick is to say I used to own a house but no longer do.

I no longer wish to own a home, not because I lost it or because I'm moving.

It was a long-term plan. It was more deliberate than buying a home. Many people are committed for this reason.

Poppycock.

Anyone who told me that owning a house (or striving to do so) is a must is wrong.

Because, URGH.

One pattern for life is to own a home, but there are millions of others.

You can afford to buy a home? Go, buddy.

You think you need 1,000 square feet (or more)? You think it's non-negotiable in life?

Nope.

It's insane that society forces everyone to own real estate, regardless of income, wants, requirements, or situation. As if this trade brings happiness, stability, and contentment.

Take it from someone who thought this for years: drywall isn't happy. Living your way brings contentment.

That's in real estate. It may also be renting a small apartment in a city that makes your soul sing, but you can't afford the downpayment or mortgage payments.

Living or traveling abroad is difficult when your life savings are connected to something that eats your money the moment you sign.

#vanlife, which seems like torment to me, makes some people feel alive.

I've seen co-living, vacation rental after holiday rental, living with family, and more work.

Insisting that home ownership is the only path in life is foolish and reduces alternative options.

How little we question homeownership is a disgrace.

No one challenges a homebuyer's motives. We congratulate them, then that's it.

When you offload one, you must answer every question, even if you have a loose screw.

• Why do you want to sell?

• Do you have any concerns about leaving the market?

• Why would you want to renounce what everyone strives for?

• Why would you want to abandon a beautiful place like that?

• Why would you mismanage your cash in such a way?

• But surely it's only temporary? RIGHT??

Incorrect questions. Buying a property requires several inquiries.

• The typical American has $4500 saved up. When something goes wrong with the house (not if, it’s never if), can you actually afford the repairs?

• Are you certain that you can examine a home in less than 15 minutes before committing to buying it outright and promising to pay more than twice the asking price on a 30-year 7% mortgage?

• Are you certain you're ready to leave behind friends, family, and the services you depend on in order to acquire something?

• Have you thought about the connotation that moving to a suburb, which more than half of Americans do, means you will be dependent on a car for the rest of your life?

Plus:

Are you sure you want to prioritize home ownership over debt, employment, travel, raising kids, and daily routines?

Homeownership entails that. This ex-homeowner says it will rule your life from the time you put the key in the door.

This isn't questioned. We don't question enough. The holy home-ownership grail was set long ago, and we don't challenge it.

Many people question after signing the deeds. 70% of homeowners had at least one regret about buying a property, including the expense.

Exactly. Tragic.

Homes are different from houses

We've been fooled into thinking home ownership will make us happy.

Some may agree. No one.

Bricks and brick hindered me from living the version of my life that made me most comfortable, happy, and steady.

I'm spending the next month in a modest apartment in southern Spain. Even though it's late November, today will be 68 degrees. My spouse and I will soon meet his visiting parents. We'll visit a Sherry store. We'll eat, nap, walk, and drink Sherry. Writing. Jerez means flamenco.

That's my home. This is such a privilege. Living a fulfilling life brings me the contentment that buying a home never did.

I'm happy and comfortable knowing I can make almost all of my days good. Rejecting home ownership is partly to blame.

I'm broke like most folks. I had to choose between home ownership and comfort. I said, I didn't find them together.

Feeling at home trumps owning brick-and-mortar every day.

The following is the reality of what it's like to turn the American Dream around.

Leaving the housing market.

Sometimes I wish I owned a home.

I miss having my own yard and bed. My kitchen, cookbooks, and pizza oven are missed.

But I rarely do.

Someone else's life plan pushed home ownership on me. I'm grateful I figured it out at 35. Many take much longer, and some never understand homeownership stinks (for them).

It's confusing. People will think you're dumb or suicidal.

If you read what I write, you'll know. You'll realize that all you've done is choose to live intentionally. Find a home beyond four walls and a picket fence.

Miss? As I said, they're not home. If it were, a pizza oven, a good mattress, and a well-stocked kitchen would bring happiness.

No.

If you can afford a house and desire one, more power to you.

There are other ways to discover home. Find calm and happiness. For fun.

For it, look deeper than your home's foundation.

While our genes can't be changed easily, you can avoid some dementia risk factors. Today we discuss dementia and five drugs that may increase risk.

Memory loss appears to come with age, but we're not talking about forgetfulness. Sometimes losing your car keys isn't an indication of dementia. Dementia impairs the capacity to think, remember, or make judgments. Dementia hinders daily tasks.

Alzheimers is the most common dementia. Dementia is not normal aging, unlike forgetfulness. Aging increases the risk of Alzheimer's and other dementias. A family history of the illness increases your risk, according to the Mayo Clinic (USA).

Given that our genes are difficult to change (I won't get into epigenetics), what are some avoidable dementia risk factors? Certain drugs may cause cognitive deterioration.

Today we look at four drugs that may cause cognitive decline.

Dementia and benzodiazepines

Benzodiazepine sedatives increase brain GABA levels. Example benzodiazepines:

• Diazepam (Valium) (Valium)

• Alprazolam (Xanax) (Xanax)

• Clonazepam (Klonopin) (Klonopin)

Addiction and overdose are benzodiazepine risks. Yes! These medications don't raise dementia risk.

USC study: Benzodiazepines don't increase dementia risk in older adults.

Benzodiazepines can produce short- and long-term amnesia. This memory loss hinders memory formation. Extreme cases can permanently impair learning and memory. Anterograde amnesia is uncommon.

2. Statins and dementia

Statins reduce cholesterol. They prevent a cholesterol-making chemical. Examples:

• Atorvastatin (Lipitor) (Lipitor)

• Fluvastatin (Lescol XL) (Lescol XL)

• Lovastatin (Altoprev) (Altoprev)

• Pitavastatin (Livalo, Zypitamag) (Livalo, Zypitamag)

• Pravastatin (Pravachol) (Pravachol)

• Rosuvastatin (Crestor, Ezallor) (Crestor, Ezallor)

• Simvastatin (Zocor) (Zocor)

This finding is contentious. Harvard's Brigham and Womens Hospital's Dr. Joann Manson says:

“I think that the relationship between statins and cognitive function remains controversial. There’s still not a clear conclusion whether they help to prevent dementia or Alzheimer’s disease, have neutral effects, or increase risk.”

This one's off the dementia list.

3. Dementia and anticholinergic drugs

Anticholinergic drugs treat many conditions, including urine incontinence. Drugs inhibit acetylcholine (a brain chemical that helps send messages between cells). Acetylcholine blockers cause drowsiness, disorientation, and memory loss.

First-generation antihistamines, tricyclic antidepressants, and overactive bladder antimuscarinics are common anticholinergics among the elderly.

Anticholinergic drugs may cause dementia. One study found that taking anticholinergics for three years or more increased the risk of dementia by 1.54 times compared to three months or less. After stopping the medicine, the danger may continue.

4. Drugs for Parkinson's disease and dementia

Cleveland Clinic (USA) on Parkinson's:

Parkinson's disease causes age-related brain degeneration. It causes delayed movements, tremors, and balance issues. Some are inherited, but most are unknown. There are various treatment options, but no cure.

Parkinson's medications can cause memory loss, confusion, delusions, and obsessive behaviors. The drug's effects on dopamine cause these issues.

A 2019 JAMA Internal Medicine study found powerful anticholinergic medications enhance dementia risk.

Those who took anticholinergics had a 1.5 times higher chance of dementia. Individuals taking antidepressants, antipsychotic drugs, anti-Parkinson’s drugs, overactive bladder drugs, and anti-epileptic drugs had the greatest risk of dementia.

Anticholinergic medicines can lessen Parkinson's-related tremors, but they slow cognitive ability. Anticholinergics can cause disorientation and hallucinations in those over 70.

5. Antiepileptic drugs and dementia

The risk of dementia from anti-seizure drugs varies with drugs. Levetiracetam (Keppra) improves Alzheimer's cognition.

One study linked different anti-seizure medications to dementia. Anti-epileptic medicines increased the risk of Alzheimer's disease by 1.15 times in the Finnish sample and 1.3 times in the German population. Depakote, Topamax are drugs.

We've all been there: You propose a suggestion to your team at a meeting, and most people appear on board, but a handful or small minority aren't. How can we achieve collective buy-in when we need to go forward but don't know how to deal with some team members' perceived intransigence?

Steps:

1. Investigate the divergent opinions: Begin by sincerely attempting to comprehend the viewpoint of your disagreeing coworkers. Maybe it makes sense to switch horses in the middle of the race. Have you completely overlooked a blind spot, such as a political concern that could arise as an unexpected result of proceeding? This is crucial to ensure that the person or people feel heard as well as to advance the goals of the team. Sometimes all individuals need is a little affirmation before they fully accept your point of view.

• It says a lot about you as a leader to be someone who always lets the perceived greatest idea win, regardless of the originating channel, if after studying and evaluating you see the necessity to align with the divergent position.

• If, after investigation and assessment, you determine that you must adhere to the original strategy, we go to Step 2.

2. Disagree and Commit: Jeff Bezos, CEO of Amazon, has had this experience, and Julie Zhuo describes how he handles it in her book The Making of a Manager.

It's OK to disagree when the team is moving in the right direction, but it's not OK to accidentally or purposefully damage the team's efforts because you disagree. Let the team know your opinion, but then help them achieve company goals even if they disagree. Unknown. You could be wrong in today's ever-changing environment.

So next time you have a team member who seems to be dissenting and you've tried the previous tactics, you may ask the individual in the meeting I understand you but I don't want us to leave without you on board I need your permission to commit to this approach would you give us your commitment?