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.

Old power paradigm blocks new planetary paradigm

The difference between our reality and the media's reality is like a tale of two worlds. The greatest and worst of times, really.

Expanding information demands complex skills and understanding to separate important information from ignorance and crap. And that's just the start of determining the source's aim.

Trust who? We see people trust liars in public and then be destroyed by their decisions. Mistakes may be devastating.

Many give up and don't trust anyone. Reality is a choice, though. Same risks.

We must separate our needs and wants from reality. Needs and wants have rules. Greed and selfishness create an unlivable planet.

Culturally, we know this, but we ignore it as foolish. Selfish and greedy people obtain what they want, while others suffer.

We invade, plunder, rape, and burn. We establish civilizations by institutionalizing an exploitable underclass and denying its existence. These cultural lies promote greed and selfishness despite their destructiveness.

Controlling parts of society institutionalize these lies as fact. Many of each age are willing to gamble on greed because they were taught to see greed and selfishness as principles justified by prosperity.

Our cultural understanding recognizes the long-term benefits of collaboration and sharing. This older understanding generates an increasing tension between greedy people and those who see its planetary effects.

Survival requires distinguishing between global and regional realities. Simple, yet many can't do it. This is the first time human greed has had a global impact.

In the past, conflict stories focused on regional winners and losers. Losers lose, winners win, etc. Powerful people see potential decades of nuclear devastation as local, overblown, and not personally dangerous.

Mutually Assured Destruction (MAD) was a human choice that required people to acquiesce to irrational devastation. This prevented nuclear destruction. Most would refuse.

A dangerous “solution” relies on nuclear trigger-pullers not acting irrationally. Since then, we've collected case studies of sane people performing crazy things in experiments. We've been lucky, but the climate apocalypse could be different.

Climate disaster requires only continuing current behavior. These actions already cause global harm, but that's not a threat. These activities must be viewed differently.

Once grasped, denying planetary facts is hard to accept. Deniers can't think beyond regional power. Seeing planet-scale is unusual.

Decades of indoctrination defining any planetary perspective as un-American implies communal planetary assets are for plundering. The old paradigm limits any other view.

In the same way, the new paradigm sees the old regional power paradigm as a threat to planetary civilization and lifeforms. Insane!

While MAD relied on leaders not acting stupidly to trigger a nuclear holocaust, the delayed climatic holocaust needs correcting centuries of lunacy. We must stop allowing craziness in global leadership.

Nothing in our acknowledged past provides a paradigm for such. Only primitive people have failed to reach our level of sophistication.

Before European colonization, certain North American cultures built sophisticated regional nations but abandoned them owing to authoritarian cruelty and destruction. They were overrun by societies that saw no wrong in perpetual exploitation. David Graeber's The Dawn of Everything is an example of historical rediscovery, which is now crucial.

From the new paradigm's perspective, the old paradigm is irrational, yet it's too easy to see those in it as ignorant or malicious, if not both. These people are both, but the collapsing paradigm they promote is older or more ingrained than we think.

We can't shift that paradigm's view of a dead world. We must eliminate this mindset from our nations' leadership. No other way will preserve the earth.

Change is occurring. As always with tremendous transition, younger people are building the new paradigm.

The old paradigm's disintegration is insane. The ability to detect errors and abandon their sources is more important than age. This is gaining recognition.

The breakdown of the previous paradigm is not due to senile leadership, but to systemic problems that the current, conservative leadership cannot recognize.

Stop following the old paradigm.

You have to use it.

Chat-GPT is a revolution.

All social media outlets are discussing it. How it will impact the future and different things.

True.

I've been using Chat-GPT for a few days, and it's a rare revolution. It's amazing and will only improve.

I asked Chat-GPT about the best non-fiction books. It advised this, albeit results rely on interests.

The Immortal Life of Henrietta Lacks

by Rebecca Skloot

Science, Biography

A impoverished tobacco farmer dies of cervical cancer in The Immortal Life of Henrietta Lacks. Her cell strand helped scientists treat polio and other ailments.

Rebecca Skloot discovers about Henrietta, her family, how the medical business exploited black Americans, and how her cells can live forever in a fascinating and surprising research.

You ought to read it.

1. if you want to discover more about the past of medicine.

2. if you want to discover more about American history.

Bad Blood: Secrets and Lies in a Silicon Valley Startup

by John Carreyrou

Tech, Bio

Bad Blood tells the terrifying story of how a Silicon Valley tech startup's blood-testing device placed millions of lives at risk.

John Carreyrou, a Pulitzer Prize-winning journalist, wrote this book.

Theranos and its wunderkind CEO, Elizabeth Holmes, climbed to popularity swiftly and then plummeted.

You ought to read it.

1. if you are a start-up employee.

2. specialists in medicine.

The Power of Now: A Guide to Spiritual Enlightenment

by Eckhart Tolle

Self-improvement, Spirituality

The Power of Now shows how to stop suffering and attain inner peace by focusing on the now and ignoring your mind.

The book also helps you get rid of your ego, which tries to control your ideas and actions.

If you do this, you may embrace the present, reduce discomfort, strengthen relationships, and live a better life.

You ought to read it.

1. if you're looking for serenity and illumination.

2. If you believe that you are ruining your life, stop.

3. if you're not happy.

The 7 Habits of Highly Effective People

by Stephen R. Covey

Profession, Success

The 7 Habits of Highly Effective People is an iconic self-help book.

This vital book offers practical guidance for personal and professional success.

This non-fiction book is one of the most popular ever.

You ought to read it.

1. if you want to reach your full potential.

2. if you want to discover how to achieve all your objectives.

3. if you are just beginning your journey toward personal improvement.

Sapiens: A Brief History of Humankind

by Yuval Noah Harari

Science, History

Sapiens explains how our species has evolved from our earliest ancestors to the technology age.

How did we, a species of hairless apes without tails, come to control the whole planet?

It describes the shifts that propelled Homo sapiens to the top.

You ought to read it.

1. if you're interested in discovering our species' past.

2. if you want to discover more about the origins of human society and culture.

Its not a fuc*ing fad.

It's not about boring monkeys or photos as nfts; that's just what's been pushed up and made a lot of money. The technology underlying those ridiculous nft photos will one day prove your house and automobile ownership and tell you where your banana came from. Are you ready for web3? Soar!

People don't realize that absolutely anything can and will be part of the blockchain and smart contracts, making them even better. I'll tell you a secret: it will and is happening.

Why?

Why is something blockchain-based a good idea? So let’s speak about cars!

So a new Tesla car is manufactured, and when you buy it, it is bound to an NFT on the blockchain that proves current ownership. The NFT in the smart contract can contain some data about the current owner of the car and some data about the car's status, such as the number of miles driven, the car's overall quality, and so on, as well as a reference to a digital document bound to the NFT that has more information.

Now, 40 years from now, if you want to buy a used automobile, you can scan the car's serial number to view its NFT and see all of its history, each owner, how long they owned it, if it had damages, and more. Since it's on the blockchain, it can't be tampered with.

When you're ready to buy it, the owner posts it for sale, you buy it, and it's sent to your wallet. 5 seconds to change owner, 100% safe and verifiable.

Incorporate insurance logic into the car contract. If you crashed, your car's smart contract would take money from your insurance contract and deposit it in an insurance company wallet.

It's limitless. Your funds may be used by investors to provide insurance as they profit from everyone's investments.

Or suppose all car owners in a country deposit a fixed amount of money into an insurance smart contract that promises if something happens, we'll take care of it. It could be as little as $100-$500 per year, and in a country with 10 million people, maybe 3 million would do that, which would be $500 000 000 in that smart contract and it would be used by the insurance company to invest in assets or take a cut, literally endless possibilities.

Instead of $300 per month, you may pay $300 per year to be covered if something goes wrong, and that may include multiple insurances.

What about your grocery store banana, though?

Yes that too.

You can scan a banana to learn its complete history. You'll be able to see where it was cultivated, every middleman in the supply chain, and hopefully the banana's quality, farm, and ingredients used.

If you want locally decent bananas, you can only buy them, offering you transparency and options. I believe it will be an online marketplace where farmers publish their farms and products for trust and transparency. You might also buy bananas from the farmer.

And? Food security to finish the article. If an order of bananas included a toxin, you could easily track down every banana from the same origin and supply chain and uncover the root cause. This is a tremendous thing that will save lives and have a big impact; did you realize that 1 in 6 Americans gets poisoned by food every year? This could lower the number.

To summarize:

Smart contracts can issue nfts as proof of ownership and include functionality.

I was entering tens of millions of records per hour when I first published Slonik PostgreSQL client for Node.js. The data being entered was usually flat, making it straightforward to use INSERT INTO ... SELECT * FROM unnset() pattern. I advocated the unnest approach for inserting rows in groups (that was part I).

However, today I’ve found a better way: jsonb_to_recordset.

jsonb_to_recordset expands the top-level JSON array of objects to a set of rows having the composite type defined by an AS clause.

jsonb_to_recordset allows us to query and insert records from arbitrary JSON, like unnest. Since we're giving JSON to PostgreSQL instead of unnest, the final format is more expressive and powerful.

SELECT *
FROM json_to_recordset('[{"name":"John","tags":["foo","bar"]},{"name":"Jane","tags":["baz"]}]')
AS t1(name text, tags text[]);
 name |   tags
------+-----------
 John | {foo,bar}
 Jane | {baz}
(2 rows)

Let’s demonstrate how you would use it to insert data.

Inserting data using json_to_recordset

Say you need to insert a list of people with attributes into the database.

const persons = [
  {
    name: 'John',
    tags: ['foo', 'bar']
  },
  {
    name: 'Jane',
    tags: ['baz']
  }
];

You may be tempted to traverse through the array and insert each record separately, e.g.

for (const person of persons) {
  await pool.query(sql`
    INSERT INTO person (name, tags)
    VALUES (
      ${person.name},
      ${sql.array(person.tags, 'text[]')}
    )
  `);
}

It's easier to read and grasp when working with a few records. If you're like me and troubleshoot a 2M+ insert query per day, batching inserts may be beneficial.

What prompted the search for better alternatives.

Inserting using unnest pattern might look like this:

await pool.query(sql`
  INSERT INTO public.person (name, tags)
  SELECT t1.name, t1.tags::text[]
  FROM unnest(
    ${sql.array(['John', 'Jane'], 'text')},
    ${sql.array(['{foo,bar}', '{baz}'], 'text')}
  ) AS t1.(name, tags);
`);

You must convert arrays into PostgreSQL array strings and provide them as text arguments, which is unsightly. Iterating the array to create slices for each column is likewise unattractive.

However, with jsonb_to_recordset, we can:

await pool.query(sql`
  INSERT INTO person (name, tags)
  SELECT *
  FROM jsonb_to_recordset(${sql.jsonb(persons)}) AS t(name text, tags text[])
`);

In contrast to the unnest approach, using jsonb_to_recordset we can easily insert complex nested data structures, and we can pass the original JSON document to the query without needing to manipulate it.

In terms of performance they are also exactly the same. As such, my current recommendation is to prefer jsonb_to_recordset whenever inserting lots of rows or nested data structures.