Tuesday, April 22, 2014

Making Health Care More Personal (Again)

Earlier this week The New York Times proclaimed that "House Calls Are Making a Comeback."  I wouldn't get my hopes up just yet, at least not for the old-fashioned version of them.  As I wrote about in my last post, we keep thinking about the past when we should be thinking about the future.

As it turned out, the house calls in The Times article were for very sick patients following a hospital stay -- not anything most of us would want to need -- and it seems that the supposed return of house calls has been trumpeted many times before (see examples from 2013, 2009, or 2006).  It is kind of odd to me that people keep talking about physicians making house calls, because I venture to guess that the majority of the U.S. population hasn't lived in a time when such house calls were common.  Indeed, it may be a sign of advanced age to have actually experienced one.

It may not even be what we really want.

I suspect that "house calls" may be a euphemism for the kind of relationship that patients wish they had with their physician.  After all, office visits are now often squeezed to fifteen minutes or less, and that's after waiting for over twenty minutes, on average.  That doesn't take into account people who simply opt to go to a retail clinic.  None of that is conducive to strong patient-physician relationships.

It may be that our best health care relationship in the near future is not going to be with a physician at all, but with a personal health assistant.

For example, take the start-up Better.  The Mayo Clinic is backing the service, a personal health assistant app that is intended to help consumers deal with the admitted complexity of our health care system. Better relies on Mayo Clinic content and resources, including nurses and physicians that power the personal health assistant.

The free version of Better allows users to get personalized health information and even a symptom checker.  For $49.99 a month, users get the better version of Better, which features a 24/7 personal health assistant.  The assistants can assist with health questions and concerns, and can also help with a wide range of health-related issues, including getting recommendations on physicians in their area, making appointments, or even health insurance advice.  There are limitations on how much the assistants can do due to state laws about practicing medicine, especially across state lines.

According to Better's founder Geoff Clapp, patients are frustrated with not getting enough time with their physicians to form a personal relationship, which he believes Better will allow.  The pricing reflects saving 2 hours a month from dealing with unwanted health tasks.  He and Mayo seek to have 200 million lives (!) using Better by 2020.

It is not clear to me if Better allows users to have a specific assistant on an ongoing basis, or if whom one gets is the luck of the call/click.  "Personal" in the 21st century may be less about dealing with a unique person than it does interactions being tailored specifically to you.

I wish Better lots of luck, but if they get to 200m users - or even half that -- then our health care system is even more screwed up than I thought.  I guess if we can't actually reduce the complexity in our health care system, the time-honored solution is to add another layer to try to manage it better (no pun intended).

Plus, at $50/month, concierge medicine starts to become more competitive; the services are not identical, but many patients may like the in-person option concierge medicine allows.  Or they'll take advantage of options like the American Well retail option, which charges $49 per tele-visit, but which I'm guessing will someday morph into a per-month option as well.

Of course, there's nothing particularly new about personal health assistants (or health coaches).  Most of them have been provided through health plans or employers, such as through Accolade or Healarium, but there have been other retail personal health assistant services, including Allayo and Humana's HomeCare Solutions.  Better brings the powerful Mayo brand into play, continuing to broaden its reach.  They are already a leader in the use of social media.

Thinking even more futuristically, there are already "virtual" personal health assistants.  NextIT developed Alme, a virtual assistant, and has versions of it for multiple industries (including Aetna's customer service version "Ann").  Last fall they announced their health care virtual assistant, which they say can assist not only with administrative problems but also clinical questions.  They see Alme not so much as a consumer solution but rather as a solution for health care professionals to assist with patient demand, which strikes me as very 20th century thinking.  Toshiba has already partnered with NextIT to provide solutions for Toshiba's tablets and laptops aimed at health care professionals.

Many people think that Apple's virtual assistant Siri will soon be able to take on health care concerns, which would fit in neatly with Apple's rumored interest in health.  Mayo is going to have a hard time staffing Better with real people if it does get those 200m users; one way or another, the personal health assistant business is going to have to rely heavily on virtual assistance if it is to scale.

The implication of all this is that instead of house calls from -- or even office visits with -- a physician, we may prefer access to a personal health assistant that is available anytime, anywhere, with little or no wait, and which may or may not involve humans interactions.  Technology is changing not only what we can do, but also our expectations. 

Intel's Healthcare Innovation Barometer, released late last year, found that consumers are optimistic about technology advancing health care.  More than 70% were receptive to remote monitoring, and more than half reported being as or more confident about a test they administered as they would one done by a physician.  They're not waiting for their doctor to tell them what to do, and, in fact, they don't want to have to wait for him/her at all.

While we're rethinking the need for patient-physician visits, we should be rethinking other aspects of our delivery system as well.  That same Intel survey found that 57% think traditional hospitals will be obsolete in the future, something I agree with.  Many hospitals have tried hard to rebrand themselves as being in the broader health business instead of in the medical business, such as through fitness centers and more emphasis on holistic medicine.  Heck, the Cleveland Clinic now has an herbal therapy clinic.  Other hospitals are trying to design their campuses to be less medicine and institutional and more integrated into the community with a wellness focus

They need to keep trying.  Personally, I'm still trying to understand why the Hospital at Home movement has not taken off.

We're still getting our health care from a system that, for the most part, relies on us going to buildings in order to get care and advice, and to get those from physicians.  That system still strictly circumscribes what only physicians can do, and in which physical areas they can do even that.  It's a system of hierarchies and institutions, of having to ask permission, and in which patients are people things are done to, not people who actively do things for themselves.

But we live in a world that is increasingly virtual, where information is broadly available and flows freely.  We live in a world where remote monitoring becomes more and more viable, and which bionics will revolutionize further, especially as we figure out how "Big Data" can make all that data actionable.  We live in a world where artificial intelligence and algorithms are getting smarter and smarter, and which may now or soon be more able to process and use the torrent of medical information and research than physicians can. 

I don't need to ask any personal health assistant which world I want to get my care from.

Tuesday, April 15, 2014

Always Fighting the Last War

There's an old military adage that generals always fight the last war.  I get that feeling a lot about the health care system, and that was illustrated this past week by the CMS release of Part B claims data.

For those who might have missed this, the AMA has been trying to block such a release since 1979, but a series of legal actions and analyses by The Wall Street Journal finally prevailed.  To no one's surprise, it revealed that a small percentage of doctors are getting paid a lot of money -- some 344 made over $3m and one earned just shy of $21m.  Ophthalmologists and oncologists topped the list, in large part because their practices pass through the costs of some very expensive drugs they administer.

The AMA, of course, wasn't happy.  On their website, they point out the "considerable limitations" of the data, such as the difference between practice revenue and personal income, and the fact that the data doesn't reflect quality or value.  Their official statement proclaims that they are committed to transparency, and seems to suggest that the public is somehow worse off because of the release.

I have a hard time feeling any sympathy for the AMA.  They've had six decades since the inception of Medicare to come up with better alternatives.  They can claim to be in favor of transparency all they want, but neither they nor the AHA -- or any of the various provider specialty organizations that I am aware of -- have exactly been leaders in finding ways to measure value or for the public to better evaluate the performance of their members.

Shame on them, and shame on us for not insisting.

The Part B data will no doubt end up being subject to a number of detailed analyses, and hopefully will work their way into some consumer- and purchaser-friendly ways to better judge performance and value, but I worry that some providers are looking at the big numbers in it and are simply thinking "hmm..."  

In his last speech as President, Eisenhower warned about the "unwarranted influence" of the military-industrial complex.  Had he been as prescient, President Johnson -- who initiated Medicare and Medicaid -- could have done the same with the medical-industrial complex.

We're now talking about $3 trillion in annual spending, or, as I prefer to think about it, revenues for someone.  We've gone from a world of local community non-profit hospitals, solo physicians, and relatively small medical device and pharmaceutical industries to a world where hospitals are merging, physicians are being acquired by those hospitals, and the medical device industry and pharma each generate over $300b in annual revenues.  And it's hard to find anyone who thinks that kind of market consolidation will do anything but increase costs.

As for the "unwarranted influence," well, estimates are that 2013 spending on lobbying for health interests was some $480m -- which was down from prior years.  The only industry spending more -- and only slightly more at that -- was financial services.  Did anyone ever expect health care to seek the same level of K Street influence that Wall Street has long had?  Add the fact that hospitals are now among the largest employers in many, if not most, communities, and the concern about influence becomes even clearer.

I suppose you'd have to say that the last war was between payors and providers, and that the providers emerged from the fiercest battles of the managed care era as the winners.  As those two sides continue to fire salvos at each other, you'd also have to say that the patients have been the innocent bystanders, and have often suffered the collateral damage.   That's the war that both sides are still fighting -- and it is the wrong war.

The war should be about improving people's health.  All the parties claim to have improving health as their goal, but it's getting harder to believe that (see, for example, Patients Come Second).  The U.S. continues to lag on most measures of its population's health.  We're getting fatter, sicker, and more medicated than ever, and yet paying more than ever for that dubious privilege.

We already have insurgents in our midst.  PwC just released a provocative report, Healthcare's new entrants: Who will be the industry's Amazon.com?  It cites of number of new entrants into the health space -- some of whom are already Fortune 50 companies -- and emphasizes that consumers are very open to getting care in new places and in new ways, such as retail clinics and using mobile apps. They see these new entrants taking some $64b of revenue away from "traditional" provider revenue -- small compared to overall health spending, but enough to get people's attention.

Their two pieces of advice for existing health care organizations: always put the consumer at the center, and figure out what matters most.

Simple as those sound, they are things that health care has historically not done well.  It's hard to claim that many health care organizations have truly been acting to put consumers in the center, or even know how to do so.  Health plans have primarily catered to employers, although that is starting to shift due to ACA and its exchanges.  Hospitals have catered to physicians, and physicians have answered to, well, I guess, God. 

Our existing health care system was built on the fundamental knowledge asymmetry between providers and patients.  It was compounded by a paternalistic system of health coverage provided by employers and the government.  That led to generations who did what they were told, were willing to submit to long waits and other indignities, rude attitudes, and incomprehensible bills and terminology.

That's not going to cut it with a new generation of Millennials who are used to technology, are masters of using social media to get recommendations, and are distrustful of institutions.

Physicians as the dispensers of all health wisdom and advice?  Not any more, not with the vast amount of information available online.  Hospitals as the model for where to put sick patients?  Forget about it -- try something like Hospital at Home.  Making patients drive someplace -- then wait -- to get tests?  Not as long as they've got a smartphone.  Secret schedules of hugely inflated charges and a myriad of "contractual allowances" for tens of thousands of potential procedures and evaluations?  Not for consumers expect to instantly compare options and prices.  Waiting for patients to have health problems and then trying to attack and manage those problems?  Outdated in a world of real-time monitoring and feedback

It's a whole new world.

The most charitable way we could describe the last war -- the existing war -- is that it was a war on illness, and we let ourselves we distracted by the power that gave health care organizations.  The new war -- the war for better health -- is going to be fought on new fronts, with higher consumer expectations, and by some entities who haven't been entrenched in the stodgy health care way of doing things.  When new entrant Apple comes calling on old entrants health plans to subsidize their new iWatch health platform, it will be interesting to see which is the most surprised by the other -- and which blinks first. 

Personally, I am skeptical that most of our existing health care organizations -- be they health plans, health systems, physician organizations, or whatever -- are going to lead the way into this new world.  That's not to say they won't play a part in it, but I think it is going to take some more consumer-focused organizations, with different attitudes about their health, to lead the way.  Maybe not Amazon (although I'd be interested to see how Jeff Bezos would approach it) but probably a combination of some already trusted brands (WalmartCVS?) and some daring new companies (ZocDocJawbone?).  And you know the current stakeholders are going to come out swinging to protect their turf -- and their revenues.

PwC's second piece of advice for the new health care world was to figure out what matters most.  I hope that will include a focus on making health care products and services "insanely great" (as Steve Jobs would have said), instead of just being insanely expensive.

Wayne Gretzky famously said he skated to where the puck was going to be, not where it is.  Health care organizations need to be thinking that way, and they better be thinking ten or twenty years out.

Monday, April 7, 2014

Hacking a Better Health System

Who knew hacking might help us reinvent our health care system?

I must be old-fashioned, or at least not a true techie, because I still thought of hacking as a bad thing, like all those cyber-criminals trying to get at our sensitive data, a problem for which health care continues to be a target.  I was thus surprised to read in The Wall Street Journal that “hackathons” are a trend for the good in health care. 

For others who are also behind this particular curve, hackathons are intense, all-night (or more) sessions when a small groups of programmers band together to attack tough specific problems with concentrated coding efforts.  If you’ve seen The Social Network or other depictions of the tech world, with scenes of unkempt young men (and they are almost always young men) sitting around furiously pounding away on their keyboards while surrounded by cans of Red Bull and boxes with leftover pizza slices, you probably get the picture.

The Journal article highlighted MIT’s Hacking Medicine’s Grand Hackfest, which is part of MIT’s Hacking Medicine initiative.  MIT has been at this since 2011, seeking synergies between MIT’s technical expertise and the vaunted Boston-area medical community.  They believe hackers can help health care with: Scaling Medicine, Accelerating Data, Identifying and Tackling Big Opportunities, Hacking Ethos for Lean Medical Innovation, and Infecting Non-Life-Scientists with the Mission. 

Pretty lofty list of goals.

Health 2.0 – which “promotes, showcases and catalyzes new technologies in health care” -- has their own version, which they call Code-a-thons.  They offer some $6.5m in prizes in their developer challenge, and have several events and challenges scheduled in the next few months.  As their recent San Diego code-a-thon illustrated, these are not necessarily big prizes nor huge breakthroughs, but they serve the purpose of getting more people excited about solving problems in health care.

Goodness knows that health IT has never been known for being either nimble or on the cutting edge, so some fresh blood with new perspectives certainly seems like a good idea, right?  As one clinician whose mobile app benefited from solutions suggested at the MIT hackathon said, "Sometimes when you are too close to something, you stop seeing solutions, you only see problems.  I needed to step outside my own silo.''

Not to be outdone by Boston, New York-Presbyterian Hospital recently held what they claim was the first Hackathon for New York Hospitals, which the specific aim of helping them improve myNYP, their patient portal.  I’ll be interested to hear if and how they incorporate the results.

Out on the other coast, UCLA-Berkeley has had three iterations of their own version, Hacking Health.  Last year’s event focused on Digital Health, and attracted 18 teams working on a wide variety of problems, such as Google Glass-enabled paramedic app. 

Stanford has their Medicine X initiative, described as “the intersection of medicine and emerging technologies.”  At their annual conference, one of the events is the IDEO Design Challenge, which aims to attract various stakeholders to develop solutions to use technology improve patient care.  This year it will focus on assisting chronic care patients with managing their condition through technology. 

Just to rub us oldsters’ noses in it, there’s an organization called YTH (youth + tech + health) that believes the “#selfie generation” can do better.  As Jamia Wilson, YTH’s Executive Director, says, “the time has come for young people to be treated as designers and developers for health technology solutions that serve them and their communities on their own terms.”  They just hosted their own Health Hackathon in conjunction with their YTH Live 2014 conference.     

The trend is not limited to the United States.  The British National Health Service has NHS Hack Days, in Canada there is Hacking Health, and in Europe there’s CPH Health Connect HackDay in Copenhagen and Hacking Health Stockholm.  I’m sure this is by no means an all-inclusive list, but it is big enough to indicate there is something going on here.

Not to wander too far away from health, but the health sector is not the only one which seeks value in hacking.  Late last year Intel bought Hacker League,  a platform for managing hackathons, while Booz Allen Hamilton just announced a partnership with start-up incubator 1776, formalizing a collaboration they’ve had for the past year as they’ve hosted “hackcelerators,” which aim to combine hackathons and small business accelerators.  If stalwart companies like Intel and Booz Allen Hamilton see a future with hacking, it could mean it is here to stay…or that its moment has already passed.

Looking back at last fall’s healthcare.gov debacle, or more recent reports of similar issues with various state exchanges, one has to wonder if they just should have held a hackathon.

PwC’s 6th Annual Digital IQ Survey found that healthcare CEOs were far ahead of other industries in championing information technology as an integral part of their strategy.  I rather doubt that many health systems or payors are using hackathons for their big mainframe-based systems – like eligibility, billing, claims payment, or (most) EHRs – but mobile efforts are natural targets for this kind of approach. 

There’s no shortage of targets.  Payors are finding ways to use mobile technology to cut administrative costs, engage members, and manage patients’ care.  Aetna is one payor in particular which brags about their IT strategy, especially in mobile, such as their iTriage app and an upcoming monitoring device called Scanadu Scout. 

The Mayo Clinic recently reported one of their apps reduced cardiac readmissions by 40%, no small triumph in an era when Medicare and private payors are hitting hospitals with penalties for readmissions.  And, of course, Apple is rumored to soon be getting in the health space, through a body monitoring device called Healthbook. 

Still, in a recent Robert Half Technology survey of CIOs, health care led the pack in lacking a mobile strategy, with 36% reporting their organization had none, which perhaps why the Harvard Business Review recently pointed to insurers’ untapped digital opportunity. 

No wonder they might be looking for hackers.   

It’s great to bring in new ways of attacking the many problems of health care, but I do worry what happens when they hit the may brick walls health care has.  I’ve been seen several instances where non-health care companies – especially financial services firms -- dipped in to health care, thinking they could bring their expertise to bear, only to be shocked at how messy much of the data is.  Exactly who the patient/member is, what services they received, how much should be paid – questions whose analogs in other industries would be clear-cut are often very murky in health care.

And, of course, people have proven dismayingly stubborn about how they take care of their own health – just look at our obesity rates.  For all the buzz about the potential for “wearable technology” in health care, a recent survey found that a third of users stopped using it within six months.   Changing bad health habits is hard, hard work.  There’s not just an app for that.

It’s one thing to build a nifty single purpose app in the health space, but the heavy lifting is connecting all the many pieces and players together, especially in a way that patients understand and buy into.  And, of course, the usual M.O. in health care is to charge lots more even for small improvements, as The New York Times recently highlighted.  A typically close minded approach in health care is the trend towards “medical scribes” to transcribe into an EHR (which I’ve talked about before) instead of simply making EHRs fit better into how physicians practice.  Why reengineer processes and technology when we can simply add costs?   

That’s got to change. 

What I like best about the hacking in health movement is twofold – bringing in new kinds of expertise and an attitude that problems can be solved.  Those have been sorely missing in health care.  Or, as Mark Twain once put it, “all you need in this life is ignorance and confidence, then success is sure.” 

Hack away!