Tuesday, November 11, 2014

The Future Is Still Not Here

US News & World Report had some fun looking back at what experts in 2004 predicted for health care in 2014.  Not surprisingly, they found that we're not quite there yet, but might be by 2025.  The future, it would appear, is always ten years away.

Those 2004 pundits expected that health care would be one of the industries most impacted in these past ten years; specifically:
2004 prediction: In 10 years, the increasing use of online medical resources will yield substantial improvement in many of the pervasive problems now facing healthcare—including rising healthcare costs, poor customer service, the high prevalence of medical mistakes, malpractice concerns, and lack of access to medical care for many Americans.

To be sure, there have been several important changes in our health care system over the past ten years.  Some of the more important ones would have to include:
In terms of realizing those predictions about controlling costs, improving customer service, reducing medical mistakes, or addressing malpractice concerns: well, not so much.

The absolute number of the uninsured has only dropped from 42.0 million in 2004 to 40.7 in 1Q 2014.  Increases in spending have moderated, thank goodness, but most experts attribute this to the recent economic downturn rather than to any structural changes.  Half of Americans now have a chronic disease, and our life expectancy rates still lag most other developed nations -- and may be declining.

If this is progress, I'm not sure we can take much more of it.

By way of contrast, think about the technology world in 2004:
Why isn't health care seeing those kinds of radical changes in the landscape?

Certainly there have been plenty of important clinical innovations -- new treatments, new devices, new drugs, new techniques -- in the last ten years.  Still, I'm hard pressed to think of changes that have become part of people's everyday lives the way that the above tech changes have,

Critics might claim that smartphones, social media and video streaming don't improve the quality of life, but just dare to try to take them away from people.  By contrast, if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance, since they cost about 40% less and typically had much lower cost sharing requirements (Kaiser Family Foundation).

I'm also waiting for reports of either physicians or patients being delighted by all those EHRs.

The U.S. News & World Report article mentioned telemedicine as an example that many (still) predict as a key part of the future.  Honestly, if a big breakthrough for 2024 is wider use of telemedicine, I'll be disappointed.

Don't get me wrong: I'm a big proponent of telemedicine, but in ten years shouldn't we be hoping for something more radical -- like, say, holographic or virtual reality visits?  I'm willing to bet that the technology for those will exist, and that consumers would be very interested in using them, but I wouldn't risk much money betting that our moribund reimbursement and regulatory mechanisms will embrace them, or that providers would jump on those bandwagons either.

Or maybe the future is wearables, as everyone is trying to get in on the expected gold rush (e.g., Fitbit, Jawbone, Apple Healthkit, Microsoft Health, Google Fit).  I suspect that wearables in 2024 will bear as much resemblance to today's as our mobile phones do to 2004's, but the real problem won't be the technology as how we'll use all that data.  By 2024 we should be using real-time data to prevent hospitalizations (e.g., as Sentrian claims it can already do) and other acute episodes, but who will pay for, and act on, the monitoring and interventions?

One company -- Pact Health -- has already figured out a way to use results from activity trackers to adjust coverage, such as raising and lowering deductibles.  It is a solution imperfectly crafted on top of a normal health plan, but at least it's a start.  Too bad existing federal and state requirements for health coverage don't directly allow for such innovative approaches.  That's a problem.

Some people might argue that other ACA initiatives, like ACOs or value-based purchasing, simply haven't had enough time to prove their worth.  That may be valid, but I'm still not seeing the where-did-that-come-from aspects of either.  

All those ACOs and other integrated health systems aspire to be Kaiser, but, as I wrote about previously, the Kaiser model may be more the past than the future.  After 70 years, they hold dominant market position in California, but it is their only market where that is true.  Their enrollment growth since 2004 averages a paltry 1.5% per year, and, for all their integration, their costs and cost increases really aren't any lower than competitors.

If in ten years we're all getting care through integrated delivery systems like Kaiser, that might be better for us, but it wouldn't be a breakthrough.

I've made some predictions about the future previously (Living in a Jetson's World),  but what I really hope for is a system that doesn't just look like today's health care system modestly improved.  I'm hoping for changes that seemingly come out of nowhere to radically reshape the system.  Maybe that's gene therapy or nanotechnology (or, better yet, nanotechnology delivering gene therapy -- as is already being piloted).  I don't know what they'll be, but someone is already working on them.

Whatever the changes are going to be, I worry that if they go through our existing delivery and financing mechanisms, they'll suffer the same fate as telemedicine -- slow, halting, incremental adoption that at best integrates with instead of reshaping.

As I wrote in Getting Our Piece of the Pie, I want to see health care's versions of Napster: innovations that are willing to wreck the system in order to reshape it.  I want to see something that connects us to our health in the way that Facebook has connected us with our social circle, that democratizes health information and even treatments like Wikipedia has done for reference, or that untethers us in the way smartphones and YouTube have.

Let's not wait ten years.


  1. Great points, as always, Kim. I was really struck by a story yesterday about a woman who knew enough to seek out an in-network hospital for her husband's injury and then got blindsided from the doctors in its ER who were not in her network (http://n.pr/10VtX8K). That seems like a real sign of failure of the legacy "insurance" system. It's become a patchwork quilt of occasional payment assistance, but no longer really provides "healthcare" in any meaningful way. Plans don't have to be free, but they should make sense and have some kind of structural integrity to them. I think it's time for the providers to take control of the system, for good of both the patients and themselves.

  2. Thanks, Bryan. Yes, I saw that NYT article, and it is yet another example of our current approach shooting itself in the foot. I've become increasingly convinced that provider networks are an outdated concept that works against the best interests of patients, as I wrote about in an earlier post -- http://kimbellardblog.blogspot.com/2014/08/provider-networkshow-quaint.html

  3. ".....if you offered to swap health insurance plans from 2004 with today's, I bet most people would jump at the chance." Comparing to a cell phone swap is brilliant