Monday, January 5, 2015

The Adjacent Possible Is Closer Than You Think

Here we are at the start of 2015, with various recaps of 2014 and predictions for 2015.  Those are always interesting to read, but what I usually have the most fun writing about is the "adjacent possible" for health care.

The term is one from biology, usually attributed to Stuart Kaufman, and popularized by Stephen Johnson in his 2011 book on innovation Where Good Ideas Come From.  At the risk of oversimplifying both men's work, the concept suggests that change is constrained by the available "neighborhood" -- of ideas, materials, etc.  Johnson illustrates, in that book and again in his most recent How We Got to Now, how new ideas are often borrowed from other fields and applied with unexpected results.

However, if the idea is too new, and/or doesn't have the necessary infrastructure or mind-set to nourish it, it can quickly die a forgotten death.  E.g., Edison was far from the first to invent the electric light, but he was the first to also provide the supporting electricity grid.

Take the auto industry.  It is terrified that millennials appear to care less about driving, car ownership, and even getting drivers licenses, and so is trying to keep itself relevant by making vehicles more technologically sophisticated.  "Cars are transforming into digital devices," according to Joe White of The Wall Street Journal, citing new infotainment and collision avoidance systems.   The New York Times profiled how automakers are furiously trying to make cars more tablet-like.  Rob Csonger of technology company Nvidia tells Fortune:
"The car is rapidly going to go from the most stupid electronic device a consumer owns to the most powerful supercomputer a consumer will ever own -- way more powerful and sophisticated than your phone, tablet, or PC."
Still, in a world of driverless cars, as-needed services like Zipcar or  Car2Go, and wirelessly connected cars that always know your preferences, the entire paradigm of owning your own car suddenly becomes at risk.  And auto makers know it.

Then there's health care.  While automakers are busy trying to turn their products into digital devices, we're still trying to get consumers access to their own health records.  According to a recent survey from Xerox, 64% of Americans don't have online access to their records, although most would like to.

With our hospital-oriented system, we're still selling consumers the equivalent of those clunky 1970's Detroit gas guzzlers.  Sure, we're doing some cool things with apps and remote monitoring, but, with a few exceptions (e.g., cardiac patients or diabetes monitoring) they have as much to do with mainstream care as putting a hula girl on the dashboard did for driving those old cars.  As evidence, a recent survey of 20,000 physicians found that only 15% had been asked by patients about incorporating data from wearable trackers or other health apps into their record.

The auto industry has also seen transparency totally change the buying experience for consumers, leveling out the information asymmetry dealers used to enjoy.  Health care?  Umm, we're still working on that...if we could ever agree what the "product" really was, how we should measure quality, or what the true price might be for a given consumer. 
I don't mean to single out the auto industry as the best one one to emulate in searching for the adjacent possible, nor do I limit that adjacent possible to technology.  I use these examples because I worry that health care isn't even looking in the right places for its adjacent possible.

Here's what scares me: 87% of enrollees in the federal exchanges are getting subsidies.  That sounds like good news, that ACA is helping make insurance more affordable, but it reminds me that care is so expensive that our financing system for it is not affordable for most people.  Add to that the 48% of the population who get coverage through their employer (and thus benefit from the tax preference) or the 15% of the population with Medicare (and thus are subsidized by the inter-generational tax funding), and it turns out that very few people actually know, much less pay, the full price of their own coverage (coverage numbers from Kaiser Family Foundation).

Our model is an expensive, intervention-oriented, medical approach.  As examples, a recent study in JAMA Internal Medicine found that high risk heart patients actually seem to fare better when their cardiologists aren't around to treat them, or Dr. Laura Esserman's assertion that we are grossly overtreating breast cancers.

Meanwhile, health care is spending a lot of effort borrowing ideas for improving customer service/the patient experience -- e.g., Sue Schade's ideas for the inpatient experience or Micah Solomon's suggestion to focus on timeliness -- but I'm less sure we're looking to reinvent the underlying model.  We continue to make progress in new treatment options, but not so much in business models.

Many believe that payment reform -- the so-called value-based purchasing -- is the solution.  I worry that payment reform at best will simply prove to redistribute the existing money differently (see Alan Weil's partly-tongue-in-cheek Why I Oppose Payment Reform).  

Others see the future in direct primary care, sometimes known as concierge medicine.  I like the concept, especially if divorced from health insurance, but primary care capitation in the 1990's showed that the trouble is what care "leaks" outside primary care and ends up in the vastly more expensive hospital/specialty care worlds.  

The always interesting Margalit Gur-Arie argues that what direct primary care really does is convince people that primary care is a cheap commodity, thus accelerating primary care's decline.  As she says: "Strangely enough, I don’t see too many dermatologists stepping all over each other to convince us that what they do is worth very little money."  She sees physician informaticists as the new general practitioners, advising that: "modern physicians, who want to become rich and famous rapidly, should find something to do with computers."

We need new paradigms, and they're probably not going to come from within health care.  We should be asking radical questions like, ok, if health care spending had to be limited to 50% of what it is now, what would we do differently?  As I wrote about in Who Ya Gonna Call, we need to be open to adjacent possibles where care looks very different and where the training and practice of the people giving that care also are very different.  It could be a whole new ball game.

And, honestly, I don't see much future for a middle ground between a system that is directly consumer-purchased or one that is totally government financed.  That's the middle ground we've been trying to stand on, and some adjacent possible is eventually going to generate an earthquake that swallows it up.

We need to keep in mind that the adjacent possible is already here, somewhere, in some form; we just haven't realized it yet.  The question is, who will see it first?


  1. Executives sitting at the top of the healthcare mountain must be worried, knowing that they must adapt to the megatrend of health reform and Obamacare or die, especially since 429 of the original Fortune 500 companies [1955] are no longer in business today. They must be looking down with fear at hungry innovators who are already exploiting the many related minitrends and the overlap of trends, because for them these are times of great opportunity. See

    Some say a single-payer system is expensive, but expensive for whom? I believe striking the right balance between the public & private sectors all comes down to understanding that different stakeholders see success differently, and getting the INCENTIVES right.

    Private sector organizations that answer to the investment interests of shareholders measure success in business terms such as profit, ROI, and payback period. Government & public sector organizations, on the other hand, measure success in terms like population health & productivity, GDP & economic growth, graduation & unemployment rates, etc.; and because they look at things over much longer time periods, they can justify longer-term investments.

    As a consumer advocate, I ask, “How would consumers measure success of a single-payer system?” While the medical industry views patients as paying customers and work to keep them (coming back & paying) while others see citizens or constituents. Would consumers measure success by availability (and how would they define that)? Would it be cost, and would that be total cost with insurance premiums, or incident out-of-pocket cost? What about wellness & quality of life, longevity and ability to live independently, or performance in school, work and sports?

    Given the fact that Americans already spend twice as much on healthcare as other nations but still live sicker and die younger, per the WHO, we theoretically “should” be able to cut our spending in half (now $3 trillion/year). But with annual revenue loss of $1.5 trillion or more at stake, entrenched incumbents in the medical industrial complex spend twice as much on political lobbying as the military industrial complex. (Remember, they see success differently.) Still, payers & providers can no longer control or ignore the health reforms, competitive pressures, and shifts in incentives.

    So, I conclude by asking, “Is the purpose of a healthcare system to benefit the medical industry? Or is it to improve the health & wellness of a nation and thus lower overall costs while improving productivity?”

  2. Wayne - I share your skepticism of the medical-industrial complex and their lobbying clout to try to keep the status quo (see, for example, "Always Fighting the Last War" -- Somehow patients/consumers have to make the medical-industrial complex realize that it IS our money and we expect value from the health care system to accrue to us.

    The recent collapse of Vermont's single payor initiative ( helps illustrate how little anyone fully realizes how much our system really costs, especially when they have to pay/be taxed for it directly.