Waiting For the Next Wave

The most interesting stories I've seen in the last week -- and this was a week where we celebrated the 50th anniversary of Medicare and Medicaid, and in which new projections suggest national health spending is starting to tick back up --  don't seemingly have anything to do with health care, but with how Microsoft is radically shifting its strategies.  If people in health care don't think there are lessons for them in this, though, well, chalk it up to health care's typical myopia.

First let me recap some of what is going on with Microsoft, then try to tie it back to health care.

Microsoft had some good news and some bad news recently.  On the bright side, it released its new operating system, Microsoft 10, to generally good reviews.  On the not so bright side, Microsoft reported its biggest ever quarterly loss -- an astonishing $3.2b -- as a result of it writing off $7.5b relating to its Nokia acquisition.  Let's parse each of these out.

If you're one of the over 1 billion people using a PC, the Windows 10 release should come as good news, not just for the new features but because Microsoft is giving it away "for free," at least for now. They're not going to charge you to upgrade or try to lure you into buying a new PC preloaded with it.  They're just letting you have it.  For a company which traditionally made its money selling its software -- unlike Apple (devices) or Google (advertising) -- that's a pretty radical change.  And a necessary one.

Microsoft, especially its new CEO Satya Nadella, has finally realized that the world of the PC is dwindling.  It's still big, mind you, and it is still important in many industries and for many tasks, but smartphones and tablets are now the devices of choice, with The Internet of Things waiting in the wings.  Apps and the cloud are encroaching on much of Microsoft's historical domain.  Microsoft is betting big that they need to get Windows 10 out as widely as possible; indeed, 14 million people upgraded in the first 24 hours.

In retrospect, we shouldn't have been so surprised by the Windows 10 move.  Last fall Nadella announced Office would be available free for most mobile devices, trying to keep it relevant in hopes users would be willing to pay for it on their computers.  If they have them.

Microsoft is going to get a mobile version of Windows 10 out this fall, first for its Lumia phones and also for Xbox.  Eventually for Hololens as well.  They've got to get their operating system into the ecosystems people are using, and have that operating system be more consistent across platforms.

That's what makes the Nokia write-off so surprising.  Steve Balmer, Nadella's predecessor as CEO,  had bet big with that acquisition a little over a year ago, hoping that Microsoft could reinvigorate Nokia's fading mobile platform and break the Apple/Android dominance.  Now Nadella says: "We are moving from a strategy to grow a stand-alone phone business to a strategy to grow and create a vibrant Windows ecosystem."

OK, whatever.

Hey, Google failed with its acquisition of Motorola Mobility, selling it off at a loss after less than two years, and Amazon failed with its Fire phone, so you can't blame Microsoft too much for missing the smartphone mark.  And its not like they are getting out of the smartphone business, just trying to find a better defined niche.

They should talk to Blackberry about that tactic.

Horace Dediu, who studies disruptive technologies at the Clayton Christensen Institute, described the Nokia write-down to The New York Times as follows:

If you were talking about any other industry, this would be considered a catastrophe that’s the equivalent to a natural disaster... Most people didn’t believe that such a catastrophe could occur this fast...[Microsoft] just couldn’t imagine that a company that was once as strong and dominant as Nokia could have virtually no value...We tend to think the strong will survive.  But a virus is a very small thing that kills big things.  

I keep wondering what the metaphorical virus is that might kill our existing health care business models.

A few months ago I wrote about how, in contrast with the rampant disruption in the technology sector, the money in health care is pretty much going to the same professions and institutions now as it was in 1960.  They're getting paid a lot more, of course, and they often do vastly more complex things for the money, but I'm not sure any sector outside maybe education looks as unchanged as health care does.  That, to me, is a problem.  That, to me, looks like failure to innovate.

This is an ongoing theme for me.  I want to see what in the "adjacent possible" health care can beg, borrow, or steal to do better for us.  And, honestly, I want innovators that want to wreck the current system more than just get rich from it.

So when I read about how hospitals might ape the health insurers' recent merger mania by following suit, or when I read about the Pentagon choosing to "modernize" their health records by giving the task to old-standby Cerner, or when I read that the new approach of using the immune system to fight cancer is being led by the usual pharma suspects -- no, these are not viruses that are going to disrupt the health care system.  Quite the opposite.

Maybe the virus could be something as simple as moving more of health care to what Malcolm Gladwell, in an interview with Eric Topol, called a "cash economy" in health care (as I suggested in a prior post),  The more services people pay directly for, in theory, the more health care providers will finally treat them as customers and hopefully even compete on value.

Or it could be something that takes us completely by surprise.

It's entirely conceivable that Microsoft's future lies not in Windows and Office, but in Skype, Xbox, and Hololens.  A Microsoft spokesperson told The New York Times: "If you miss the first wave, you have to hang on and then drive or anticipate the next wave. We want to be part of the next wave of disruption."

Who in health care is prepared to ride -- or help create -- that next wave?

Adding Insult to Illness

It turns out that there may be something worse than having end stage cancer.  That is getting chemotherapy when you have end stage cancer.

A new study in JAMA Oncology found that such chemotherapy didn't achieve its supposed purpose in patients within the last six months of life.  For sicker patients, it didn't improve the quality of life (QOL) in their final week (QOD), relative to patients who did not receive chemo.  Worse yet, the patients who began the chemo healthier fared worse than similar patients who did not receive it.  The authors concluded: "Not only did chemotherapy not benefit patients regardless of performance status, it appeared most harmful to those patients with good performance status."  The authors call for changes in guidelines relating to use of chemotherapy in terminal patients; I should certainly hope so.

As if all that wasn't bad enough, in true U.S. health care system style, patients -- and their health plans -- pay dearly for this torture-as-treatment.  More on that in a bit.

No one is saying chemotherapy has no value, particularly for cancers caught in the early stages.  Part of the problem is that it's hard to prospectively tell who is in their end stages, which the study defined as the last six months of life  An accompanying editorial in JAMA Oncology by Blanke and Fromme cited a study that found that estimates of patient survival were inaccurate 80% of the time. 

They go on to say: "We believe the efficacy results by Prigerson et al are generally true, represent current practice, and stand as a relative indictment of routinely offering chemotherapy to patients with terminal cancers." 

Blanke and Fromme feel that the problem lies both in oncologists not wanting to have the hard conversations with patients and in patients wanting to fight "until the bitter end," as they put it.  Perhaps these kinds of difficult conversations will become more common if Medicare implements its plan to start paying for them, although I'm just waiting for the crazies to come out with their "death panels" objections. 

The fact of the matter is that people do die and that sometimes more treatment causes more harm than good.  It isn't always easy to tell when that is, but pretending that our typical "more is better" attitude is always best is simply putting our heads in the sand. 

And we can't ignore the financial side of all this.

A few days ago a group of over 100 leading oncologists co-signed an editorial decrying the high cost of cancer drugs in the U.S.  They applauded the progress that is being made in cancer therapies, but noted the high cost and cost increases in these therapies, and expressed concern about the burden they place on patients and the health care system overall. 

In a nutshell, "the current pricing system is unsustainable and not affordable for many patients."

Drug prices generally have been criticized widely lately, with cancer drugs being a particular target but not the only.  Treatment for Hepatitis C, for example, is proving more expensive than many Medicaid programs can afford, spurred but effective-but-expensive drugs like Sovaldi.   

Hey, at least the Hepatitis drugs actually promise hope of curing the disease, whereas many of the new cancer treatments offer marginal, if any, improvement over existing therapies -- but at a much higher cost.  As David Howard, a professor of Public Health at Emory, told the Wall Street Journal,
"The U.S. has always taken a very hands-off attitude, that patients are going to have access to new medical treatments regardless of the cost."

Maybe it is time to start just saying no.

Pharma's defense of their pricing is that they need to invest in R&D to generate clinical breakthroughs, especially since margins are generally much smaller in countries whose governments directly negotiate prices.  Fair point, although there is some question about how closely R&D investments actually do track with rising revenues and, at some point, R&D needs to be paid by all customers, not just the gullible ones like us.  

The New York Times reported that all the furor over drug prices is generating a groundswell for greater transparency about them, but I'm not sure how much good that will do (assuming we could figure out what the real "price" of a drug is, what with discounts, rebates, and other behind-the-scenes deals that are common in the industry).  We only care about costs when we have to pay them directly, not when our health plan pays them.  According to Medscape's 2015 Physician Compensation Report, only 25% of physicians regularly discuss costs with patients anyway. 

Costs and terminal prognoses seem to be two topics that neither physicians nor patients really want to talk about.

What we should care more about is paying for marginal improvements in life expectancy.  How much should we pay for an extra two months of life, especially when those last two months are spent in misery?  It's not the kind of discussion that we seem to know how to have, and it literally is costing us -- not just in dollars but also in patient quality of life.

It's easy to blame the drug companies for pushing expensive treatments that don't provide much value, but they're not the ones writing the prescriptions, nor the ones demanding them.  That falls on our doctors and ourselves.  We may pretend that financial considerations don't matter, just as we can try to pretend that there are limits of what can be done to keep us alive, but what's silly is for us to keep pretending that we're not pretending.

It's easy to castigate the various parties who profit from care that doesn't actually help, and may hurt, patients, but we shouldn't be spending our time looking for the villains here.  Everyone says they're looking out for the patients' best interests, but that doesn't appear to be the case.  If we truly care about that, we should start with telling the truth, even when that truth isn't what the patients want to hear. 

And when I say "telling the truth" I mean not just not lying, but truly being open -- about costs, risks/benefits, and all the other messy complications that muddy recommendations for treatment.  We want simple answers, clear choices, and quick fixes, but those aren't always possible. 

Our health care system is most known for being expensive and disjointed.  We may or may not be able to change either of those anytime soon, so wouldn't it be great if we could at least be known for being the most honest with patients?

Nag On My Shoulder

We seem to like to have help with our health.  In addition to a doctor (or doctors), we might have a case manager, a health coach, a pharmacist, a personal trainer, or a nutritionist, to name a few.  But we soon may be able to have all of their expertise whispering in our ear 24/7.

Whether that would be a good thing or a bad thing remains to be seen.

The Wall Street Journal recently profiled an interesting company called OrCam.  OrCam's origins were in helping visually impaired individuals.  A small wearable camera processes surrounding images -- faces, steps, even handwriting -- on the fly and informs the user, almost as if they were seeing the objects directly.  Now OrCam is testing what they bill as a digital personal assistant -- Casie -- to add even more value.

I can see all sorts of potential for health care.

The WSJ article gives the example of you walking down the street, and Casie recognizes the face of one of your Linkedin contacts.  Perhaps you hadn't spotted them or simply couldn't place them, but Casie could then discreetly murmur the correct information into your ear and suddenly you're Bill Clinton, able to remember everyone's face and key details.

If OrCam can recognize your Linkedin contacts, I would bet that it can recognize a donut, or a cigarette, and remind you about the health risks before you get either in your mouth.  It's not that we don't usually know these kinds of things are bad for us, mind you, but a little angel on our shoulder (or, rather, in our ear) could help battle those devils that tempt us into bad health choices.

Such a digital assistant might also notice you haven't taken your morning pills.  Lack of adherence to taking medication has been labeled a $300b problem.  There are a variety of apps to help remind people to take their meds, but an increasingly urgent voice in your ear the further out of compliance you get might be a more effective way to keep you on track.

Maybe it could be trained to look at that rash on your arm and offer an informed diagnosis, taking teledermatology to the next level (Spruce, are you paying attention?).  It might evaluate your gait, notice if your face shows signs of a stroke, listen to your cough, and advise you when any of those suggest you need to seek care.  If it is happening to or around you, the digital health assistant might be able to offer help.

Pack a portable ultrasound into the device -- this technology is already here -- and suddenly whole new worlds of things your digital assistant could help you with really open up, especially if paired with a Watson type of AI.

Ideally, one would like to be able to tell your digital assistant how you are feeling, much like you might tell your doctor or try to do with an online symptom checker, and get a diagnosis  The accuracy rate of the current symptom checkers is not perfect -- a recent study found they only came up with the "correct" diagnosis a third of the time -- but even these checkers triage pretty well, and they're only going to get better (the success rate already varies widely between different symptom checkers), especially as they are increasingly able to monitor your vitals.

I'd be curious to know what the equivalent rate is for in-person or telehealth diagnoses from physicians.  I'm not so sure that "only" a third is so low.

Fitness trackers are all the rage, but the attrition rate on the use is terrible; a third stop using after six months.  Perhaps something like Casie could have better luck keeping you engaged.  It could "watch" your fitness efforts -- then cheer you on when you're reaching your goals, coax you when you are faltering, even nag you when you want to quit.  You might pick the Dallas Cowboy cheerleaders to do the cheering, Richard Simmons to do the coaxing, and your high school gym teacher to do the nagging.

I don't think I'd choose any of those, but you get the idea.

Digital assistants aren't new, of course.  We've already got Apple's Siri, Google Now, and Microsoft's Cortana.  Even smart glasses aren't exactly breaking new ground, what with Google Glass, whose high profile introduction and retail pullback don't spell the end of Google's interest in the idea (e.g., reportedly it will allow users to "take pictures" using hand gestures and to get augmented information about things in their field of vision).  Google is reportedly focusing more on business applications for the product, perhaps because research shows consumer interest in smart glasses lags other forms of wearable devices, but is much higher if their employer pays for it.

Smart glasses have faced adoption resistance for a variety of reasons: people think current models look goofy, there are concerns about privacy when everything in sight is suddenly a picture/video, or perhaps it has just been lack of a perceived killer app.

OrCam addresses the first objection by being a fairly inconspicuous clip-on, and the second by deleting audio and video content after it has been processed and analyzed, sort of like Snapchat does for messages.  "Our goal is processing, not archiving, ” says OrCam's founder and chairman.

And maybe digital health assistant will be the killer retail app.

I think the concept of "augmented reality" raises the bar for digital assistants.  Instead of just warning you about eating that donut, the digital health assistant might flash a picture of you with an extra thirty pounds just to re-enforce the risks it poses.  Or what you might look like in twenty years, especially if you developed diabetes from eating all that sugar.  It'd be like the health care version of "scared straight."

And waiting for you to look at your computer screen or smartphone might not be soon enough.

OrCam is a reminder that our digital future doesn't necessarily lie in smart phones or smart watches or even smart glasses.  Devices may be cool but, in the end, it's not about the device but about the functionality it offers us.  The power of the Internet of Things is that our devices should become indistinguishable from our environment; some future generation of OrCam will use tiny cameras embedded in our clothes and elsewhere, broadcasting pertinent information to us -- audio, visual, even tactile.

This is why companies like Facebook and Google are pouring so much money into virtual reality -- not just to escape reality but to augment it.

People talk about "the digital doctor," but what really makes that concept interesting is that it may not involve a doctor at all.  I just hope my digital assistant knows when to be quiet and when to make me listen.

Nice Work If You Can Get It

Philosopher Eric Hoffer once wrote: "Every cause begins as a movement, becomes a business, and eventually degenerates into a racket."

Lately, health care seems less about causes and more about rackets.

A couple weeks ago the Feds charged 243 people with Medicare fraud, alleging some $700 million in false billings.  Big win, but just the tip of the iceberg of suspected fraud, which some experts believe could account for as much as $70b in Medicare and Medicaid payments.  Yikes.

For example, People profiled the case of Michigan oncologist Farid Fata, who recently plead guilty to multiple counts of fraud.  His indictment charged that: "At times, Fata bullied, berated and browbeat patients who dared to question his treatment, telling them they risked death without him or in the case of a patient who could not afford copays, 'It's your life or your money,'"

Talk about a racket.

Health care is a big business, generating over $3 trillion in annual revenue, so some level of criminal activity is to be expected.  What I worry about most are not the criminals who are purposely cheating, but, rather, the people who seem to feel they are entitled to siphon off as much as they can from the health care spigot.

CMS released their second iteration of Part B claims last month (to the continued consternation of the AMA).  I wrote about the initial release last year, with its eyebrow-raising finding that hundreds of physicians were getting millions of dollars annually from Medicare.  Now Bloomberg reports that the latest release -- still for 2013 -- shows 3900 such "Medicare millionaires."

As the headline says, nice work if you can get it.

I'm not suggesting that all or even most of these physicians are doing anything improper (although Bloomberg notes that two of the three highest paid doctors in the initial release are already facing legal troubles), and certainly the data are not perfect, but -- really?  3900 making at least a million a year from Medicare alone?

I doubt that many of these Medicare millionaires are making their living from office visits.  More likely they have simply figured out how to game the system for all they can get, not always with a corresponding positive impact on their patients' health.

For example, The New York Times recently reported on the boon in diet clinics, caused by requirement in ACA that health insurance pay for obesity and nutrition screening.  They quote Marketdata Enterprises as estimating that medical weight-loss clinics are a $1b industry, and will grow 5% a year through 2019.  All this for programs that "often employ techniques that are unproven and even some that have been discredited."  Many of these clinics also sell supplements that not only aren't covered by insurance but that also "are backed by little, if any, scientific evidence for promoting weight loss."

Similarly, The Times reported on the boom in the concussion industry, caused by interest from such diverse concerns as the Defense Department and the NFL.  Research money is flowing in, and many new forms of diagnosis and treatment are being tested.  Unfortunately, as The Times said, "medical experts are raising concerns that it is a business where much of the science is sketchy, belief frequently outruns fact, and claims of technological breakthroughs evaporate soon after they are made."

"It is a Wild West out there," Michael Singer, CEO of Brainscope, told The Times.  Brainscope's concussion device is FDA approved, something that is not universally true in the field.

I'm not even sure that FDA involvement makes things much less of a Wild West, as they seem quite happy to approve treatments that are no better clinically yet end up being much more expensive than existing alternatives (witness stents or spinal fusions).

Undue influence is another way to game the system.  The latest Open Payments release showed that drug and medical device makers paid some $6.5b to doctors and teaching hospitals in 2014, for research, consulting, speeches, royalties, and other activities.  They can afford the payments; the profit margin for pharmaceutical companies is estimated to average close to 20%.

Payments went to some 600,000 doctors and 1,100 hospitals.  That's out of 900,000 active physicians and pretty much every teaching hospital, so odds are pretty good your doctor got a payment.  A Promedica analysis found several physicians who received payments from a drug company nearly every working day; 768 received payments more than half of the days in 2014, and 14.600 got such payments on at least 100 days.

Bloomberg charged that the payments are intended to "convince doctors that 2nd choice is OK."  As Dr. Jerry Avorn, a Harvard medical school professor, told them:

"It’s striking that the top two drugs are expensive new products for diabetes that are by no means first-line choices.  No one is spending this kind of money to educate doctors about metformin, the inexpensive generic drug that’s the most important foundational treatment we have for this disease."

The AMA, of course, is still defending the payments and protesting the accuracy of the underlying data, and the pharmaceutical companies argue that newer drugs require more "education."  I'm sure that some, even many, of these payments are legitimate.  Certainly I have no beef with inventors getting paid for their patents.  But the trick is to make sure that patients' best interests remain foremost, not the providers' bottom line, and the burden of proof is on them.

Twenty years ago consumer-directed health plans were a cause.  Now they've clearly become a business, capturing around a quarter of the employer marketplace and accruing some $22b in HSA/HRA assets.  Not too shabby.  Whether they have moved to the racket stage depends, in part, on your political views...and your income level.

mHealth is a more recent cause, with wild forecasts -- 33% CAGR over the next five years, $100b in "savings" over the next four years.  I'm wondering from whose pockets that $100b is supposed to be coming, and into whose it would end up.

Honestly, some days I think that our existing health care system, with its ingrained medical-industrial complex that protects its own, is beyond salvaging.  Too many people are making too much money and have too much of a vested interest in the status quo.  As I wrote last year in Getting Our Piece of the Pie, I worry that new entrants may be less interested in up-ending the status quo and more interested in simply getting their share of the money.

There's plenty of innovation -- new medical devices and techniques, new drugs, ACOs, value-based payments, PCMHs, reference pricing, telehealth, wearables, to name a few -- but most seem to involve the usual suspects, operating under the existing financing, delivery, and regulatory structures.  That's no way to start a movement and no way to assure they won't all end up like what we've got.

If we don't want health care to degenerate into a racket, we need innovations that come out of left field, with disruptors who want no part of the status quo.  As Apple used to say, Think Different!