More About Us, Less About Them

Something Amazon just did is worth those of us in health care paying attention to.  It doesn't have anything to do with their long-rumored interest in health care, and it wasn't even The New York Times disturbing profile of Amazon's supposedly brutal workplace culture.  Instead, it was the layoff of "dozens" of engineers at Lab126, Amazon's hardware development center, as first reported by The Wall Street Journal.  These were the first layoffs in the division's history.

Lab126 is responsible for Amazon's consumer devices, including their very successful Kindle e-reader and the new Fire TV.  More notably, though, they were less successful with the Fire tablet and they failed spectacularly with the Fire smartphone.  Connect the dots to the layoffs as you wish.
 
What makes this is a cautionary tale for the rest of us is that even Amazon -- which is noted for their prowess with their online consumer experience -- can't necessarily get the physical consumer experience right.  I think Wired captured the problem best, asserting that Amazon's consumer devices would have been more successful "if Amazon focused more on consumers, and less on consuming."

Now perhaps the relevance to health care may be clearer.

Consumer devices are all the rage in health care.  The global mHealth market is predicted to be $49b by 2020, with some 73 million units shipped in 2015 and an eye-opening CAGR of 47.9% expected from 2013 to 2020 (although other analysts already see slowing demand).  J&J, which knows a little something about consumer marketing and about health care, is teaming up with hardware manufacturer PCH to help spur the development of hardware for the consumer health space.  They plan to "accept everything from medical devices to consumer-facing activity trackers, provided they target an area of unmet need."

Some people -- e.g., Yuri Teshler, writing in Forbes -- think that all this consumer-oriented technology will help consumers "fix" health care.  That'd be nice, but I'm not so sure.

At the core of Amazon's devices is the goal to, well, get consumers to buy more stuff from Amazon.  They make it ridiculously easy to purchase almost anything consumers want to buy, and are constantly looking at how to expand their reach.  When that coincides with what people actually want to do, such as with the Kindle, it works out well for everybody.  When what consumers want is a smartphone that is the equivalent of an iPhone, and what it actually is best at is buying things, then not so much.

So I wonder: what is the goal of consumer devices in health care?  Are they intended to help us achieve better health -- or to consume more health care services?  I hope for the former but I fear it may end up being the latter.

Of course, none of this is limited to consumer health devices.  It's something that permeates the health care system.  Think about your most recent experience with the health care system: did you really feel your better health was the uppermost concern throughout the experience, or was it more about generating more services that you (or someone) had to pay for?  That may sound harsh, but I've sat too long in too many waiting rooms, filled out too many forms that I've already filled out elsewhere, and gotten too many confusing bills for wildly overpriced services to be nicer about it.  And I don't even use all that many heath services.

I was struck a couple of weeks ago by an opinion piece in JAMA: "Obstacles to Developing Cost-Lowering Health Technology."  It's authors, doctors Kellerman and Desai, note that:

The inventor’s dilemma is that creating a product that improves health is not enough; the product must also be able to generate a healthy return on investment. In the United States, the surest way to generate a healthy return on investment is to increase health care spending, not reduce it.

They cite a 2013 Rand report that reached much the same conclusions, and which offered a number of policy recommendations that, as best I can tell, no one is in any hurry to implement.  Rand concluded: "The longer we wait to institute fundamental reforms, the more money we will spend on health care offering little or no health benefit."

Yet we keep getting more of the same, to the point where, for example, even oncologists think cancer drug prices are too high.

Think about the terminology used in health care.  It speaks volumes about the underlying culture and its attitudes towards us.  Health care providers call us "patients."  Health plans call us "members."  Medicare and Medicaid call us "beneficiaries."    The name for one of the newest fads -- "patient centered medical homes" -- serves to remind us that we're not normally considered the center of our health care, and that the focus is on our medical care, not our health.

At least "consumer-directed health plans" pay lip service to us being in charge.

From what I understand, the term "patient" became part of medical terminology due to the Latin term for "one who is suffering," and the more general adjective "patient" reflects the implicit expectation that, as patients, we're expected to suffer in silence, not complaining about the pain or the various indignities we may endure.  

Well, the hell with that.

I've written before on this terminology problem, although I haven't heard any groundswell of suggestions for better terms to describe us when it comes to health care.  "Consumer" or "customer" are words that might describe us in other industries, but we're still not quite there when it comes to health care.  Perhaps they should just call us "Benjamins," as in "it's all about the Benjamins."

I'm all for people and organizations making money in health care, but I don't like to be seen as some kind of ATM for them either.  The health care industry needs to realize that we don't really want to be its customers, don't want to need to consume their services, and certainly don't want to have to be unduly patient about it when we do.

What we want is to be healthy.  Give us the devices, services, and experiences that make that as simple as possible and then you can call us whatever you want.

Next Stop: Tinder for Docs

I've been thinking about patient-physician relationships.  After all, Annals of Internal Medicine published a shocking piece about bad physician behavior towards patients, and ZocDoc, the online physician appointment service, is valued at $1.8b after their most recent funding round.

I'll talk about each of those shortly, but first I want to talk about a phrase that started me thinking about the topic.

Noted entrepreneur/innovator/physician Jordan Shlain recently described the doctor patient relationship as "the atomic unit in medicine."   I assume he's using "atomic" in the original sense of being the smallest unit (although he also references data being the electrons orbiting the atomic unit, which means the metaphor really should be "nuclear").

Dr. Shlain urges that language should be specific and precise, so two things about his phrasing struck me: the order in which he describes the two parties, and the reference to medicine rather than to health.

In his description, it is a "doctor patient" relationship.  Maybe it is quibbling to pay attention to which party is listed first, but, come on, even the AMA uses "patient physician relationship" rather than "physician patient."  Even so, how many of us truly believe the physicians we deal with always "place patients' welfare above their own interest and above obligations to other groups," as the official AMA policy suggests?

Which leads to the Annals of Internal Medicine article.  I won't recount the specifics here, other than to say that in it describes two graphic instances of inexcusable physician behavior towards unconscious patients.  In an accompanying editorial, the editors say that the article "exposes medicine's dark underbelly."

The problem is less the appalling behavior -- there are badly behaving jerks in every profession -- as it is that none of the other medical personnel present even spoke up in protest.  The Annals editorial urged physicians to have the courage to "call our colleagues “assholes” when that label is appropriate."  And that, in itself, speaks volumes.  Verbally chastising them seems necessary but nowhere near sufficient.  Why not call upon them to report bad behavior -- to the hospital, to the state medical board, even to the police when "appropriate"?

It's supposed to be about protecting patients, not doctors.

The article has received widespread coverage -- e.g., The New York Times and U.S. News & World Report -- but, sadly, it is not the only story of its kind.  For example, an anesthesiologist in Virginia was caught on tape repeatedly verbally abusing her unconscious patient.  At least she was ordered to pay $500,000 in damages.

One wonders how many similar cases simply don't get caught.

I was dismayed by what the chair of committee on ethics for the American College of Obstetricians and Gynecologists said to The New York Times about the Annals article:  "What was the point of publishing this article?  No harm was done."  Seriously?  And this was the chair of their ethics committee?  No lay person could read the descriptions of what was done to the patients and view that "no harm was done."

Our relationship with our doctors must not be a very equal one.

Dr. Shlain also refers to the relationship in the context of medicine, rather than health.  We all like medical care when we need it, but, by legislative edict, the only people who are allowed to prescribe it for us are physicians, so of course physicians are part of medicine's "atomic unit."

However, we only care about medicine in the context of seeking better health.  That's the real goal, not more medicine -- and it's a stretch to say that the doctor-patient relationship is the cornerstone of our health.   It's part of good health, to be sure, but there are a lot of other important factors -- the person's attitudes and activities, their family's and social network's effects, and so on.

People are spending over $30b annually out of their own pockets on alternative and complimentary medicines, close to $50b on exercise equipment, even some $36b on organic foods.  These efforts don't seem to be doing much to make us healthier, mind you, but it shows that when it comes to our health, we're not just relying on what our physicians prescribe for us.

Our doctors aren't our only partners in health -- or necessarily our most important ones.

So how does any of this relate to ZocDoc?  Keep in mind that ZocDoc is a subscription-based service, with physicians paying a rumored $3,000 annual fee to belong.  It doesn't have a huge network of physicians.  It doesn't allow patients to see those physicians via video or online visits, as TelaDoc and other vendors do.  All it does is offer online appointment scheduling, and user-generated physician reviews.

And that appears to be worth $1.8b.

Surveys indicate that patients increasingly want their physicians to offer digital services, especially online appointment scheduling and bill pay, yet fewer than 20% say their current doctor offers those.  The rise of both retail clinics and telehealth further illustrate that more patients are choosing immediate access to medical professionals they do not know rather than waiting to see physicians they do know.  

I would be very curious to know how many of ZocDoc's patients make appointments with doctors with whom they already had relationships, or if they use the service for a one-time appointments, much like they might order a ride from Uber.

A 2012 survey found that 22% of American adults didn't have a primary care doctor, and the percentage drops off rapidly by age -- 90% for 55+ versus 64% for those 18-34.  If I were a primary care physician I'd be pretty worried about getting those younger populations into a relationship -- or keeping them in one.

The people who talk most reverently about the patient-physician relationship these days seem to be either physicians or politicians, not patients  On average, people supposedly see 19 doctors over the course of their lives, with whom they have different types of relationships for varying durations.  They're not always all that special.

If doctors are going to treat patients disrespectfully, be more interested in medicine than health, or treat patient encounters like transactions (e.g., visits of fifteen minutes or less), then they shouldn't be surprised if patients start not placing much value on the relationship.

If we're not careful, we may get to the point where we pick our physicians like we were picking a date on Tinder, based purely on proximity and superficial characteristics.  Let's hope not.

What Health Care Needs Are Some Zombies

Finally, some good health care news: according to Accenture, half of digital health start-ups are going to fail within two years.

No, really: that's the good news.

Accenture projects that funding for digital start-ups is going to boom over the next few years, reaching $6.5b annually by 2017.  Their analysis categorized four key areas of funding from 2008 - 2013: infrastructure ($2.9b), treatment ($2.6b), engagement ($2.6b), and diagnosis ($2.1b).  They stress that the start-ups that will succeed will do so by combining capabilities across the four areas, such as by use of integrated Social, Mobile, Analytics, Cloud and Sensor technologies ("SMACS").

This boom shouldn't come as much of a surprise.  For example, use of physician virtual visits is predicted to double by 2020, and I wouldn't be surprised if that prediction is too low.  The Wall Street Journal recently profiled several start-ups that are trying to be a "Uber for health care."  As the founder of one of those start-ups, RetraceHealth, told the WSJ, "Once you've had pizza delivered, you rarely go pick up pizza again."

There is a lot of low-hanging fruit, and maybe even some pizza, in health care that digital health start-ups could help us pick off.

Accenture concludes:

All stakeholders—payers, providers, IT vendors, life sciences, pharma and industry newcomers—will need new strategies to respond to inevitable digital disruption
and its potential to dis-intermediate target patients, health consumers and members. Traditional healthcare organizations must develop ways to be relevant to the new health consumer, by encouraging and embracing, rather than resisting, digital
healthcare start-ups.

All that is well and good, and probably, to some extent, even true.  So where are the zombies?

The trouble is, a lot of those start-ups aren't going to make it.  Of some 900 start-ups that Accenture looked at, 51% had received less than $50 million between 2008 - 2013 -- and hadn't received any funding in over 20 months. Maybe they're not receiving more funding because they've, somehow, become spectacularly profitable, but more likely they've become what Accenture calls zombies.  They're dead but they don't quite know it.

Accenture views this as good news for several reasons.  One is that the start-ups have a pool of innovative talent who should be attractive to other health care organizations.  The start-ups may be acquired less for their products or their technology than for the people who created them. 

And, of course, some of those products or technology may have value.  Those 900 zombie start-ups had, by Accenture's count, 1,700 patents, some of which could take off in the right hands, especially if paired with the right array or complimentary technologies and a wider built-in customer base.

Big technology companies -- Apple, Google, Microsoft, etc. -- have relied on the strategy of buying start-ups to gain access to their talent and patents.  Down-on-their-luck companies like Blackberry or Kodak still have a 'treasure trove" in their patent portfolios that can keep them afloat or make them more attractive for an acquirer.

Accenture mixes metaphors by recommending that health care organizations be "like vultures circling prey" when it comes to the zombie start-ups.  I.e., "innovative enterprises will swoop in on digital health start-ups to capture relevant and at-the-ready resources."  (I haven't seen vultures attacking zombies in any horror movies, although shout-out to George Romero about the idea).

The trick, of course, is what to do with a zombie start-up.  I'm not an expert on the zombie genre, but I know that usually you either kill them or they kill you -- or turn you into a zombie.  Making them work for you is harder to do (except maybe in voodou movies, but that is a whole other metaphor).

It's not enough to pick up some innovative people and their ideas.  The organization has to be open to, even eager for, change, and change is something that many health care organizations often do grudgingly (or only if significant impacts on reimbursement are involved).

A recent op-ed in NEJM, by Asch and Rosin, "Innovation as a Discipline, Not a Fad" is on point.  While their examples didn't address acquiring zombie start-ups, they do speak to the necessary mind-set: how can we, as an organization, act faster and test more ideas less expensively.  It is exactly the kind of attitude Accenture is urging.  Zombie start-ups offer one way -- not the only way -- towards that end.

A caution to this call for innovation comes in a post in MobileHealthNews by Bradley Merrill Thompson, a lawyer who specializes in FDA and other regulatory matters.  He recognizes the need for health care to change, applauds Uber's business model and technology, but casts doubt on carrying their analogy too far into health care.  Uber has a somewhat reckless attitude towards regulatory barriers, believing they don't apply and/or are outdated, and Mr. Thompson doesn't think this is the way to go in health care.

He gives five well thought out reasons for his caution, which I won't rehash here, but I do want to comment on two of his statements:

• "I’ve been doing this regulatory work for 30 years, and in that time I can honestly tell you that very rarely is a good idea illegal." 
• "Laws are there for reason, and in the case of healthcare that reason often includes protecting patients from harm."

I'm not so sure I can agree with those, or his conclusion that we shouldn't be a little more reckless about our innovation.  I worry that too much of health care's regulatory structures are to protect providers, or the medical-industrial complex, rather than patients, and that those structures can make good ideas -- ideas that are good for patients -- illegal, or at best so difficult to comply with that they might as well be (see, for example, posts on the cartel-like behavior of state licensing boards or our crazy-quilt approach to medical education)  

Health care providers have historically stubbornly resisted being measured, and it is telling that a recent study in JAMA Internal Medicine which looked at 16 national collections of performance measures found that only 7% addressed overuse.  The authors concluded that the measures may implicitly endorse the "more is better" attitude so prevalent in our health care system.  

Whatever happened to "first, do no harm"?
 
So when it comes to protecting patients from harm, to doing what's best for the patient, yeah, maybe a (metaphorical) zombie apocalypse wouldn't be such a bad thing.  Maybe they can infect health care with some new attitudes.

Survey Says

Two new physician surveys -- one of physician leaders and one of primary care physicians -- are out, with some interesting findings.  For example, 69% of physician leaders agree that physicians should be held accountable for the costs of care, as well as for the quality.

This, my friends, is what is considered progress in health care.

The physician leadership survey, conducted by the American Association for Physician Leadership (formerly ACPE) and Navigant, suggests that physician leaders may be ahead of other physicians on the issue of costs.  When I last wrote on the topic, a broader 2013 survey of physicians found that only 36% -- no, that's not a typo, it really was only 36% -- felt that physicians bore a major responsibility for costs, seeing trial lawyers, insurers, pharma/device manufacturers, even patients, as being more to blame.

Perhaps this kind of difference of opinion is why the physician leaders are the leaders.  The question is, is anyone following?

Meanwhile, The Commonwealth Fund surveyed primary care providers -- including not just physicians but also nurse practitioners and physician assistants -- and found that half of primary care physicians feel that use of quality metrics to assess and reward performance has a negative impact on quality.  It is not clear whether they object to being measured at all or if they simply don't like the current generation of measures.

The physician leaders, on the other hand, are more bullish on transparency about quality: 92% think it is important, with more than half saying it was very important.  Of course, only 29% have any confidence that non-physicians can manage the issue, whereas 70% of them think they can.

I wonder what confidence they would have in primary care physicians coming up with solutions.

I don't have much sympathy when physicians or other providers complain about being measured ("giving doctors grades").  Yes, possibly the measurements can be gamed or lead to cherry-picking healthier patients, but that just suggests we should come up with better measures (for example, 360 reviews for surgeons).  In the 21st century, neither patients nor payors should just assume that health care providers are all doing a good job, especially when it is demonstrably true that some are not.

As Ronald Reagan famously said, "trust but verify."

We shouldn't expect that quality measures will necessarily look like what we're used to -- e.g., Hospital Compare, Healthgrades, or even some of the new sites to compare surgeons.  In the absence of easy-to-understand measures, consumers may fall back to consumer reviews, like those already offered for health care providers by Angie's List, Zagat, or Yelp.  Yelp is even teaming up with ProPublica to beef up its consumer ratings and to add some objective data.

Physicians like to think they can't be evaluated like a plumber or a restaurant, and perhaps they are right, but that doesn't mean consumers won't opt to do so.

On the brighter side, despite all the furor about shortcomings in EHRs, 50% of primary care physicians feel that health information technology is having a positive impact on their ability to provide quality care to their patients.  This is an issue upon which physicians and their leaders seem to agree: 88% of the physician leaders think that implementing clinical HIT is important.

The primary care physicians' support for HIT is slightly at odds with other physician surveys.  The Koreo Physicians Practice 2015 Technology Survey found that two-thirds did not believe they have gotten a return on their EHR investment, perhaps because 37% report that their EHR has caused them to see fewer patients, as opposed to 12% seeing more.

Let's just hope that the focus on HIT is in improving (and measuring impact on) quality/value, not simply trying to increase productivity.

Some other highlights from the AAPL and Commonwealth surveys:

• The primary care physicians believe that penalties for unnecessary admissions/readmissions -- one example of "value-based purchasing" -- have a negative impact on care (52%), whereas 63% physician leaders disagree that moving to value-based arrangements will hurt the quality of care.
• A surprising 64% of primary care physicians report being paid capitation or salary for some or all of their patients.  Fifty percent currently have quality incentives as part of their compensation, 43% have incentives based on efficiency, with 55% receiving one or both kinds of incentives.
• The primary care providers are not fans of either PCMHs or ACOs.  More believe those models have had positive impacts on quality than had negative ones, but most thought there has been no impact or weren't sure.  Their opinion was somewhat more favorable if they actually were in one of the models (which less than a third are). They may want to get used to them: a majority of the physician leaders see at least ACOs as a permanent model for risk sharing arrangements in the coming years.
• Almost all (89%) of the physician leaders are worried about the supposed primary care physician shortage, but only 29% of the primary care physicians see increased reliance on NPs or PAs to deliver primary care is having a positive impact on the quality of that care (versus 88% of the NPs/PAs).  Evidently, traditional turf issues remain.
• Seventy-four percent of the leaders think that medical training is "archaic" and needs to be updated, something I completely agree with.

One thing that the physician leaders and the primary care physicians seem to agree on is that the medical profession is in some trouble.  Sixty-nine percent of the leaders think that the medical profession is a less attractive career now than when they started, while 47% of primary care physicians say they are considering retiring earlier than expected due to the current environment.

To paraphrase Shakespeare, methinks they doth protest too much.

Certainly the practice of medicine is changing.  Probably their authority is not as unquestioned as it once was.  Perhaps there are more demands on them.  It may be troubling that more medical school graduates are opting to not pursue residencies, some going straight into businesses like digital health start-ups.

All that may be true.  But medical school enrollment is higher than ever, so I wouldn't get too worried just yet.  Survey says, we're still going to need physicians...just maybe not in quite the same ways.