Tuesday, September 29, 2015

To ER Is Human

One of my favorite quotes from The Princess Bride is when Inigo Montoya tells Vizzini, who repeatedly uses the word "inconceivable" for situations that were not only conceivable but actually happening: "You keep using that word.  I do not think it means what you think it means."  I think of that line whenever I think about the use of "emergency" as part of "emergency rooms" (excuse me, they like to be called "emergency departments" now).

I was prompted to think of ERs by a WSJ op-ed by Dr. Paul Auerbach.  In it, he argues that non-emergency visits to the ER aren't going to stop, much as we might wish patients to do a better job of evaluating when they are actually suffering an "emergency."  He notes the limited access to timely care from primary care physicians, and how it is not reasonable to expect people to make such rational evaluations when they or their loved ones are suffering.

As he says, "You can't teach patients economics lessons when they don't feel well."

Dr. Auerbach wants more resources to "make emergency departments more efficient," as well as to build primary care and specialty capacity.  ERs certainly could be more efficient, but I suspect that simply adding more physician capacity won't really get at the underlying problems.  I do agree that these non-emergency visits are likely to continue, and that the health care system has to accommodate them, rather than making patients accommodate to it.  

The rise of urgent care centers and retail clinics should be helping decrease ER visits, but neither those nor more people having coverage seem to be denting ER visits, which nearly half of us make every year.

According to the CDC, 27% of ER visits only had a 15 minute wait to see a doctor, nurse practitioner, or physician assistant, but third waited over an hour.  Only 12% of visits lasted under an hour; the plurality (35%) lasted 2-3 hours.  To Dr. Auerbach's point, less than 12% of all visits were evaluated as actually being "immediate" or "emergent."  

Promedica has teamed with Yelp to give ER statistics by hospital, such as average ER wait times and average time before being sent home, more available to consumers (see Promedica's tool), hoping they'll check it before rushing off to the local ER, but they should be mindful of what Dr. Becker said about when to give economics lessons.  

Making this data available may not have the impact Promedica/Yelp hope.  Digital design/strategy firm Huge did a "neuromarketing" study on what impact posting average wait times had on consumers.  They found that proximity was still paramount, regardless of expected wait times, but that posting the wait times could positively impact the perceived brand image of a hospital, even if their average wait was longer than the national average.  Indeed, some thought shorter wait times meant worse quality.

What ERs tend to have in common is that many people are shocked at the cost.  A 2013 study found wide variability in ER charges for common conditions, with the median charge of $1,233 being 40% higher than the average American pays in monthly rent.  And good luck trying to find out the costs in advance.

We're making it too hard for consumers.  We give them all these options -- not just ERs but free-standing ERs, not just urgent care centers but also retail clinics, plus physician offices, outpatient clinics, telehealth, even telehealth kiosks -- but aren't as good about helping them know when to use which.  Widely touted app iTriage has the right idea -- steering users to the right providers/facilities based on their symptoms -- yet its recommendations always seem to include ERs anyway. 

Honestly, if you are clear when which patients should go to which option for what conditions, you're smarter than I am.  You probably are anyway, but what worries me is that I'm not sure many providers know either, even when a single health system is offering the options.

Some ERs have created separate triage tracks with distinct pricing and waits for different levels of need.  Others are using technology to accomplish that.  Houston has launched ETHAN -- Emergency Tele-health and Navigation -- for its 911 EMTs.  If EMTs believe a 911 caller doesn't actually have an emergency, the EMTs at the scene can do a video consult with an emergency physician, who can then steer the patient to other options if appropriate, such as at primary care clinics.

Similarly, Jefferson Hospital in Philadelphia uses their JeffConnect telehealth service to connect potential ER visitors to do a video consult with an ER doctor, expecting they can deter some visits.  The service costs $49 per visit -- much cheaper than an ER visit would be.

These efforts are good starts, but they're just scratching the surface of what needs to be done. Ideally, what we need is something like this:

  • A service -- web-based, app, and/or phone -- lets you explain your health issue, and uses algorithms/AI to help identify the suspected problems(s).
  • Depending on what is wrong, it might automatically call 911, call Uber to get you to the ER with the shortest wait time/shortest distance/most expertise with your problem, or connect you to a physician via video consult for further evaluation.
  • If the problem is not truly an emergency, it can steer you to lower cost, shorter wait options, perhaps the next day, possibly making an appointment for you.
  • The service would keep your health history, current prescriptions, and insurance information, then transmit those, your self-described symptoms and proposed diagnosis to whichever provider you are sent to, so you don't have to start all over again when you arrive.
None of that is beyond our current technological capabilities...so why doesn't such a service exist?

Patients are still going to end up in the "wrong" place, but we can help make that happen less often, and we can try to stop penalizing them -- through higher costs, longer waits, and unnecessary tests -- when they do.  It's supposed to be patient-centered, not ER-centered, right?

Tuesday, September 22, 2015

Can Slick Trump Sick?

Health insurance is getting some love from investors, and not only the money going to the increasing consolidation of the industry giants.  CB Insights says $1.4b of venture capital has gone to the insurance tech space since the beginning of 2014, with health insurance-related investments getting more than all other insurance sectors combined.

A lot of that money is going to companies that make it easier to deal with health insurance, but some is going to start-ups -- like Oscar, Clover Health, and Zoom+ -- that actually hope to reinvent the nitty-gritty, often grimy business of providing health insurance (or, as Wired put it, at least make it "suck less").

As some of the health co-ops are finding, though, it's not so easy to break into health insurance.

Oscar, of course, has long been a media darling.  Last April they raised $145 million in a funding round that effectively valued them at $1.5b, and Google just put in another $32 million that ups that valuation to $1.75b.  All this for a company that only has 40,000 members, is offered only in New York/New Jersey (with plans to expand to California and Texas), and which in 2014 lost $28 million on $57 million in revenue.  But never mind all that; they've got a nice website.

That's not really fair, of course.  They've focused on using technology to improve the customer experience, are ahead of the industry curve on use of technology like fitness trackers and telehealth, and are working to use data to match patients with the best physicians for their conditions.  Still, as CEO Mario Schlosser admitted last year to Fortune, in wake of member complaints about ineffective communication as to how the health plan actually worked, "The healthcare system is astoundingly complex."

Oh, really?

Clover Health, which just raised $100 million in a funding round through some impressive lead investors, has a somewhat different strategy.  It focuses on the Medicare population, putting their primary emphasis on using data to improve patient outcomes.

Clover uses their algorithms to identify high-risk patients, sends nurse practitioners to their homes to develop personalized care plans, and continually loops in new data to update patient profiles.  The key is integrating data from disparate sources -- e.g., medical records, lab tests, even contacts with members -- to create an overall patient profile, then identify and fill any gaps.

As CEO Vivek Garipalli told TechCrunch, "You imagine a Medicare patient goes to a primary doctor’s office, goes to a cardiologist, goes to a hospital, there is no quarterback for that data.  No one has the time or the data to guide that patient and coordinate all those interactions and make sure each provider gets the right info at the right time.”  This is the elusive goal of interoperability and of patient-centered teams, but Clover thinks they've cracked that challenge.

So far Clover (headquartered in San Francisco) is only available in six New Jersey counties, but they claim to have 50% fewer hospital admissions and 34% fewer readmissions than the average for Medicare patients in those counties.  Most of their competitors would claim to have similar efforts for high-risk patients, so we'll have to see if their model scales.

Then there is Zoom+, or, rather, "Zoom+ Performance Health Insurance."  It is the outgrowth of ZoomCare, a network of retail clinics in Portland (OR).    Zoom+ claims to be "the nation’s first health insurance system built from the ground up to enhance human performance," and thinks of itself as "Kaiser 4.0."


Zoom+ has focused heavily on the user experience, wanting "health care to be more like visiting an Apple store," according to Fast Company Design's profile of them.  CEO Dave Sanders says: "Health care is one of the largest household spending categories other than a car or food.  For that kind of investment, it needs to be a life-enhancing platform, not just a commodity or a utility. Oh, and by the way, when you’re really sick, it’s got your back too."

The five design principles that guide Zoom are:

  1. Credibility begins with aesthetics
  2. Define "anti-requirements"
  3. Vertically integrate
  4. Build trust with savvy partnerships
  5. Accentuate the positive
By comparison, you don't get the feeling that, say, Anthem focuses a lot on aesthetics.

Zoom+ features not just cool retail centers but also mobile capabilities, a Personal Performance Path, and a Zoom+ Guru, among other services.  It is not your mother's health insurance, and right now can't be yours either unless you happen to live in Portland.

I'm all for reinventing health insurance.  I'm all for making the customer experience much, much better in health insurance and in health care generally.  But I do worry that some of these upstarts may be taking advantage -- perhaps inadvertently -- of one of the underlying problems with health insurance: risk selection beats execution.

Here's why: About 5% of the population incurs about 50% of the overall costs.  If the overall cost in a population is $6,000 per person, as it is for employer coverage, then those 5% average $60,000 each, while the remaining 95% average a little under $3,200.  It doesn't take too much of a change in the make-up of a population to dramatically skew its costs:
Company A thus gets a 17% cost advantage over Company B if it can just slightly lower the percentage of the really sick people who enroll in it.  That can offset a lot of administrative efficiencies, provider contracting advantages, or population health management efforts. 

Of course, under ACA, health insurers can't overtly practice risk selection.  They can't medically underwrite, can't cancel coverage, and have to take all-comers.  They can't even blatantly market to healthy people.  ACA also has provisions to risk adjust between health insurers, but they are at best imperfect

Health insurers can, however, market features that are more likely to appeal to younger, healthier customers, like snazzy websites, fitness trackers, or training advice.  None of those are only of interest to "healthy" people, but, as the chart above suggests, it doesn't take much of a shift in the risk profile to have noticeable impacts on costs.   

Health insurance needs more consumer-focused technology, more effective use of data, and more focus on promoting health instead of reacting to sickness.  However, I'm not getting too excited until I see a health insurer that does away with provider networks, refuses to be complicit in outlandish provider charges, and offers a plan of benefits that consumers can actually understand.  

Until then, we may just be putting new colors on the old chassis.

Monday, September 14, 2015

Giving It Away

I'm fascinated with companies bold enough to blow up their own business model.  I'm especially fascinated when part of how they do so by giving away services "for free."   A couple weeks ago I wrote about how Microsoft was attempting to do both of those, and now Verizon is making an equally interesting move with their introduction of Go90.

As usual, I only wish the example was from a health care company.

Go90 is a streaming service that allows users to watch television shows, videos, and similar content on their mobile devices (the name reflects how users typically orient their mobile devices to watch videos in landscape mode).  Unlike previous streaming services, such SlingTV or HBO NOW, the streaming is only for mobile devices, rather than Internet streaming more broadly (although Verizon may follow-up Go90 with a TV service).  Plus, of course, it's "free," whereas SlingTV and HBO NOW both carry monthly fees.

Verizon acquired the platform for Go90 from Intel, which had been developing an Internet video service in its own effort to revamp its business, That service, named OnCue, fell out a favor within Intel after a CEO change, and Verizon snapped it up for under $200 million.  The stakes for Verizon got higher after AT&T acquired DirecTV, which is AT&T's effort to stay relevant in a more interconnected world.

The cable industry is already undergoing upheaval, realizing that its traditional bundling of channels may no longer be viable.  Various options have sprung up to let viewers have more control over which channels/programs they have to pay for (including Verizon's previously announced "skinny" package).

Even more significantly, the cable industry is terrified that they're losing the eyeballs of younger viewers, as illustrated by this graphic from The Wall Street Journal:

Verizon is trying to combat this trend by directly targeting millennials with Go90, using their favorite devices for watching media and at their favorite price point.  In order to increase appeal to non-Verizon customers, they're not limiting it to Verizon customers, nor branding it Verizon,  They further hope that Go90 will become "social entertainment," increasing its appeal to those uber-connected (pun intended) millennials.

Of course, "free" is rarely actually free.  The service does include ads, and, as Variety reports,  all that content counts towards data plans, which are not free.  Still, if you were going to watch your videos on your phone/tablet anyway, a free service like Go90 should have some appeal.

The thing that struck me initially was the chart showing video patterns by age.  It looks surprisingly similar to many charts of health care usage by age, such as the percentage of people with a primary care doctor by age (64% for 18-34 versus 90% for the 55+, according to The Physicians Foundation), or the number of physician visits by age, according to the CDC:


These patterns may not scare the health care industry the way that the corresponding video medium preferences scare the cable industry.  After all, health care professionals can rationalize, as people get older they'll use more health care services, and, anyway, we seem to be developing chronic diseases at earlier and earlier ages (e.g., the recent study on diabetes/pre-diabetes prevalence), so the health care industry can always expect people to come to them.

Maybe.  But maybe not; the future only resembles the past until it doesn't, and then it can look entirely different.  I think health care should be placing a few more bets in case the younger population decides to ditch accessing care in traditional ways like they're ditching cable.

An obvious parallel to Go90 would be with telehealth.  I keep reading about its explosive growth, but most of the uses still appear to be tied to health plans, with their deductibles, copays, and/or coinsurance.  There are some direct-to-consumer offerings, such as through American Well or Doctors on Demand, but they typically charge per visit or per month.

It'd be interesting to see what would happen if a health system or physician group let people access all the virtual care they wanted "for free," while still charging for in-person services.

CVS recently announced it would be piloting services with three different telehealth companies, mostly in connection with its MinuteClinic offerings.  CVS was the first to rid its stores of tobacco products, and it would be equally bold for them to offer a free telehealth service to customers.  One would think the in-clinic/in-store referrals could more than pay for the service, and I'd bet that some health systems might pay for the right to be local referral centers for specialty care.

But we shouldn't only be thinking about free video services just because that is what Go90 happened to do.  The underlying "problem" in reaching young people about health services is that, generally, they are more likely to be healthy -- or, at least, think they are healthy.  Seeing a doctor, even virtually, is just not something they really want to do, unlike watching TV shows on their smartphones.  If the health care industry wants to engage younger customers, it needs to do so for activities that they already want to do.

For example, pharmaceutical companies are already tapping Fitbits as a way to collect better data on people in clinical trials, and employer wellness programs have also jumped on the Fitbit bandwagon.  Both of those are intriguing starts, but I doubt either group of users have any doubts about the reason for the largess.  They only re-enforce the existing business models, rather than appear to upend them.

Similarly, there are already over a hundred thousand health-related apps, many of which have free versions, but not many of which threaten the existing health care business models.  When we see apps that lets you, say, perform and interpret your own labs or imaging for "free," that would be revolutionary.

The interesting question will be whether someone in the health care industry will voluntarily up-end their own business model, as Verizon is doing with theirs, or if someone from outside the industry does it for them.

I know what my bet would be.

Wednesday, September 9, 2015

The Right to Repair Ourselves

Geoffrey Fowler wrote an interesting article in The Wall Street Journal: We Need the Right to Repair Our Gadgets.  He describes how manufacturers have made it difficult for us to fix our personal tech gadgets (The Guardian concluded the same earlier this year), and discusses how he's managed to overcome some of those obstacles.

As I was reading it, I kept thinking, boy, replace "gadgets" with "our bodies" and "manufacturers" with "health care professionals," and he could be talking about health care.

Mr. Fowler asks the central question:  "At issue: Who owns the knowledge required to take apart and repair TVs, phones and other electronics?"  He asserts: "We’re more capable of fixing technology than we realize, but the electronics industry doesn’t want us to know that. In many ways, it’s obstructing us."

Again, think of the parallels for health care.

This obstruction takes many forms.  Mr. Fowler claims that some manufacturers control repair plans, limit access to parts, or use digital software locks to prevent consumers from fixing problems themselves.  If you have an Apple product with a bad battery, too bad, because you can't replace it yourself.  Apple uses special screws to ensure you can't even open the case.  Maybe they're just trying to prevent reverse engineering, but I suspect the people engaged in that are far more capable of defeating this tactic than some poor consumer who just wants to put a new battery in.

It's not that the manufacturers want to do the repairs themselves, mind you; they just want to make it difficult enough that, when there is a problem, you'll just give in and buy a new device.

This strategy of "planned obsolescence" has been around for a long time.  It has often been applied to automobiles, with their annual model changes, but it goes much further.  Popular Mechanics, for example, lists eight products "designed to fail," including not just cars and consumer electronics but also software, video games, ink cartridges, textbooks, and light bulbs.

Mr. Fowler took on the task of fixing a friend's broken Samsung TV.  Samsung grudgingly referred him to an authorized repair shop, insisting that the repairs needed to be done by a "qualified" technician.  Not surprisingly, the estimate from the repair shop was awfully close to the price of a new TV, so Mr. Fowler took to the Internet.

He quickly identified the likely source of the problem, found the necessary (and surprisingly cheap) replacement part, and viewed an applicable YouTube video.  He also discovered several communities of self-repair enthusiasts, one of which claimed they can fix two-thirds of the broken consumer electronics they see.  That's not only averting a lot of spending on replacements, but also reducing e-waste.

If you're old like me, you might remember that if you had a PC in the 1970's, you probably built (and repaired) it yourself.  If you had a TV in the 1960's, you probably had to routinely replace its vacuum tubes (Millennials, go ahead and google them).  You didn't have to be an expert mechanic to do most car repairs yourself until the manufacturers starting putting in all those computer circuits in the 1980's.

You might also remember when going to the ER was a rarity, and that it took a lot for your family doctor to send you to a specialist.  There was much more of a tendency to fix problems at the lowest level of care,including wait-and-watch and/or self-doctoring for many common problems.  Today a low grade fever is likely to cause an ER visit and a dose of antibiotics.

The analogy of planned obsolescence only goes so far because, of course, we can't get new bodies (although we can get some new parts, like knees, hips, or organs).  In health care, the goal seems to be to persuade us to get more care, and more expensive types of care at that.  It's a self-perpetuating cycle.

Think back to Mr. Fowler's central question.  Who owns the knowledge necessary to "repair" our health issues?  For centuries physicians have held that knowledge close to the vest as part of their professional expertise.  In the world of the Internet, much of that knowledge is now available to consumers -- e.g., Pew's 2013 report found 72% of Internet users had searched for health information, and Google's enhanced health search results now cover 900 conditions in-depth.

Thought leaders like Eric Topol have called this the "democratization" of health care."  Dr. Topol doesn't just think it is good for consumers to have access to all this information but also calls for patients to "own" their own medical data, rather than the current situation where it is locked in the silos of each provider who treats them.

I think Mr Fowler would agree with Dr. Topol.

Similarly, I suspect that Dr. Topol would draw the same conclusion about health care that Mr. Fowler does with consumer electronics: we're more than capable of "fixing" ourselves for many health issues, but the health care industry doesn't want us to know that and, in many ways, does its best to obstruct us from doing so (see a prior post).

A new book -- The Patient's Playbook --  urges us to take control of our medical care, rather than simply letting it happen to us, and I couldn't agree more (I love the description "tiger patients" used in one review).  However, to me it is a little like advice on how to survive if I happened to get caught in a hurricane.  I'd want the advice, but I'd rather know how to avoid hurricane in the first place.

A variety of health apps are starting to break down the traditional barriers about what consumers can do versus what health care professionals need to do for them, and that's great.  I just hope the FDA is very thoughtful in their reviews of such apps, not only which apps need their approval but also not underestimating what consumers can do on their own.

There are certainly many people with complex health issues that require sophisticated treatment by medical experts.  However, that is not the vast majority of us.  I'm not advocating that we should do brain surgery ourselves, but there are a host of health actions for which we shouldn't need medical interventions.

We've built a health care system that is like a Indy race car -- very advanced, very good at its intended purpose, driven by expert drivers, and, of course, very expensive, but not well suited for everyday driving.   We need a health care system that lets us do more of that everyday driving when it comes to more routine health care.

Do-it-yourself health care, anyone?