Sunday, July 31, 2016

Uber For Health Won't Play Nice

People talk "Uber for health care."  After all, Uber has been wildly successful, valued over $60b, which makes it bigger than Ford and GM.  AirBnB, the Uber of hotels, is worth some $20b.  Heck, even the disposable razor industry has its own Uber, with Dollar Shave Club just getting acquired for $1b.  Any industry that isn't looking in its rear view mirror for potential Uber-type competitors may find itself disrupted into irrelevancy.

And, goodness knows, health care could use some disruption.

There are no shortage of candidates for health care Ubers.  Telemedicine and other on-demand services are often cited, with such companies like TeleDoc, American Well, Heal, Pager (which was founded by an Uber co-founder), or MedZed.  Some offer video calls with nurses and doctors, some even offer in-home visits.  Accenture predicts over $1b will be invested in such companies in 2017.

Other Uber candidates include the dozens of health start-ups that are based around mobile apps, including not just on-demand services but also services like appointment scheduling (ZocDoc), chronic condition self-management (Glooko), even therapy (TalkSpace).  Not to be left behind, we supposedly have Ubers for blood draws and home health.

Uber itself is dipping its toe into health, with UberHEALTH offering flu vaccinations and rides to medical appointments,

Not everyone sees an Uber impact on health care, at least not yet.  Rick Bates, writing in TechCrunch, warns not to expect an Uber in health care anytime soon, He notes the "unrivaled" regulation in the space, the importance of trust, and the limits on choice that consumers have.  Uber may have changed consumer transportation preferences in a short time, Mr, Bates says, "but in the realm of healthcare, there are too many regulations, constraints, and basic laws of human behavior to overcome."

Similarly, Rock Health, while detailing the "uberification" of health care through on-demand services, cautioned that "the unit economics are far more challenging for on-demand health care versus other on-demand sectors, with transportation as an example."  They argue that technology adoption in health care is driven more by reliability and price than novelty and convenience.  As a result, "the path to bridging a successful on-demand business is likely to be longer and more complex than originally hoped."

Both the proponents and the skeptics have valid points, but we may be missing the point.  Uber wasn't looking to break into the taxi industry, and the Uber of health care won't be looking to break into the health care system.

Uber didn't care about the taxi industry's restrictions.  It views itself as a technology company, not a taxi or even a transportation company (although they are starting to be regulated more like the latter).  They didn't seek to buy a fleet of cabs, nor did they worry about getting regulatory approval for its drivers or what they charged customers.  They just started using their technology to match riders and drivers, figuring they'd deal with the regulatory backlash once they were too firmly entrenched to easily get slapped down.

I.e., they didn't try to fit into the rules.  They knowingly broke them.

Most of the start-ups that claim to be a health care Uber have still ended up being part of the health care system, just adding consumer-convenience through better technology.  They're playing nice, usually eager to make deals with hospitals, physician groups, and/or payors.  That is, after all, where the money is, and it is easier to try to grab a slice of the $3 trillion we're already spending than to invent a new industry.

But that's not what Uber did.  They didn't go to the taxi companies and offer to spiff up their technology.  They didn't go to the taxi regulators and suggest changes to the regulations.  They created a new industry, one that only resembled the one they were supplanting in that both exist to get people from point A to point B.

In some ways, a better example of disruption than Uber may be Napster.  Its founders didn't want to fit into the music industry, and weren't even trying to get rich from their idea.  They just wanted people to be able to share songs, and they succeeded far beyond anyone's expectations  That their idea almost brought the music industry to its knees was beside the point.

That's what could happen to health care with a true disruptor.

Napster was shut down, but iTunes was born out of its premise, and has been a huge success, as have Google Play, Spotify, Pandora, and others.  They've fundamentally redefined how we buy and listen to music.  Neither the record labels nor the musicians are crazy about these new worlds, nor are they making as much money, but that is what happens when an industry is disrupted.

An Uber or a Napster of health care may not use doctors, or it may not abide by state-based licensing restrictions.  It may not care about health care's arcane coding languages: diagnosis and procedure codes, place-of-service modifiers, etc.  It may not care about FDA approvals or importation restrictions.  It may not care about health insurance, with all its many regulatory requirements, benefit provisions, and capital needs.

In short, it may not look or act like anything else that currently exists in the health care system.

People like to point out that health care is different from other industries because we entrust our lives to it.  We need to trust what care we're getting and from whom we're getting it.  That is, they say, very different than getting a ride or downloading a song.  That may be true, but it is also true that far more people are killed from medical errors than from automobiles, so the health care industry shouldn't be too complacent about its "unique" role.
The health care industry shouldn't be looking in the rear view mirror for its Uber or Napster.  They won't be on the same road.  They'll be coming from the side, or in the air -- from someplace that the industry isn't expecting, isn't looking at, and may not even initially recognize

That's how we'll really know when health care has its Uber.

Monday, July 25, 2016

Not More Docs -- Fewer Patients

Health care needs a better business model.

HHS reports that U.S. health care spending will surpass $10,000 per person this year, will grow almost 6% annually for the foreseeable future, and will consume over 20% of GDP by 2025.  About half of our spending goes for labor costs, with health care employment remaining one of the "bright spots" in our economy.  Indeed, health care jobs continued to soar even when the economy tanked in our most recent recession.  

Despite that steady growth, we continue to talk about a physician shortage, especially for primary care.  Medical school enrollment is at new highs, yet it is not projected to dent the demand.  As a result, we're importing more physicians -- as many as 25% of U.S. physicians were born outside the U.S. -- and trying to figure out how to use more physician extenders like physician assistants. There are similar projected shortfalls for nurses, pharmacists, and other key health care workers.

One has to wonder why well-paid, high prestige jobs in a booming industry would go begging.  One could look at the high costs (both time and money) for training and/or the effect of the various licensing cartels -- er, boards -- but the simple answer may be reflected in those steadily rising costs.  All of those costs are revenue for someone, and no one really cares as much about slowing them as much as the people and organizations earning them do about protecting them.

E.g., it's not that we don't or won't have enough health care professionals, it's that it's just hard to keep up with the demand they help create

Last year Atul Gawande wrote about the "avalanche of unnecessary care," citing not just low-value but "no value" care that represent undue financial and other burdens on patients.  Unnecessary perhaps, and in some cases even harmful, but always revenue for someone in the health care system.

Of course, now we're moving towards accountable care organizations and value-based purchasing, but to say the jury is still out on these would be to overstate the trial.  The health care system has successfully weathered a wide variety of attempts to control costs over the past sixty years (e.g., ever since Medicare and Medicaid helped open the floodgates), and a betting person would have to give it the edge in these latest efforts as well.

If health care was, say, the smartphone industry, people would be thrilled with such steady revenue growth.  Investors would flock to it, economists wouldn't worry much about people diverting other spending to pay for their smartphones, and smartphone purchasers would most likely be pretty happy with their new phones.

In health care, though, there is a pervasive sense we're not really getting good value for all that spending.  International comparisons consistently show that, despite our vastly higher spending, our health outcomes and health status are practically third world.

The problem is that we're not buying health; we're buying medical care.  Often it does help improve our health, or at least ameliorate some of our health issues, but no one in the health system is really getting paid to keep us healthy.  In fact, most parties get paid only when we aren't healthy.  And, for the most part, they get paid even if they don't actually make us better.

That is the mother of all perverse incentives.

We pay lip service to keeping people healthy, such as by stressing annual physicals and various preventive screenings, but the data on their efficacy is embarrassingly slim, with some evidence that the false positives -- with all their associated follow-up treatments -- may outweigh the benefits.

Even health insurers, which arguably do benefit if their members are healthy, care most about being able to accurately predict how much their costs will go up.  Having their costs go up means higher revenue for them too, if they've forecast correctly.  It's easier to hire better actuaries than to try to keep members healthy

Face it: the business model our health care system is built around is sick people.  Whether you are a drug company, a hospital, or a doctor, repeat customers help fuel your revenue, and the sicker they are, the more that revenue is.  That is not to impugn the motives of (most of) those people; they are simply responding rationally to the business model we have.

We're going to need a different business model.  Dave Chase likes to remind us that, according to RWJF, clinical care only drives 20% of clinical outcomes, yet gets 90% of our spending.  Social and economic factors and health behaviors account for most of what happens to our heath.  Yet that care is the focus of our current business model.

We're on the wrong path.

We're going to need a business model that focuses on health, not sickness and certainly not just medical care.  It needs to be a business model that earns money by its customers being healthy.  As Esther Dyson recently tweeted, "best way to lower healthcare costs (not prices) is to reduce need for care bc people are healthy!"

Whether we like it or not, the new business model is probably not going to be built around the current crop of health care professionals and institutions.  Hospitals can call themselves "health systems" and doctors of medicine can say they will manage our good health as well as our sickness, but there's a certain square peg/round hole aspect to these claims.

If we want a better health care system, let's start with one that doesn't constantly strive to get more doctors, more hospitals, more prescription drugs, more medical devices, but rather one that competes on how we get fewer patients -- fewer people who need care.  The more customers who stay healthy, and the healthier they are, the more money to be made.

It sounds simple, but it would be a radical change.

People will still get sick.  People will still get cancer and heart disease.  People will still get injured.  There's going to always be a need for medical care to deal with these health issues.  We will need to figure out how to fairly pay for their care, without breaking the bank.  But the tail shouldn't wag the dog -- as it does now.

I'm all for efforts to make our health care system deliver more value and better health, but I'm much more interested in business models that will transform it into something that truly is about health.

Friday, July 15, 2016

What Pokémon Go Means for Health Care

Just what the world needs: another article on Pokémon Go.  And one that tries to relate it to health care, no less!

In recent days there have been a flood of stories trying to explain the Pokémon Go craze.  And it is a craze, a bona fide hit.  Just a few days after it was released as a free mobile download in the U.S., it is the biggest game ever here, with more daily users than Twitter and with users spending more time engaged with it than Facebook, reports TechCrunch.  Pretty impressive for what is basically a mobile take on an old video game (The New York Times calls it "Millennials' first nostalgia blast").

For those of you who have not yet succumbed to the mania, here's a quick recap of the game:
  • It uses your smartphone's camera and GPS system to overlay fictional features onto the real world, so that you "see" both at the same time.
  • Pokémon is the name of the fictional species that are the point of the game.
  • Players can grow a Pokémon by obtaining an egg, which require walking to incubate and hatch, or they may capture one by hitting them with a  Poké ball (also launched from your phone). 
  • Players can obtain more Poké balls, and other free goodies, at PokéStops that are also shown on the map.  These are usually real world historic or landmark sites, and end up being social hotspots for players, especially if the PokéStop has been marked by a Lure module to attract Pokémon.
  • Players can also meet up with other users in "gyms" to battle other Pokémon players.

Many -- e.g., The New York Times and Fast Company -- believe that Pokémon Go is finally going to make augmented reality mainstream, as well as showing AR's advantages over virtual reality, since the latter typically requires at least a headset plus a high powered PC.  It makes AR quick, easy, and free, teaching players how AR can seamlessly fit into the real world.

The game has players wandering around their neighborhoods, their eyes torn between their phones and the real world, visiting places they never stopped at before and meeting people they might never have talked to before.  Sometimes this had led to unintended consequences, even injuries.  There are reports of people trying to play while driving, falling into ditches, walking into traffic, even finding a (real) dead body.

Of course, all those are things that people might have done while texting or checking Facebook on their phone.

The Pokémon Go craze has sent Nintendo's shares skyrocketing, boosting its market cap by some $9b.  Nintendo's future isn't set as a result of the game, though.  They still have to figure out how to maintain the phenomena, as well as how to monetize it (e.g., charging retail locations a fee to be a PokéStop.).

People are already talking up the game's health benefits.  The New York Times reports that it "has kids on the move."  MobiHealthNews calls it the "fastest growing unintentional health app," noting the walking required to incubate eggs or to visit PokéStops.  More importantly, when people are playing the game they are not sitting passively behind a screen in their house.  They are outside, moving around, and often interacting in-person with other players.

Pokémon Go is not, by itself, going to lead to dramatic improvements in the nation's health.  Nor was it intended to.  It is, however, yet another example about we can use games, or at least gamification, can help us with our health (see Health Care Is Better as a Game).  We tend to treat our health as serious business, and it is, but that doesn't mean we always take it very seriously, not as judged by our health habits.  It seems ironic that one of the best ways to improve those habits may well prove to be to play games.

However promising gamification in health care may be, it is the AR that may well hold the most promise for health care.  Google was not wrong to pursue Google Glass, just premature.  Pokémon Go may be signaling that we're now finally ready for AR, and that it will be consumers as well as professionals who can benefit from it.

The potential uses in health care are virtually endless, but here are a few examples:

  • Ever been lost in a hospital, meandering haphazardly despite various signs and color-coded arrows?  How much better would an AR map be?  It could constantly point the way, redirecting if any wrong turns are made, and even offer helpful interpretations to the medical jargon passed along the way.
  • Ever feel like your doctor spends too much time staring at your chart or a screen?  Instead of looking there for information about you, how much better would it be if he/she was looking at you, with AR notations for key information about you?  And there's no reason why we shouldn't be able to see those displays as well.
  • Ever not understand what your doctor is telling you about your diagnosis or treatment?  It is well documented how few patients leave their doctors office/ER/hospital understanding what they were told.  How much better it would be if your phone could listen to the conversation, and provide AR "translations" into layman's terms of what is being said?  
  • Ever been told you needed a prescription, a test, or other treatment, and wondered how much it might cost?  You might have even asked your doctor, who most likely doesn't know either.  How much more powerful transparency efforts would be if those prices showed up as AR in the place of service at the time of the discussion about them, again with both the patient and the doctor seeing them?
  • Ever make "bad" food choices, despite calorie and nutritional information more omnipresent on labels and menus?  How much better would an interactive AR display of the information be?
Health care has no shortage of information.  Its problem is more making that information accessible to the right people, at the right time.  This is the real potential of AR, and figuring out how to do so in as impactful yet unobtrusive way will be the challenge for developers.   

Pokémon Go is not the model for the future of health care, but it offers a model for it we should be paying attention to.

Saturday, July 9, 2016

The Most Important Health Care Jobs of the Future

Fast Company ran an interesting article The Most Important Design Jobs of the Future, predicting 18 of the most important design jobs of the future (at least 3 to 5 years out).  A couple of them were in health care, and arguably all of them would have some impact on health care, but I thought it might be fun to do a similar list specific to health care, and not limited to design.

Let's hope no one comes back in a few years to show how wrong I was.

I'll skip the usual suspects -- e.g., doctors, nurses, pharmacists.  Yes, those jobs will (almost) certainly still be around, but they may not be central as they are today.  And those jobs will evolve in ways that reflect the trends illustrated by the jobs I list.

Let's start with two jobs on Fast Company's list:

Human Organ Designer.  In their description:
Human organ designers will be experts in bio-engineering and design, fitting newly created organs and artificial limbs to humans. They will be fully capable of executing end-to-end design and implementation process for ready-to-use or custom-fit organs; have deep knowledge of the software and hardware involved in bio-electronics; and work within a team tackling multiple biological sub-systems.
Synthetic biologist/nanotech designer: In their description: "within five years synthetic biologists will be designing treatment that ties to the DNA of the patient. These medicines will be designed in software and printed on 3-D biological printers."

Now here's the rest of my top ten, listed in alphabetical order:

AI: AI -- artificial intelligence -- is already being applied to health care, as IBM Watson is showing.  We're going to see a revolution with AI like we saw with mainframe computers to PCs to mobile devices.  I.e., we're each going to have our own AI assistant, and that assistant will help us with our health and other everyday concerns.  Our grandchildren are going to think it was strange that we went to a doctor's office or ER for anything but the most critical health conditions.  Our AI will be our first and closest health adviser -- monitoring our health, proactively offering advice, and responding to our questions.

Big Data scientist: this actually encompasses a host of jobs, but for simplicity I'll treat the field as one.  Health care has no shortage of data now, but it often is siloed.  Moreover, even when shared it is hard to get practical use from it.  Data is going to become much freer, and there will be a lot more of it, with data from wearables and other sources.  Making sense of this data, turning it into information by spotting trends and correlations, and applying that information to specific patients at the right time is a massive task, but one that Big Data scientists will increasingly tackle.

Customer experience officer: People don't like the health care system.  Too much waiting (see the recent study on how much of a typical office visit is actually spent with a doctor), in unpleasant settings, and with too little knowledge of what is about to happen, when.  Health care can do better.  Health care organizations need to strive to "delight" their customers during their encounters -- not "even though" they are sick/injured/worried but because they are.  The Customer Experience Officer will lead the charge.  

Game designer: Health care is not a game, but it may be better as a game.  We don't like to exercise, we don't like to eat our vegetables, but we do like to play games.  There is increasing belief that games can help both educate us about our health and support better health habits -- as Games for Health and others are showing.  Designing games that will engage us and motivate us to better health over the long term is a challenge that some clever designers will relish -- and make a lot of money on.

Geneticist: We've known about DNA for 60 years, mapped the human genome almost 15 years ago, and now can even get our DNA mapped for $200.  We're still learning which genes are associated with which problems, as well as what triggers them, but the field of gene therapy is already exploding.  Why waste time, say, taking allergy medicine when you can correct the genes that allow the allergies?  Our descendants may view not improving their genetic makeup like we might view not setting a broken bone.  The field for geneticists has never been wider.

Microbiologist: One of the most surprising finds of the 21st century has to have been the impact that our microbiome has on our health.  Bacteria living in or on us outnumber our own cells.  Their presence sometimes adversely impacts our health, and their absence is equally likely to cause health issues.  Finding the right balance could help many of our health problems and obviate many of our current efforts to treat them.  Microbiologists will help us figure out that balance.

Robot assistant: There are not enough people to take care of our aging population, nor enough money to pay them even if there were.  Fortunately, there's not going to be any shortage of robots, and health care is a prime market for them.  Robotic surgery is cool (and expensive) but we're all going to want personal care robots once we start to lose some of our independence.

Virtual/augmented reality designer: VR is one of the hottest areas of focus in the tech industry, although augmented reality may beat it to the punch in terms of practical applications.  VR is often thought of in terms of games, but it can be a marvelous tool for teaching or simulations.  We're only beginning to scratch the surface of what these technologies can do for us, so innovative designers will be able to make their mark in a big way.


What we will think of as health care by the end of the 21st century is likely to bear as little resemblance to our current model as health care in the 19th century does to us.  I just hope our ability to change how we think about it can advance as rapidly.