"Local" Healthcare Isn't What It Used To Be

We live in a world where bigger is better.  Our phones are getting bigger.  Our televisions are getting bigger.  Our biggest companies are getting bigger (at least if they are in tech).  Our cars, especially SUVs, are getting bigger.  Our houses are getting bigger.

And, in healthcare, our hospitals are getting bigger, our physician practices are getting bigger, our health insurers, pharmaceutical companies, and medical device manufacturers are all getting bigger. 

It's time to question whether any of this is good. 

We're seeing it happen with retail malls already.  As has been widely reported, all across the country malls are re-purposing, dying a slow death, or dead already.  With Amazon and other online shopping giving seemingly limitless choices, easy price comparisons, and insanely quick home delivery, why bother to fight the traffic and the crowds, only to trudge through the mall in hopes of finding what you're looking for?

But retail shopping is not quite dead.  We're already seeing the one-time anchor tenants of malls starting to resize, as well as "big box" stores.  They making their existing stores smaller and opening up new, smaller stores.  "Retailers are realizing that they have to downsize stores to save money,” one retail expert told The Washington Post.

Healthcare is finally starting to realize it is, in fact, a retail business, and there is a trend for healthcare to locate in malls, part of the many ways malls are reinventing themselves.  But, of course, healthcare may be too late on this curve too.

Another, and perhaps better, example of how retail is changing was outlined recently in The Wall Street Journal.  Despite the much-ballyhooed increase in urban living, it's not all downtown condos for millennials and empty-nesters.  Millennials, it turns out, like the advantages of urban living but still want homes in the suburbs.  So suburban real estate developers are starting to incorporate retail in alongside new homes. 

"The single biggest challenge is walkability," Steve Patterson of Related Development LLC told WSJ.  People want schools, shopping, restaurants close by.  Another developer, Mark Culwell of Transwestern Development Co., added: "The resident comes home, relaxes a bit and then goes to a store half a block away without having to get back in the car." 

Unless, of course, he/she has to go to the doctor or, even worse, a hospital. 

Along these lines, NEJM Catalyst just published an interesting article by Jennifer Wiley, Nir Harish, and Richard Zane, three physician leaders.  In it, they make the case for "decentralization of health care."  As they say:

The traditional delivery model of a hospital as the “hub” of care, with a single centralized facility providing every facet of disease management and treatment, from specialized surgical cancer care to routine eye exams and chronic blood pressure management, should be questioned

Their argument is based around two key premises.  One is that "in the not-too-distant" future, health care systems will get paid for keeping people healthy.  Procedures like surgeries will go from being "golden gooses" to being an expense.  Having a big building with high fixed costs will be big disadvantage.

The second premise, of course, is that we have so many technologies that allow for more at-home options.  As they describe it, "...an entire industry is increasingly leveraging the power of “mobile health” to connect patients with providers."  E.g., portable electrocardiograms, x-rays, and ultrasounds.

They cite the example of Johns Hopkins' Hospital at Home program that "admits" patients to their own homes, and "are linked to the hospital through remote monitoring technology and receive daily visits from a physician and other caregivers (e.g., nurses, respiratory therapists, and physical therapists)."

A key to this away-from-the-hospital future may be what the authors call "community paramedicine," highly trained paramedics and EMTs whose "ability to deliver specialized tertiary care virtually in a patients’ driveway is changing the landscape of traditional care delivery models."

Finally, they point out a trend towards "microhospitals," whose 20 - 30 beds "rely heavily on virtual consultation and protocol-driven care for patients with specific care needs."  Construction Dive says they have a "big future," noting their convenience factor (although, typically for health care, regulation may prove a barrier). 

A similar trend is happening with nursing homes, such as in the Green House Project, which The New York Times just profiled.  Instead of the big, institutional nursing homes many of us picture, Green House's facilities are smaller and try to suit themselves to residents' preferences rather than vice-versa.  Susan Ryan, senior director for the Green House project, told NYT: "We try very hard to say, ‘This is home for life.'" 

This is not to say that either microhospitals or Green House nursing homes are revolutionizing their industries yet, but they may be pointing the way. 

Imagine suburban housing developments with microhospitals, Green House-type nursing homes, retail clinics, and doctors' offices all located within walking distance, alongside those stores, restaurants, and schools, not to mention all the online options that are and will increasingly be available.  Wouldn't you want to live there?

As long as most of us can remember, people have said "all health care is local."  What that usually meant, though, was "come to us."  Come to our hospital, our office, our facility, mainly because it was the closest to where you lived, and never mind what was available at the next hospital or in the next city, state, or even country. 

Increasingly we're going to see that health care may, indeed, be local, but it's going to mean what we can do in our homes or, at least, within walking distance from our homes.  Health care institutions and professionals who can't adapt to that are going to go the way of malls, dying or having to reinvent themselves. 

"Patient-centered" is a nice slogan, but it can't just be a slogan and it can't just be something that is applied in the usual places of care.  To make it a realty, it means truly centering health care around, and integrating with, where and how people actually live.   

As long as people are local, which even Ray Kurzwell thinks may be at least another thirty years, healthcare will be as well.  But who is giving that care, how, and where: those don't have to be -- and won't be -- "local" in the way they have been. 

We Have Seen the Future, and It Is...Estonia?

Like me, you may not have been paying close attention to what has been going on in Estonia.  That's probably something many of us should change, at least anyone interested in our digital future(s). 

OK, I have to admit: I had to look Estonia up on a map.  I knew it was in northern Europe, and that it had been involved in the whole U.S.S.R. debacle.  As it turns out, Estonia sits just across the Gulf of Finland from -- that's right -- Finland, and across the Baltic Sea from Sweden.  Skype was invented there, if you're keeping score.

More to the point, over the last twenty years it has evolved into arguable the most advanced digital society in the world.

Estonia's new brand concept

Nathan Heller has done a deep dive into Estonia in the most recent The New Yorker.  I recommend that you read it, or check out Estonia's e-Estonia site.  Basically, in Estonia:

• everyone has a digital identity, safeguarded by a chip-encoded ID card and two-factor authentication;
• virtually all other government transactions are done online, including voting;
• most public and even private records are accessible online, so that, for example, in applying for a loan or a marriage license all needed data is pre-populated;
• patient medical records are all online (owned by the patients), and are shareable only as patients specify;
• most public records are stored in blockchain, and use the X-Road open source data platform for both public and private data.

If it sounds like a heavy government presence, that would be wrong.  One Estonian told Mr. Heller: "In Estonia, we don’t have Big Brother; we have Little Brother.  You can tell him what to do and maybe also beat him up."

They believe their efforts have saved two percent of G.D.P., by reducing salaries, expenses, and hassles for citizens.  Think about that: 2% of G.D.P.  As Everett Dirksen once said, pretty soon you're talking about real money.

And they're not done.  Just today, for example, Estonia announced it was launching its own form of cryptocurrency, which it refers to as a crypto token and calls "estcoin."  It can't actually be used as currency because Estonia, as part of the European Union, must use euros, but they're trying to figure out what it could be used for. 

They have some ideas about that, and many revolve around further support for their e-Residency program.  They claim that program created "a borderless digital society for global citizens:" 

E-Residency is a transnational digital identity that anyone in the world can apply for to obtain access to a platform built on inclusion, legitimacy, and transparency.  E-residents then have access to the EU business environment and can use public e-services through their digital identity.  

Some 28,000 people from around the world have already applied for e-Residency.

They admit that estcoins may be a solution in search of a problem, and they're OK with that.  Their attitude is, "OK, here's a cool new tool: what problems can we help you solve with it?" 

That is not your typical governmental attitude. 

Amazon has revolutionized retail by constantly trying to reduce "friction" for consumers.  Estonia has done that for government services and, increasingly, other commercial services.  No wonder they rank high in international competitiveness and ease-of-doing business rankings. 

The man behind the e-Residency concept, Taavi Kotka, told Mr. Heller:

If countries are competing not only on physical talent moving to their country but also on how to get the best virtual talent connected to their country, it becomes a disruption like the one we have seen in the music industry.  And it’s basically a zero-cost project, because we already have this infrastructure for our own people.

Kaspar Korjus, who announced the estcoin, put it bluntly: "Our focus will remain on our overall objective to grow our new digital nation and democratise access to entrepreneurship globally."

That is competing in the Internet age.

In the U.S., of course, we're talking about strengthening our borders, not becoming borderless.  Most of us still vote in local polling places, often using analog machines or even paper ballots.  We joke about standing in line at the DMV (although we're not very amused) and complain about how hard it is to file our taxes.  "Good enough for government work" typifies how we've dumbed down our expectations for government services.

In our health care system it's not much better.  We continue to plod towards electronic health records, although with much less progress on those EHRs actually being able to share data and virtually no progress in patients actually owning their own data or even in preventing it from being sold to third parties.  Waiting at the DMV has nothing on waiting in a doctor's office or ER.  We're talking about blockchain in healthcare, but there are heavily entrenched interests in the status quo. 

We don't have universal coverage (as Estonia does), and even some of our recent gains in covering people are starting to slip away, with Republicans happy to trade tax cuts for 13 million people potentially losing coverage.

We're still struggling to figure out how to deal with state lines in health care, as telehealth has illustrated.  Importation of prescription drugs has similarly shown how we have the same problem with national borders. 

Guess what: data increasingly drives our economy, even in health care, and data doesn't recognize borders.

We're not going to be a digital nation anytime soon.  We don't have an e-United States initiative.  We're not going to lead the world with creating a blockchain-based health care system.  We have huge sunk costs of infrastructure limiting not only what we do but what we think we can do.   We are a big battleship that turns oh-so-slowly.
 
But perhaps we're going to see state or local technological leaps forward.  Andrew Keen suggests that states may lead the charge in adopting new technology, specially pointing out how Rhode Island is looking at Estonia's example.  Meanwhile, Delaware -- long a locus for companies to incorporate in -- has passed a law allowing companies to use blockchain for corporate records, including stock trades.

Maybe next we'll see a local community fully jumping into the 21st century, not just for government services but for local private sector ones.  Wouldn't it be great, for example, if the near duopolies in the health care systems of, say, Cleveland or Pittsburgh came together to implement shared technologies for a frictionless patient experience? 

So what I'm wondering is: who/where in the U.S. is going to be our Estonia?

Welcome, Comrade Patient

Capitalism is in big trouble, even in the U.S. and especially among millennials.  So reports Fast Company and The New York Times.  Even capitalism-friendly publications like The Wall Street Journal and Bloomberg warn about it. 

The oft-cited reasons include problems like increasing income/wealthy inequity and dimmer outlook for good jobs, but I have to wonder how much of a role our health care system plays in these kinds of attitudes.

After all, in a health system driven by capitalism you'd like to think we'd be continually improving our health, getting more choice and convenience, and all at lower costs.  None of that seems to describe how it is working in health care, which may help explain why more are becoming disillusioned with it.

The WSJ article cited a 2016 Harvard Institute of Politics survey, in which only 42% of younger Americans said they supported capitalism and only 19% identified themselves as capitalists.  One student explained: "socialism has gotten less spooky; it's no longer associated with communism the way it was.  Straight-up capitalism has a lot of potential to be really corrupt."

The 2017 version of the same survey found that two-thirds of those 18-29 are fearful about the future of our country, with only 14% believing we're on the right track.  No wonder; the World Economic Forum says millennials in the U.S., UK, and Japan are the first generation in recent history who are posed to be worse off than their parents. 

The WSJ also showed a 2016 Gallop poll in which capitalism and socialism were rated equally favorably (both just over 50%) by respondents ages 18 - 29, which was a stark contrast to every other age group (support for capitalism goes up by age, while support for socialism declines).  Similarly, a 2017 WSJ/NBC News survey found that the 18-29 age group was much more likely to say the government should do more to help people, again in contrast to other age groups. 

People like economist Richard Wolff or sociologist Wolfgang Streeck suggest that perhaps capitalism is coming to an end.  Professor Wolff thinks it may be replaced by worker cooperatives, but Dr. Streeck warns: "We’re going into a long period where we don’t know what is coming.”

That sounds like what our health care system may be facing.

In some ways, the U.S. health care system is a model of capitalism.  Lots of people are making lots of money, whether they be stockholders in health companies, doctors and health care executives, or even supposedly non-profit parts of the system.  The sector's continued strong job growth is the envy of many other industries and the pride of many local communities.   

The problem is, though, unless you are one of the lucky ones doing well with our current system -- and maybe even then -- you're probably not too happy with it. 

It costs too much, whether we look at the cost of care or the cost of the health insurance that is supposed to pay for that care.  We get plenty of innovative new drugs and treatments, but at astronomical new prices.  We see waves of consolidation, whose main effect seems to be reduced choices and higher costs.  The data is too siloed.  Healthcare professionals report dangerous levels of burnout.

And, of course, not only do we spend more than any other country, our heath outcomes are worst than most developed countries.

Last year, Senator Bernie Sanders made unexpected headway in his race to be the Democratic candidate for President despite -- or perhaps because of -- his socialist leanings.  One of his key planks was for Medicare for all, an idea that has seen a strong resurgence generally.  Even more popular is the (admittedly vague) push for single payor.

A Harvard-Harris poll found that 52% of Americans supported a single payor system, with even 35% of Republicans supporting.  Young people were most supportive.  Politico found that 49% of Americans support a single payor health care system, even more popular than adding a public option to compete with private health plans (44%). 

The Kaiser Family Foundation tracking poll showed 53% supporting single payor, with similar support for both that and a Medicare-for-all approach.  Pew Research Center found "only" 33% favored single payor, but noted that support is increasing quickly, and that almost half of those 18-29 support it. 

Perhaps most astonishing is that a Merritt-Hawkins survey found that 56% of physicians now support single payor, a sharp reversal from prior surveys.  42% voiced strong support.

Now, Medicare-for-all isn't single payor -- not with about a third of Medicare beneficiaries enrolled in private, competing Medicare Advantage plans and with all Part D recipients in them -- and even single payor does not mean nationalized health, like Britain's National Heath Service.   But these many survey results are warning signs that our current approach to financing health care is pushing an increasing number of people to call for something else. 

Vermont actually passed single payor, but the plan floundered when taxpayers saw the cost.  Colorado tried to pass single payor through an initiative, which down in resounding defeat.  Yet keep in mind that we didn't like the Affordable Care Act until it started to look like we might have it taken away, and then support grew.

The moral of the story may be that, when it comes to financing our health care, we don't really know what we want, but we sure don't really like what we have.

Right now, millennials are not as engaged in health care as older age groups because they tend to need it less.  They don't have as many health problems and don't see health professionals as often.  That's why getting them to buy health insurance is a constant struggle, even when they have the lowest premiums.   

But as this radicalized generation, who are already frustrated with economic inequity and the prospects for their future, realize how much they will have to pay for older Americans' health needs as well as for their own, push will eventually come to shove. 

We have some hard thinking to do about how we finance health care, and for whom.  We have some hard thinking about what the role of profit, competition, and capitalism should be in our health care system.  We have some hard thinking to do about why our health care system is not serving more of us better.

It may not be socialized medicine.  It may not be single payor.  It may not even be Medicare-for-all.  But it for sure will not be what we have now. 

Health Disparities and Lost Einsteins

One of the most evocative phrases I've seen lately comes from a new study from The Equality of Opportunity Project on the inequality of becoming an inventor in the U.S..  The authors decry the "lost Einsteins" in our society, i.e., "people who would have had high impact inventions had they become inventors." 

The study doesn't specifically reference the impact health disparities has on producing these "lost Einsteins," but it could have. 

Source: New York Times

I won't recount the methodology the study used, but here are its three key learnings:

1. There are large disparities in innovation rates by socioeconomic class, race, and gender
2. Exposure to innovation substantially increases the chances that children become inventors.
3. Star inventors earn more than $1 million per year, suggesting that further increasing financial incentives or reducing tax rates may have small impacts on innovation.

The problem is not ability. The authors say:

Differences in ability, as measured by test scores in early childhood, explain very little of these disparities. Children at the top of their 3rd grade math class are much more likely to become inventors, but only if they come from high-income families (Figure 2). High-scoring children from low-income or minority families are unlikely to become inventors. Put differently, becoming an inventor relies upon two things in America: excelling in math and science and having a rich family.

In his New York Times opinion piece about this study, David Leonhardt notes: "Low-income students who are among the very best math students — those who score in the top 5 percent of all third graders — are no more likely to become inventors than below-average math students from affluent families.  

It's worse than that.  Mr. Leonhardt's take on the data is as follows: 

Women, African-Americans, Latinos, Southerners, and low- and middle-income children are far less likely to grow up to become patent holders and inventors. Our society appears to be missing out on most potential inventors from these groups. And these groups together make up most of the American population.

Patents/1000 children (light to dark).  By The New York Times | Source: Equality of Opportunity Project

As Steve Case told Mr Leonhardt , "Creativity is broadly distributed. Opportunity is not." 

It is largely what happens in the childhood environment that drives the innovation gaps.  Better schools, improved nutrition, and healthier surroundings should all help, but another key seems to be being exposed to innovators who are like themselves.  E.g., being around male innovators is not as important to girls as being exposed to female innovators.  

Closing the innovation gaps -- finding these lost Einsteins -- could have a dramatic impact on innovation and thus economic growth.  The authors believe that: "If women, minorities, and children from low-income families were to invent at the same rate as white men from high-income (top 20%) families, the rate of innovation in America would quadruple."

I can't help wondering how many of these lost Einsteins are lost because of health issues.  

After all, the U.S. has some of the worst health disparities in the world.  Some of that is due to affordability of health care, some to availability of health services, some to living in "food deserts" or simply not having enough to eat (1-in-6 kids!), and some to living in unhealthy environments, such as being exposed to lead poisoning (1.2 million kids) or air pollution.  

Income matters.  Race matters.  Location matters.  Education matters. 

Look at the rates of, say, asthma, diabetes or obesity disparities across the U.S..  Or maybe homicide rates or opioid overdoses/deaths.  Or look at differences in infant mortality rates and think about the Einsteins that not only get lost, but are never even born.  

 

All those make it clearer why some of those potential Einsteins have things other than some new innovation to think about.

This is the "health care system" we've built, or allowed to be built.  These are the differences in health outcomes that we bemoan, but largely just wave at hands when it comes to actually trying to reduce them.  

For example, The Washington Post/Kaiser Health News recently reported on how it is more profitable for hospitals to treat children with asthma, usually through expensive ER visits, than to address the underlying reasons for the asthma.  And, of course, it is low-income, often minority residents that end up being victimized the most by this.

An executive at Johns Hopkins, speaking of the at-risk populations and some proposed at-home preventive interventions, conceded: "We know who these people are. . . . This is doable, and somebody should do it."

Somebody, indeed. Maybe one of those lost Einsteins could have figured out a way to do it.

Let's keep in mind that we're not just missing perhaps the next Steve Jobs or Sergey Brin.  We may be missing the next Louis Pasteur, the next Wilhelm Conrad Rontgen, the next Jonas Salk, the next William Greatbatch, or the next Craig Venter.  People who can help truly invent our way into the 21st century health care we should have.

If we only had, say, $30 billion to spend on health, we'd get the biggest bang for our buck investing all of it in public health infrastructure and initiatives.  It wouldn't look anything like our current health care system -- or, rather, our medical care system --  but it could go a long way towards reducing all those glaring health disparities.

If we managed to scrape up $300 billion, we could not only do a better job in public health but also could target some critical, high-impact medical care needs, such as enhanced prenatal care or targeted preventive screenings.   

With our current $3 trillion in health spending, though, we manage to ensure that the people who finance and/or deliver medical care, or make the drugs and devices involved in that care, do very well financially, but the rest of us, not so much -- either financially or in our health status.  

Even a lost Einstein can see that is perverse.  

Our economy can't afford to lose all those Einsteins.  Even more, our society can't afford to go on treating the health of any of us, Einsteins or not, as carelessly as we're doing now.

Health Care's Buggy Whips and Segways

In a thought-provoking piece, Joseph Caddell and Robert Stiegel warn of "misinnovation."  They talk about it in the context of national security and intelligence technologies, but health care should pay attention. 

By "misinnovation," they aren't talking about bad ideas, or even good ideas done badly.  Misinnovation is actually innovation -- just not the right innovation.  They characterize it into two immediately recognizable types:

• Buggy Whip Misinnovation: "innovating along a well-established technological arc for too long":
• Segway Misinnovation: "mismatching innovation to a need, often by jumping on the wrong technological arc"

The buggy whip problem goes back to the infancy of the automobiles.  Some people saw the future and bet on the new technology, while others thought buggies and buggy whips had served us well for centuries and would continue to do so.  They focused their efforts on making those as good as possible, not realizing until too late that they'd lost the market.

It's the old "what business are you in" question: buggies or transportation?

Dr. Caddell and Col. Stiegel cite the famous (and possibility apocryphal) Henry Ford quote:

Or perhaps better buggy whips.

Segways, on the other hand, were supposed to be the future.  Details of the secret invention were few and far between, but expectations were high.  It was said to be bigger than the PC, bigger than the Internet.  Seriously.

And what we got was, well, those goofy things security guards ride in malls. 

It's not that Segways are poor technology.  Far from it; they are pretty slick, and good at what they do.  It's not that they are of no use or that no one buys them.  It's more that not many of us think they solve a need that we have. 

When you think about it, misinnovation abounds.  Think about Microsoft introducing Zune just before the original iPhone was released, or the last generation of propeller fighter planes, that were immediately made obsolete by jets. 

Or, in an era of the internet, the companies who continue to improve the much maligned fax machine. 

Or upgrading stethoscopes (200 years old) and x-rays (125 years old) when portable ultrasounds, and ultra-low dose CT scans are available, respectively. 

Oh, that's right; faxes, stethoscopes, and x-rays continue in widespread daily use. 

In health care, misinnovation thrives. 

Health care has no shortage of innovation. There are plenty of innovators who are working diligently to bring new ideas to it.  The innovation is coming both from within the industry and from other industries.  We see innovations like wearables, Big Data, gene therapy, nanobots, 3D printing, to name a few.  It's an exciting time to be in health care.

What we don't see is enough thought and discussion about which of these are truly innovation and which will, at some point in the future, be viewed as misinnovation.

Let's think about the two types of misinnovation as they relate to health care.

There is a lot of money spent on "reinventing" hospitals. There is much effort on redesigning them to improve the patient experience.   Politico just ran a series of articles looking at the future of hospitals, such as virtual hospitals, McHospitals, more community-oriented hospitals, even hospitals less focused on beds.  UPMC announced they were spending $2b to revamp its hospitals into "digitally based specialty" hospitals.

These are all well intentioned, may help patients -- but fall into the "better buggy whip" category.

Hospitals are curious places.  We put a vulnerable people together with people who have often exotic  germs.  We put debilitated people into environments where they often become even more debilitated.  We put people who need care and comfort into emotionally sterile settings with not enough staff to give it to them.

We don't need better hospitals.  We need the thing that will take the place of hospitals.

Similarly, there is a revolution in smartphone-based apps for health care.  The list of things you can now do on your smartphone is amazing.  For years, Dr. Eric Topol has been evangelizing what they can do now and will increasingly be able to for our health.  If you're not impressed and astonished, you're not paying enough attention.

This is all exciting.  It's helping democratize our health care, and may even help improve our health.   And it fits into the Segway category.

There's a need for more ubiquitous monitoring, analysis, and advice in health care, but simply putting more apps on our mobile devices is not the solution.  We don't need fifty -- a hundred! -- health-related apps telling us how we're doing and what we should do about it.  We certainly don't need competing apps that give us conflicting results and/or advice.  We don't want to have to pick the right apps to ask the right question in order to get the right answer.

We don't need more apps.  We need the thing that makes sense of what they can tell us.

The list could go on and on.  Invasive surgeries or intensive radiation therapy are buggy whips.  More kinds of long-term use prescription medicines are Segways. 

If we're doing damage to the patient, even in the interest of curing them, it is an approach for which we should be thinking about alternatives.  If we're doing things that help people live with their condition or limitation, we should be thinking instead of how to get rid of it. 

Try to think about what we're doing as someone from the future might look at it -- like Star Trek's Dr. McCoy finding himself in 1986:

We're not in the 23rd century.  We don't have those kinds of technologies yet.  But we're not in the 20th century anymore either, much less the 19th century.  We should be looking at technologies and approaches from those times with great skepticism, and not spending too much time further innovating them. 

Our innovations should be more recognizable to someone from the 23rd century than to someone from the 19th.

Nor should we be doing cool things just because they're cool, as Kirti Patel recently put it.  We should be doing things that consumers need and that will help them be healthier.  We have a health care system that seems like it would rather put someone in a fancy motorized wheelchair -- or a Segway! -- than to get them to walk more while they still can. 

I love innovation.  Health care needs it more than ever.  But let's try to be sure it actually is innovation, not misinnovation.

Sunk Costs Are Sinking Healthcare

Peter Drucker is often credited with the famous expression "culture eats strategy for breakfast" (or lunch).  In other words, you can have all the visionaries you want, brainstorm the greatest ideas ever, and develop very snazzy Powerpoints, but if the people responsible for making the strategy actually happen either don't know how to -- or simply don't want to -- carry it out, well, forget about it.

Dr. Brent James, the Vice President and Chief Quality Officer for Intermountain Healthcare, goes Professor Drucker one step further: "If culture eats strategy for breakfast, then infrastructure eats culture for lunch."

As NEJM Catalyst explained, "In other words, infrastructure lays the foundation for culture."

Infrastructure in organizations dictates much of how things get done in them.  It enables most of the organization's tasks.  It is essential.

However, infrastructure also often defines what people in organizations think can be done, perhaps even what should be done.  Much of this is implicit rather than explicit.  People don't always recognize how their underlying infrastructure shapes their perceptions of not only the existing but also the possible.

This is a problem for health care.

We have hospitals, so we must try to fill them; not only that, we need to make them even bigger.  We have scanners, so we must use them.  We have new drugs or new devices, which are all-too-often at best only marginally better than existing ones, so we must start giving to patients.  We develop new surgical procedures, so we compete on who can start doing the most of them the soonest, not always even pausing to ask if those surgeries are necessary or appropriate for all the people who end up getting them.

We have funding mechanisms that don't work well even for the people who have access to them, so of course we try to give access to them to more people.  We have health plan designs that no one really understands, so we keep making them even more complicated (anyone know what a Tier 4 non-network drug is, or why there is such a thing?).  We have bills that can at most charitably be described as incomprehensible, so we're adding more procedures and more codes to make them moreso. 

We have EHRs that everyone hates and many think actually interferes with patient care, but we rush to extend them.  We have billing systems and claims processing systems that are in a figurative arms race against each other, the former seeking to enhance revenue while the latter tries to impede those efforts, even at the price of impacting people's care, so we keep pouring more money into each.

We buy up hospitals and medical practices in the name of integration and/or efficiency, even though there is precious little evidence that such consolidation does anything except to raise costs.  The infrastructure just gets bigger and more bureaucratic. 

 We spend over $3 trillion a year on our health care system, as wildly inefficient as it is and as much wasted care as it delivers, and yet we're putting ever more into the infrastructure that supports it. 

There is in economics something called the "sunk cost fallacy."  This comes when people or organizations continue behaviors mainly because they've already invested so much in them -- whether that investment are dollars, time, or effort. 

The more of any that are "spent" on something, the more reluctant people are to admit that perhaps it is time to stop such spending. 

Sound familiar when thinking of health care?

People think we're spending too much on health care and on health insurance.  Clinicians are frustrated with their administrative burdens, and admit that there's significant overtreatment.  Politicians on both sides argue that the existing system isn't working, but neither offer any fundamental changes to it.

Yes, spending on health care technology is booming.  Yes, there are plenty of health care start-ups who ostensibly seek to "disrupt" the health care system.  But, are they remaking our health care system? 

No, the existing health care infrastructure is eating their breakfast, lunch, and dinner.

I'm as big a believer in technology and innovation as anyone.  I believe that, at some point, the health care system will get disrupted, in ways that we're not thinking enough about and that can lead to healthier lives, at lower costs (not just lower rates of increase),. 

But our sunk costs about how we think about health care are limiting us.  Our existing infrastructure is so large and so complex that the prospect of truly getting rid of major portions of it is too daunting for almost any innovator.

After all, with $3 trillion in play and known inefficiencies, it is much easier to make money -- and to get investors -- if an innovator can figure out how they can make just some small part of it just somewhat better, and keep a sliver of all that spending for themselves. 

Imagining and implementing a whole new infrastructure is a lot harder, and a lot riskier.

The analogy is already overused, but still instructive: Uber and AirBnb didn't reinvent their industries by pouring money into the existing infrastructure of the taxi and hotel businesses, respectively.  They imagined a whole new business with a distinct (and less capital-intensive) infrastructure. 

So forgive me if I don't get excited when, say, UPMC invests $2b into new hospitals, Epic is switching to CHRs, or Roche is putting $11b into R&D.  I don't expect to see new paradigms for our health care system to come out of that kind of spending, nor do I think my health care is going to get any less expensive.  Or that I'll become any healthier.

Done right, infrastructure can, indeed, help "cure" health care, as Enmi Kendall and Anya Schiess wrote earlier this year.  Done right, changing the culture within health care will make it possible for us to change the system and its infrastructure.  But neither one of those is easy and neither is a given to happen. 

The first step in digging oneself out of a hole is to realize that you are sunk in it.   

Patients Are a Design Problem

When I say "patients are a design problem," I don't mean that the people who happen to be patients are a design problem.  They may well be, but that's an issue you'll have to take up with Darwin or your favorite deity (or, all-too-soon, perhaps a CRISPR editor...).

No, I mean that making people into patients is a design problem.  And it's a big one.

Over the last twenty years, there has been much discussion and debate about whether patients are, or should be, actually "consumers."  But I've never met a doctor or other health care professional who thinks of the people they treat as "consumers," or, in fact, as anything other than patients.

The term "patient," referring to people getting medical treatment, has been in use for hundreds of years.  It is not a coincidence that it is related to being "patient," that is, suffering without complaint.  No wonder medical professionals like to use it.

There have been many calls to change the word -- see, for example, Pat Mastors or Julie Neuberger -- but what we have is deeper than a semantic problem.  Changing the word we use to describe people caught in the health care system doesn't change the dynamics of that system.  A new word would not change how such people are treated or have come to act.

This is a design problem.

Consider the following:

1.  Physician Respect: We treat physicians as something special.  We hear about how difficult it is to get into medical school, how tough the process of being trained as a physician is, how hard they work, and how much they need to know.  We watch them perform miracles routinely on television, and expect our own physicians to have the empathy of Dr. Welby (some of you may have to ask your parents), the encyclopedic knowledge and keen intuition of Dr. House, and the technical prowess of Dr. Shepherd (some of you may have to ask your wife or girlfriend).  That white coat is no longer needed and may, in fact, be counterproductive, but serves to remind of us the deference the health care system believes physicians are due.
2.  Patient experience: It's hard to get appointments.  The appointment time is often just a vague indicator of when we'll actually see our doctor.  We may have to put on an embarrassing gown and get up on an uncomfortable table.  We may have services done to us that we don't really understand and which not uncommonly are unpleasant, to say the least.   We may be asked to fast unnecessarily for hours before blood work or procedures.  We often are unsure about what is going to happen next, or when. It is not a patient-centered system.
3.  Medicalization:  We talk about the health care system, but we really mean the medical care system.  We almost never include, or pay for, the other things that impact our health, like diet, exercise, and environment.  Instead, we seek our health care providers for our health issues and advice, to the point where some physicians now give out "prescriptions" for exercise.
4.  Better, Soon: We've seen remarkable strides in what medical care can achieve, such as antibiotics, polio vaccines, organ transplants, joint replacements, pacemakers, chemotherapy, and advanced types of imaging, to name a few.  We have become a nation of pill-poppers.  When something is wrong with us, we expect to be able to get it fixed, and we expect that to happen quickly.
5.  Confusion reigns: Nothing about health care seems easy.  It's hard to pick a physician, or a health plan.  The terminology makes no pretense at being understandable to anyone not a health care professional.  The bills are practically indecipherable, especially since the pricing behind them is intentionally opaque.  If you need multiple doctors, tests, or procedures -- which you almost certainly will -- you'll have to navigate the maze around getting them.  No one, lay or professional, claims to understand the "system."
6.  Responsibility: We've delegated responsibility for our health to our health care professionals, especially our doctors.  It is more established than ever that regular exercise, moderate eating, and a balanced life would do more to improve our health than any regime of medical treatments.  Yet we continue to expect that the results of our increasingly poor habits will be "fixed."

These are why we are "patients."  These are why we are expected to be patient.

There are constant calls to reform, even disrupt, the health care system.  There are new entrants, new models, new technologies, and plenty of new money.  As I wrote a few years ago, though, most innovations in health care seek not to disrupt the health care system, but to get their share of the spending.

A new article by Clayton Christensen and colleagues points out:

more than $200 billion has been poured into health care venture capital, mostly in biotech, pharma, and devices where advances typically make health care more sophisticated — and expensive. Less than 1% of those investments have focused on helping consumers to play a more active role in managing their own health, an area ripe for disruptive approaches.

Their article highlights Iora Health, while, in another series of articles about disruption, Robert Pearl, M.D., is keen on CareMore, Forward, and Health City.  But none, in my opinion, go far enough.  None redesigns the "system."  None really tilts our system away from medical care system and towards empowering people to take charge of their own health.

We will always need physicians (although not always human ones!), and many other health care professionals.  That's a good thing.  They have knowledge and skills that can help us.  They deserve our respect.

But we should design our health care system around us, not them.

Make the "system" simpler.  Focus it around our health, not our care.  Expect us to have responsibility for our own health -- but ensure we have the tools we need to manage it.  Spend money to prevent health issues, not address them once they've happened.

It won't be easy.  We don't know how to motivate people to be more responsible about their heath, to the point we're excited about digital pills that track whether we take them.  Nifty technology, but I wish we invested more in the underlying problem(s).  Let's make Professor's Christensen's 1% more like 90%.

If patients are a design problem, then maybe people can come up with a design solution.

Bjork, Blockchain -- and Healthcare

Healthcare should pay more attention to Bjork.

To be fair, I think everyone should pay more attention to Bjork.  I've loved her since she was in the Sugarcubes.  Her voice is astonishing, her music is always interesting and often magical, and when she sings she commits more fully than any other singer.  If her fashion sense is sometimes out there, well, we expect some eccentricities from our geniuses (and, oh-by-the-way, that infamous swan dress is now honored in a museum). 

But all that aside, health care should be paying attention to how Bjork embraces new technology.  That now includes blockchain.

With her latest album, Utopia, due to be released later this month, Bjork is teaming with blockchain company Blackpool to use blockchain and, more specifically, crypocurrency to try some new things.  As reported by Musically, fans can:

• Pre-order the album using several different kinds of cryptocurrencies, such as Bitcoin or Audiocoin, along with more conventional forms of payment.
• Earn 100 Audiocoins -- worth $0.19 currently -- just for pre-ordering.  The digital coins will be deposited into a e-wallet, and can be exchanged for other cryptocurrencies, converted into "fiat currencies (like dollars), or kept for future use.
• Receive additional Audiocoins by interacting with Bjork and her music, such as attendance at concerts or perhaps promotion on social media.  
• Use their Audiocoins to buy additional Bjork music or related materials.  

It wasn't explicitly spelled out but presumably the fan participation will be tracked using blockchain.

Bjork and Blackpool will develop more details about how fans can earn and use their cryptocurrency over the next couple years, but it certainly is a unique approach.  As The Next Web put it, "at the moment it just kinda sounds like a hybrid between a CVS pharmacy rewards card and a fan club. That’s not necessarily a bad thing."

Blackpool CEO Kevin Bacon told Musically:  

You could create blockchain-enabled digital treasure hunts, although what we don’t want to do is turn this into Pokémon Go! But why not reward your fans for engaging with what you do, and reward them in a meaningful way?

Keep in mind this isn't the first time Bjork has creatively used technology in conjunction with her music:

• She made a critically acclaimed video ("All Is Full of Love") featuring robots -- in 1998.  
• In 2011, Biophilia came as a standard audio version but also featured a collection of apps that transformed the audio experience.  MoMA included the app as the first downloadable app in their permanent collection, noting: "With Biophilia however, Björk truly innovated the way people experience music by letting them participate in performing and making the music and visuals, rather than just listening passively."  There is now also a Biophilia Education Project to help inspire creativity in children.
• A subsequent album, Vulnicura, led to a virtual reality (VR)-based exhibit also expanded the musical experience.  It has appeared in major museums around the world.

Bjork may be not just a genius with her music but also in using technology to change how we experience it.

I have previously written on why and how bitcoin, blockchain, and even smart contracts might be used in health care, but to pretend that I actually understand any of them would be overstating the case, to say the least.  Fortunately, more knowledgeable people in the field are increasingly coming up with applications for it, as a recent synopsis in HealthIT Analytics illustrated.

Let's think, though, about how Bjork's latest experiment could be translated into health care.  Imagine, for example, a direct primary care practice (DPC) that:

• Allows/encourages patients to pay for their services using crypocurrency;
• Uses a smart contract to establish the mutual obligations, the agreed-upon measurements for "success," and the mechanisms for performance-based rewards/penalties;
• Tracks patients' behaviors (preventive visits, exercise, etc.), readings (vitals, labs, etc.), and records (diagnoses, treatments, etc.) using blockchain (a blockchain EHR!);
• Allows patients to earn additional cryptocurrency for meeting desired health goals and/or activities.    

I used DPC as the example because the fixed monthly fees may be easier to work with than fee-for-service, but there is no reason a similar approach couldn't be used for health plans, health clubs, or even fee-for-service providers.  

Bjork's blockchain-based :"CVS rewards card/fan club" that rewards fans for a variety of desired types of involvement is particularly intriguing.  Applying the concept to health care would help recognize that most things impacting patients' health happen outside of health care settings, and could create ongoing, visible, positive incentives for patients. 

Not just DPC; Fitbit and Apple Watch: are you paying attention?

We're not going to transform the entire health care system into blockchain immediately, nor should we.  There are still too many unknowns.  However, experimenting with it within a moderately closed environment like a DPC practice might be a great place to start. 

Blackpool's Kevin Bacon has a great perspective on blockchain:

There’s a lot of talk about whether crypto and blockchain is a bubble. I don’t see it as a bubble: I see it as a burst of energy. I think you’ll see a lot of activity, a lot of things will disappear or get left to rot, but the important things will stay and grow. 

I think blockchain and crypto will be like the dotcom boom and bust in the late 1990s. We’ll see enormous adoption over the next couple of years, then some kind of bubble burst, but then a long-term change.

Blockchain won't solve the health care mess we find ourselves in, especially in the U.S.  There are too many fundamental issues that we need to address.  What it may do, though, is give us a new set of tools to help solve it.  We need to see that boom and bust that Mr. Bacon refers to, and see what uses are left standing.

I'm looking forward to hearing more about what Bjork does with her new initiative, and I hope some health care organization takes note.

Meanwhile, I can't wait to see how Bjork will use what Fast Company says may be the next iteration of the Internet itself -- Dispersed Computing.   But that's a topic for another post...