Monday, July 24, 2017

Health Care's Kodak Moment

For those of us of a certain age, a "Kodak moment" connotes a special event that should be captured by a photo, presumably on Kodak film.  For younger generations,  the term probably doesn't mean anything, because they don't know what Kodak is and have never seen film.  That's why, for some, "Kodak moment" has come to suggest a turning point when big companies and even entire industries can become obsolete.

Health care could soon be at such a point.

Anthony Jenkins, a former CEO of Barclay's, recently warned that banks could face a Kodak moment soon.  He said they're already seeing a "Uber-moment," where smartphones and contractless cards are transforming the industry.  "The Kodak moment is completely different," Mr. Jenkins explained.  "That’s where customers realize there’s a totally better and different way of doing what they want to do, and the incumbent becomes obsolete."

In a separate speech, Mr. Jenkins elaborated that, due to new technologies, "we can imagine total transformation of the banking system, using blockchain for example, in a world where banks don't really exist anymore."  He predicted banks have 5 to 15 years to face these challenges, or become irrelevant to their customers.

The "good" news, he added, is that: "Banks can avoid that, but they have to act now, and what they really need to do is think about innovation, but also transformation, doing something radically different."

For "bank" or "banking system" feel free to substitute "doctor/hospital" or "health care system"

It might be useful to recap some of Kodak's downfall.  As Scott Anthony outlined last year in Harvard Business Review, it wasn't technology that did them in.  It wasn't that Kodak wasn't aware of trends that might impact their business.  It just didn't take them seriously enough, or react quickly enough.


  • Kodak invented digital photography, well back in 1975.  The engineer behind it has said management's reaction was "that’s cute – but don’t tell anyone about it," but they did invest billions into it.  However, they tried to replicate film quality rather than focus on digital's simplicity.
  • Kodak also was early into online photo-sharing, buying Ofoto in 2001.  It could have become Instagram, Snapchat, or even Facebook before their founders were even out of high school.  But Kodak wanted it to help boost printing digital images, not promote sharing memories.
  • Unlike Kodak's still thriving competitor Fuji, they stuck primarily to their core business, not wanting to risk the profitability of film, while Fuji expanded to adjacent and not-so-adjacent businesses.
Again, it wasn't that Kodak unaware of what was looming.  Vince Barabba, a former Kodak executive, has said that as early as 1981 Kodak's research suggested that digital photography would replace film, in as little as ten years.  Kodak's management just couldn't accept that film wasn't going to continue to be their core business.

Kodak declared bankruptcy in 2012 and now has a market capitalization of under $400 million, down from its peak of $30b.  

Incumbents all-too-often grow protective and/or fail to take advantage of new opportunities.  Kodak's rival Polaroid also lost out to the digital wave, and neither of them thought much about smartphones.  Xerox basically invented the PC at PARC, but let Apple and IBM steal the market.  Sony bet on Betamax's quality rather than duration of recording, and so lost the VCR war.

The irony of disruption, Mr. Johnson noted, is that it is "actually a great growth opportunity," and that "incumbents are best positioned to seize disruptive opportunities."  His advice -- aimed at digital transformation but applicable more broadly -- is for businesses to ask themselves three questions:

  1. What business are we in today?
  2. What new opportunities does the disruption open up?
  3. What capabilities do we need to realize those opportunities?

Health care has a number of legacy problems that make it ripe for disruption.  It's still focused on medical care, not on health, and it does so in a way that is both reactive and provider-centered.  It uses too much technology that is way too clunky.  It assumes that the historical information asymmetry between health care professionals and the rest of us is inviolate and that shopping for health/health care, based on either price or quality, is beyond us.  

Innovators look at these problems and see opportunities.

The opportunities -- or, threats, depending on one's point-of-view -- on health care's horizon are numerous.  They include:
  • Digital health makes real-time information and communication feasible, such as with wearables and telehealth.
  • Big Data will help us finally understand what is happening with patients and predict with better accuracy how we can manage our health.
  • Robots will take over health care tasks/jobs that humans either don't want to do or lack the required precision to do.
  • Artificial intelligence (AI) will be able to make sense of all that Big Data ad all the various research studies, and can serve to either augment or, at least in some cases, replace physicians.
  • 3D printing will allow us to replace an ever-increasing number of body parts, even systems, and do so with unprecedented speed and affordable cost.
  • Nanotechnology will allow us to monitor and maintain us down to a cellular level.
The wolves are at the gate, so to speak.  Google's Deep Mind or IBM's Watson are already big into health care.  3D printing is on the verge of becoming mainstream.  The market for health care robots is booming, as are the nanotechnology and wearable markets 

Meanwhile, traditional health care companies -- from providers to middlemen to manufacturers to insurers -- are waiting with some trepidation to see what 21st century behemoths like Amazon or Apple are going to do in their space.  McKesson's Tom Rodgers told CNBC: "Everyone in the supply chain is nervous.  It's a low-level paranoia that Amazon will drive down profitability."
Getty Images | Alex Wong
Disruption might come from innovators within the health care industry, but it might also come from unexpected sources -- and in unexpected ways.  Kodak didn't take digital photography seriously enough, and it certainly wasn't expecting smartphones as the new camera.  

Health should have a number of the old-fashioned Kodak moments -- the birth of a child, a miraculous recovery, achievement of a health goal, and so on.  Whether health care organizations or even the entire health care system suffer the other kind of Kodak moment depends on how (and when) they respond to the disruptive opportunities now available to them.  

If your organization isn't thinking about what could cause its Kodak moment, rest assured: competitors/potential competitors are.

Wednesday, July 19, 2017

We Get What We Pay For

Politico (Dan Diamond) had two great pieces last week -- one on how tax-exempt hospitals benefited from the Affordable Care Act (ACA) while cutting charity care, and the second on how the Cleveland Clinic has built an island of prosperity amidst an impoverished community.  

I'd like to say I'm surprised, but I'm not.  I wrote about the supposed community benefits of "non-profit" hospitals two years ago, and Politico's analysis suggests things are getting worse.

They looked at the top seven hospitals, as ranked by U.S. News & World Report, and found:
The top seven hospitals’ combined revenue went up by $4.5 billion per year after the ACA’s coverage expansions kicked in, a 15 percent jump in two years. Meanwhile, their charity care — already less than 2 percent of revenue — fell by almost $150 million per year, a 35 percent plunge over the same period.
So, surprised, no.  Outraged, appalled -- yes.

My favorite trick is how hospitals claim the gaps between those outlandish charges and Medicare/Medicaid reimbursements as a community benefit.  They can also claim community outreach programs or screenings, local investments, even staff education.

Neither hospitals or the IRS are even doing a good job complying with the ACA reporting requirements, according to Politico, yet: "Not a single hospital has lost its tax-exemption because of the new measures in the ACA."

These are hospitals enjoying federal state, and local tax preferences.  They often don't pay property taxes, for example, despite often being huge property owners.  They get tax-preferred borrowing AND tax-deductible donations from you and me to build/buy even more.

Meanwhile, they are part of what critics call a "crushing lack of competition," with half of our country's hospital markets considered "highly concentrated."

Politico cited a 2016 study that found 7 of the top 10 most profitable hospitals in the U.S. were technically not-for-profit.  The lead author of that study noted, "The taxing system may not be working properly if nonprofit hospitals are making a lot of profit and not necessarily putting it back into the community."

The hospitals dispute all this, of course.  AHA didn't waste any time, shooting back the next day.  Ron Pollack, AHA's President and CEO, claims that Politico "takes a narrow view of community benefits and fails to account for the full array of programs and services hospitals provide to their communities," and that "One out of every four hospitals in America operates in the red."

Hospitals, Mr. Pollack asserts, are "finding new ways to help improve the health of their communities" and are "also working tirelessly to address and combat the social determinants of health."

Maybe he should read the second piece, on the Cleveland Clinic's uneasy coexistence with its neighborhood.

By almost every account, the Cleveland Clinic is a smashing success.  It is an $8b empire, is consistently lauded in "best of" rankings, makes plenty of money (over $500 million last year), draws (wealthy) patients from overseas, has a sprawling (165 acres!) main campus, and is Cleveland's largest and Ohio's second largest employer.

In a Rust Belt city, the Cleveland Clinic is a shining example of how health care can drive a local economy.  

But, the neighborhood around it?  "That community is poor, unhealthy and — in the words of one national neighborhood-ranking website — 'barely livable.'"  Their own community assessment ranks the two surrounding neighborhoods as the "highest need."

CEO Toby Cosgrove told Politico: "We have three obligations.  We need to provide great health care, we need to provide great jobs and we need to support education. And we have done all those three things."  Yes, except that  the benefits of the Clinic's vaunted expertise are not accruing to the local population, at least not as by measured by, say, diabetes incidence or mortality rates, those jobs aren't going to them either, and their education suffers by the Clinic not paying local property taxes.  

Dr. Cosgrove acknowledged issues with the local community and the need for more population health, but he threw up his hands at the problem: 
We don’t get paid for this, we’re not trained to do this, and people are increasingly looking to us to deal with these sorts of situations.  I say that society as a whole has to look at these circumstances and they can’t depend on just us."
Yes, but you're in charge of the entity receiving huge tax breaks in return for doing exactly those things. 
Workers demolished the Church of the Transfiguration to serve as the site of a new Cleveland Clinic hotel.
(Marvin Fong, Plain Dealer file)
It's not just the Cleveland Clinic, of course.  UPMC, Johns Hopkins, or numerous other non-profit giants are doing well but not necessarily improving the lives of their surrounding communities (and, of course, most such hospitals are busily expanding to more affluent suburban communities).

Still, it's unfair to blame non-profit hospitals for seeking profits rather than community health, just like it's not fair to blame physicians for opting for orthopedic surgery instead of primary care or pharmaceutical companies for investing in expensive new treatments instead of preventive remedies.  
They're just doing what Jerry Maguire taught us: "show me the money."
We spend our $3 trillion on big hospitals, highly compensated health care executives and physicians, 16 million health care jobs, thousands of health care facilities, ridiculous numbers of prescriptions, and high-tech medical devices, then we have the nerve to wonder why our health outcomes are so poor.  We don't live as long as we should, we have alarmingly high rates of chronic diseases, and we have a sneaking suspicion that many of the medical services we get are unnecessary.  

Meanwhile, 43 million of us live in poverty, some 42 million of us struggle with hunger, 30 million of our homes have serious health and safety problems, close to 2 million of us use homeless shelters or live on the streets, and less than 3% of us live a healthy lifestyle.

We act mystified about how much more we spend on health care than other countries, but that may just be because of what we count.  We spend our money on medical care, rather than on social determinants of health (SDOH), on which many other countries spend more.  

Our problem is not so much a problem of technology, or innovation, or even how we pay but rather what we've chosen to pay for.  As long as we keep focusing on (and paying for) medical care rather than on health more broadly defined, we're just going to keep getting more of the same.   

Wednesday, July 12, 2017

Placebos All the Way Down

Two remarkable articles -- one on placebos, one on informed consent -- caught my attention.  To set them up, a famous, perhaps apocryphal, story:
A scientist tried to explain the solar system to a lay audience.  When he finished, a skeptical woman told him he was wrong: the earth was flat, and rested on the back of a giant turtle. The scientist asked her what the turtle rested on.  "Another turtle," she replied confidently.  He then asked what that turtle was on.  The woman would have none of it.  "You can ask all you want, sir, but it's turtles all the way down."
Faith is a funny thing.  Especially in health care.
Let's start with placebos.

Brian Resnick wrote an in-depth look on them for Vox.  Simply put, the placebo effect is that a patient's belief or expectation that something will remedy their symptoms often does, in fact, help -- often as much as "legitimate" treatments.  Placebos are more effective than many realize.

He cities 2015 research that found not only solid evidence that the placebo effect exists, but is actually growing stronger -- although, curiously enough, only in the U.S.  The research focused on pain control medicine, but there are similar trends with antidepressants and anti-psychotic drugs as well.

As Mr. Resnick says, "belief is the oldest medicine known to man."  Every culture has had some sort of healer, in whom great faith was placed.  For most of history, the treatments that such healers had in their bag of tricks was fairly limited.  We like to think that modern medicine is more sophisticated, more based on science, but consider the following:
That science thing doesn't look so good now, does it?

Ted Kaptchuk, a Professor at Harvard Medical School, told Mr. Resnick: "The placebo effect is a surrogate marker for everything that surrounds a pill. And that includes rituals, symbols, doctor-patient encounters.”  Let's keep in mind that the placebo effect is not limited to pills.  For example, some studies suggest that "fake surgeries" -- where the patient thinks he/she had a surgery but only got an incision -- may have an even more powerful placebo effect than pills do.

Indeed, in Salon, Dr. Ronald P. Grelsomer said:
The bigger the treatment, the more expensive the pill, the more well-known the doctor, the more impressionable the patient, the greater becomes the placebo effect. What bigger treatment is there than surgery?
Mr. Resnick lists several types of placebo effects, which I'll summarize as follows:
  1. Regression to the mean: Most people get better over time anyway.
  2. Confirmation bias: When we expect to get better, we often do.
  3. Expectations and learning: we've learned over time that doctors and medicine help us, and we expect that they will again.
  4. Pharmacological conditioning: our brains can mimic the effects of many drugs, if it thinks it is getting them.
  5. Social learning: if others get better from something, so should I.
  6. A human connection: "usually intangible traits like warmth and empathy help make patients feel better."
Mr. Resnick cautions that placebos, for the most part, work on symptoms, not underlying causes.  E.g., they don't improve lung function, but they can make people think their lung function is better.  Still, researchers now are saying that placebos can work even for how strenuous exercise seems, so it is clear they are powerful.

It makes one wonder if we really understand what a placebo really is.  Indeed, there is research that suggests that even when patients are told they're getting a placebo, it can still work.

In this context, Dr. Grelsomer brings up the issue of informed consent.  There's a dual problem: if the patient is unknowingly given a placebo, where's the informed consent?  And if the risks of a treatment are fully explained, patients may be scared, leading to a "reverse placebo" effect that can comprise their recovery.

Which leads to the second article, Richard Gunderman, M.D., and James Lynch, M.D., writing about "The Decline and Fall of Informed Consent."  Millions of people have to sign informed consent forms in health care settings every year in order to receive treatment.  However, "The only problem: it is often neither informed nor a real consent."

They cite, for example, a professor who had a chance to enroll in a clinical trial, for which a thirty page informed consent document had to be signed.  After trying to make sense of it, he finally said: 
I am pretty smart, but I have enough to worry about with my diagnosis, and this informed consent form is so overwhelming that I simply can’t tell the difference between what is important and what is just legalese.  
The authors conclude that such forms now often resemble "a monstrosity," not protecting patients but, rather, doctors, researchers, and institutions.  In their opinion, the example of the thirty page form is not an outlier, but is routine.  They note:
"One of the most important goals of informed consent is to protect patient autonomy, but the complexity of the forms makes patients more reliant than ever on doctors, researchers, and institutions to explain the risks and benefits.
Ironically, informed consent leads to more reliance on trust, which just leads back to placebos.  It's good for us to trust our caregivers, but that trust itself shouldn't be the basis for the care we get.

Both Mr. Resnick and Dr. Grelsomer bring up the possibility that, since they can be so effective, perhaps we should make placebos part of "mainstream medicine."  Dr. Grelsomer asserts: "We are winning the battle over conditions that require science and losing out on those that just need a little placebo."

Maybe.  For all we talk about patient-centered care, patient autonomy, and informed patients, when most of us get sick we want that all-knowing healer -- usually a physician, but sometimes a chiropractor, an acupuncturist, a dispenser of supplements, etc.

Still, if all we want is healers, well, sugar pills don't cost $3 trillion.

Dr. Kaptchuk sees placebos as "basically the water that medicine swims in."  That water is murky, impure, full of tides and eddies.  He'd like to see the art of medicine truly turn into the science of medicine, and so should we all.  It's hard to decide which is worse: placebos, mainstream treatments that have no empirical evidence, treatments still given even though shown not to work, or treatments that are just unnecessary.

It may not be placebos all the way down, but they and their ilk go much further down than we'd like to admit.

Tuesday, July 4, 2017

America the Not-So-Great

Most Americans -- myself included -- think we live in the greatest country on earth.  After all, we have the biggest economy, the most powerful military, the most pervasive popular culture, and, of course, the American Dream.  We've got Wall Street and Silicon Valley, Walmart and Amazon, Hollywood and Nashville.  We have -- well, we used to have -- the biggest city, the tallest building, and the largest manufacturing output.  

But when it comes to some of the basics, we're not doing so well.

Take health care, for example.  If you listen to politicians, we have the best health care in the world.  And, indeed, if you have enough money (or really good insurance), happen to live in the right zip code, and manage to stumble upon the right doctors/hospitals, that's true.  You can get the best health care in the world here.  But fail any one of those qualifiers, maybe not.

Most of us know that, whatever else is true about it, we definitely have the most expensive health care system in the world -- by far.  Many of us have also started to realize that we're not getting very good value for that spending.  By most objective measures, our health outcomes are middle-of-the-pack, or worse.

Various other studies offer an embarrassment (literally) of findings, including:

  • The University of Washington scored nations on a health-care quality index (HAQ), and found the U.S. rated at the bottom of the second decile, next to Estonia and Montengro.  
  • The Lancet rated the U.S. only the 28th healthiest country.  
  • Bloomberg rated the U.S. 50th out of 55 countries in their Health Care Efficiency Index.   
  • The Commonwealth Fund ranked the U.S. health care system last of eleven industrialized nations.  
  • Over 60 countries have better infant mortality rates than we do; we rank between Bosnia and Serbia.  
  • The U.S. health care system ranked 15th among the 60 countries in the U.S. News & World Report's "Best Countries" survey.
  • A Health Affairs study found we had one of the largest income-based health disparities in the world.  
  • There are significant geographic and racial differences in health care within the U.S. as well.  

If our problems were only with health care, we'd have our hands full.  But that's not the only problem area.

We profess to place a great deal of importance on education, but the facts would suggest otherwise.  We may have most of the best universities, but even they are slipping in worldwide comparisons.  More telling are the results for primary and secondary education.

Earlier this year the Pew Research Center summarized some of the disturbing results.

  • We're middle-of-the-pact for high school students on reading, science, and math results.
  • We're at least in the top ten -- although not top 5 -- for math and science for 4th and 8th graders.
  • Only 40% of our 4th graders, 33% of 8th graders, and 25% of 12th graders are at least proficient in math.  
  • Only 29% of Americans rated our K-12 STEM (science, technology, education, and mathematics) education as above average in the world; only 16% of scientists agreed, while 46% rated it below average.

As with health care, we spend more than our peers to get these dismal results, although at least our educational spending is not quite as stratospheric in comparison.  Also like health care, its costs -- especially for higher education -- is rising more rapidly than income.

There is more than $1.2 trillion in student debt, which is only behind mortgages in consumer debt.  Defaults are hitting record levels.

As dismaying as these facts, there are still other important areas where the U.S. lags.

Infrastructure -- e.g., roads, bridges, dams, airports, schools -- recently got a D+ from the American Society of Civil Engineers (ASCE).  Of the 16 categories scored, only one (rail, surprisingly) got as high as a B and only two (ports and solid waste) got a C+.  The rest were D or D+.

Drinking water, for example, got a D.  That would come as no surprise to anyone living in Flint, but what happened there is only the tip of the iceberg, so to speak.  A new survey found that 87%  think that clean water is our most important natural resource, but two-thirds believe their local drinking water is at risk.  96% think we should be investing more.

Many people -- including President Trump -- have called our infrastructure "third world."   As harsh as that sounds, it's not far off.   The President has called for a $1 trillion infrastructure investment, but ASCE thinks we need more like $4.5 trillion by 2025.  Spending is only one of the problems;  Bloomberg's Noah Smith thinks we're "forgotten how to do infrastructure."  Projects that would take weeks or months elsewhere can take years or even decades here, and cost much more.

Then there is an area where one would think the U.S. would do particularly well: internet speeds.  We are home to internet giants like Google and Facebook, and we pride ourselves on our smartphone ownership (80%) and broadband penetration (73%).  But we still settle for poor performance.

We are just barely cracking the top 10 in average internet speeds; our average speed is only two-thirds of the leader (South Korea).  We're only 16th in peak average speed, with that speed being less than half of the leader (Singapore).

It's even worse on the mobile side, where we rank only 28th, our average speed only 41% of the leader (United Kingdom).

We should be doing better.

Our federal debt is closing in on $20 trillion, we have states teetering on bankruptcy, and most Americans live in "financially precarious circumstances."  Yet, as Mr. Smith asserted, "construction, like health care or asset management or education, is an area where Americans have simply ponied up more and more cash over the years while ignoring the fact that they were getting less and less for their money."  

We simply cannot afford to tolerate poor performance or wasteful spending.

These are disparate problems, and will take disparate solutions, but one thing is clear: this is not a time for "more-of-the-same."  We will have to innovate our way out of these messes.  The U.S. has always prided itself on innovation, but, here again, we're not even doing that very well, barely cracking the top ten most innovative countries.  We're lagging on investment in R&D and basic science.

If we truly love our country, we need to expect -- demand! -- more for it, and for us.

Tuesday, June 27, 2017

Health Care Goes to the Mall

It's either auspicious or ironic: decades after other retail industries, health care is coming to the mall.

These are not, generally, good days for the malls.  We've all seen strip malls that were never finished or that have simply fallen on hard times, but in recent years those stalwarts of American shopping -- enclosed malls -- are sharing that fate.  Credit Suisse says that 20-25% of the 1,100 U.S. malls will close over the next five years.

Analysts talk about "zombie" malls, whose anchor tenants -- like Sears, JC Penny, or Macys -- have pulled out, creating an exodus of other tenants.  The malls themselves still stand, but their largely deserted storefronts and scarce shoppers mean they're dead but they don't know it.
Malls took off the mid-20th century, mostly in the suburbs and especially once they started to be enclosed.  The location, convenience and range of choices were unbeatable.  

Still, the concept started to seem dated by the 1990's, so the "lifestyle mall" was born.  They usually are not enclosed, try to recreate the feeling of a walk-able city center, and typically include destination restaurants and entertainment options like movie theaters or comedy clubs.   

Now that lifestyle concept is further evolving.  The Wall Street Journal predicts that "the mall of the future will have no stores."   They cite malls filling empty spaces with churches, schools, even offices or apartments.  E.g., Ford is leasing 240,000 square feet at a suburban Detroit mall for new offices.

The New York Times had a similar report on the changes to malls.  As one developer told them, "Dining and entertainment is the new anchor — not Sears, not Macy’s."  

One of their examples was how Austin's first enclosed mall had closed, and now is reopening as a new campus for a local community college.  It will ultimately serve as many as 20,000 students, and will also include 1,200 residential units as well as some retail.  

One thing that many agree upon: malls of the future will include: health care.

Another Wall Street Journal article focused specifically on health care moving to malls, and included several examples:
  • Dana-Farber Cancer Institute has leased 140,000 square feet of a 286,000 square foot Boston-area mall, which also has several other health and wellness tenants.
  • The Maury Regional Cancer Center has been in the Columbia Mall (Columbia, TN) since 2012.
  • The Biggs Part Mall in Lumberton NC has Southeastern Regional Medical Center as a key tenant.
  • UCLA Health operates primary care centers in the Village at Westfield Topanga.
  • Vanderbilt Health has been part of the One Hundred Oaks mall in Nashville TN since 2009.

The portfolio manager for One Hundred Oaks mall told WSJ, "We have been very pleased with the performance of [One Hundred Oaks mall], driven in large part by the built-in traffic generated from the Vanderbilt University Medical System."  No wonder, the mall had been failing, and now Vanderbilt Health leases half of the mall's space. 
Other examples include Cedar Sinai (The Runway at Playa Vista -- LA) and Prime Healthcare (Plymouth Meeting -- Philadelphia), according to Bloomberg.  

Healthcare Dive profiled the WSJ article, and added that 57% of hospital exces in a recent survey listed improving access to ambulatory and outpatient care as their top priority, and that JLL Corporate Solutions recently urged health care organizations to adopt a "patient-centered" real estate strategy.

How much more "patient-centered" could it be than to locate in malls?

Johns Hopkins Medical President Gill Wylie told Bisnow that he watches retail vacancies for opportunities: "We do urgent care and primary care.  So I'm sitting there thinking, 'Gee if all these Staples end up closing, there might be space out there.'"  They've already snapped up four former Blockbuster locations for urgent care facilities.  

Mr. Wylie said he also pays attention to big department stores and malls, citing their infrastructure, parking, and ADA compliance as givens.  

JLL Managing Director Matt Coursen told Bisnow:
In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care centers off campus.  The on-campus environment should be reserved for acute care  and intensive care surgery centers that traditionally make hospitals more money.  Don't put anyone on campus that doesn't have to be there.  
In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at:
In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at:
In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at:
In the last three years, it has become pretty apparent that it makes more sense to get some of these urgent care or specialty care clinics off campus," Coursen said. "The on-campus environment should be reserved for acute care and intensive care surgery centers that traditionally make hospitals more money. Don’t put anyone on campus that doesn’t have to be there

Read more at:
Interesting perspective.

Fady Barmada, of Array Advisors, led the conversion of New York City McDonald's to an urgent care center, and noted that: "Health systems know that, by co-locating themselves with well-used and well-attended retail facilities, they can increase the visibility of their facilities and become platforms for the creation of unique and interesting programs."

But moving to retail locations won't, in itself, make health care organizations more patient-centered.  To do that, they'll have to make the patient experience easier (if not always enjoyable), give them clear choices, and truly treat them like valued customers.

Moving is easy.  Changing is hard.  

Read more at:

Tuesday, June 20, 2017

Good Ideas From Unexpected Places

How about this: in Harvard Business Review, two leaders at Johns Hopkins suggested that hospitals could learn something about buying equipment from -- drum roll, please -- the airline industry.

You don't often find many people defending airlines these days, much less holding them up as good examples of anything (except, perhaps, about what not to do, what with overbooking, cramped leg space, plenty of add-on fees, and, of course, dragging paying passengers off planes).  That their recommendations make sense probably says more, though, about how poorly health care often does things than how well airlines do.

The point that Peter Pronovost and Sezin Palmer make is that "hospitals purchase technologies without requiring that they communicate with each other."  They have lots of high tech equipment, each with lots of important data, but the equipment is generally not interoperable (of course, even the same types of equipment often aren't interoperable -- EHRs being the prime example).

As they say, "health care is woefully underengineered."  This leads to all sorts of workarounds and double-entry, which at best make patient care more difficult and at worse threaten patient safety.  They urge that heath care take advantage of system engineering to truly integrate technology, workflow, and clinical practices.

Hard to argue.

Their great quote:
We don’t expect airlines to build their own planes. They buy them from experienced system integrators such as Boeing or Airbus. There’s no reason that hospitals shouldn’t have a similar model. 
For example, they suggest that, instead of building hospital rooms and then filling them with equipment that don't communicate, hospitals could buy hospital room modules that come with fully integrated devices.  It could be not just rooms, but clinical units, whole floors, even a "hospital in a box," each coming already integrated.

The approach goes beyond hospitals, of course.  For example, aircraft engines increasingly tap into the Internet of Things (IoT), so that they can be continuously monitored and problems addressed before they become serious.  That is something that health care talks about a lot, in terms of monitoring our heath, but so far has failed miserably at.

Of course, the airline industry still uses air traffic control systems that are decades old, their baggage tracking systems still manage to lose your bags, and it seems to take a suspiciously large number of keystrokes to rebook you if your plane gets cancelled.  So the airline industry could use some systems engineering of its own.

Upon reflection, the two industries are not as dissimilar as they might seem on first glance.  In both cases, we literally put our lives in their hands, hoping that the people and equipment all function correctly.  Both are very capital-intensive.  Both use some technology that is decades old as well as some cutting edge technologies.  Both have seen rapid consolidation of service providers, leading to less competition.

And neither has a great track record about doing exactly what they promise to do exactly when they say they're going to do it.
Health care or airport waiting room?
On the other hand, you can easily shop for flight choices and prices (although airline pricing may just rival health care pricing for its inexplicable variations), can book your airline ticket and pick your seat using your smartphone, and on-board entertainment options are becoming fairly sophisticated.

The equivalents in health care pale by comparison.

Health care can do better.  John Nosta writes in Psychology Today that healthcare innovation is "in the ICU."  In other words, in serious trouble, but not dead yet.  He believes the underlying technologies are there to spur innovation, and that "an inflection point is at hand."  He cites in particular a survey done by Klick Health, which found that consumers don't think that health care is very innovative, but they wish it was.

Specifically, health care was at bottom of 18 industries in terms of which respondents felt was the most innovative (17%), but top of the list of ones that they thought should be (40%).  Ninety-one percent believed innovation will positively impact healthcare over the next five years.  Ninety percent also felt technology would have a positive impact on their health, with 70% believing technology will help them personally manage their health.

Contrary to oft-mentioned concerns about technology interfering or even replacing the physician-patient relationship, the Klick respondents felt that it would benefit from innovation, such as in better diagnosis and treatment.

Health care all-too-often sees itself as unique, and tries to solve problems using health care people applying health care solutions.  That may be necessary in many cases, but it can't be the only approach.  There are too many other industries, using too many interesting business models, process improvements, and technologies, to limit problem solving to "traditional" health care models.

Suzanne Fox, the former CTO for HHS, recently told Washingtonian: 
The most successful groups I’ve seen in terms of the innovation work I oversaw at HHS or discussions I’ve been a part of in other settings, the more diverse groups, the better the innovation becomes.  You’re going to want to hear from people who haven’t yet developed the muscles for a certain way of thinking about health care, who are going to maybe have that outside idea that’s creative.
So, if we're going to innovate in health care, we need to flex those non-health care muscles.  We need to break down barriers.  We need to listen to diverse voices and ideas.  We need to apply ideas that we might not normally think would apply to health care.  We need to beg, steal, and borrow good ideas from wherever they come.

Even if that means learning from the airlines.

Tuesday, June 13, 2017

Fidgeting May (or May Not) Be Good For You

I swore I wasn't going to write about fidget spinners.  Just a toy, just be the latest fad -- the Rubik's cube of this generation, or perhaps the Pokémon Go of this year -- with no broader implications, for health care or anything else.  Yet here I am, writing about them after all.

If you know any children, you already know what a fidget spinner is.  You may even have one yourself.  They seem to be everywhere lately, even in the hands of President Trump's youngest son as he exited Marine One recently.

What that says about us is not quite clear.

Although they generally share the same three-prong shape (there's also a newer variation, a fidget cube), fidget spinners come in all colors and prices -- one writer listed some 62 variations.  They can range in price from a cheap as a dollar to several hundred dollars.  

You can even turn your mobile phone into one, if you really want to.  Or get the app.  

CNN reported that fidget spinners accounted for the top 15 most popular toys on Amazon, and fidget toys and fidget cubes combined accounted for 49 of the top 50 spots.  If you don't get their appeal and think they're just silly, well, kids probably don't think you're cool anyway.

One of the early rationale for fidget spinners was for children with ADHD (attention-deficit/hyperactivity disorder).  The theory was that they allowed them to focus better by giving an outlet for their extra energy.  Their benefits supposedly also applied to adults with a wider range of mental health concerns, such as PTSD or anxiety.  

Unfortunately, the basis for any of these claims appears dubious.   There is some research that gross motor activity did help improve working memory for children with ADHD, but it was not focused on fidget spinners and using them probably would not qualify as gross motor activity.  Clinical psychologist Scott Kollins warned NPR: "It's important that people don't get into trying these fads when we do have treatments that can help these kids."

And, while ADHD diagnoses have exploded (which some have blamed on Big Phama's desire to sell more drugs), most of those children you see with fidget spinners almost certainly don't have ADHD.  They just like to play with it. 

The notion that fidget spinners are good for kids, or at least benign, is increasingly coming under attack.  Schools in at least 11 states have banned them, claiming they are at least distracting and possibly dangerous.  Imagine teachers trying to get kids focused on math while they are spinning away (and the rest of the class is texting under their desks), and the bans make a lot of sense.

Even worse, there are warnings about fidget spinners being a choking danger, a possible source of internal bleeding (due to the batteries), even a risk for lead poisoning.  Who knew they might be so hazardous?

Alex Williams, writing for The New York Times, has a different theory.  Mr. Williams argues that, while we once might have been the "Prozac Nation," suffering from depression, we now are the "United States of Xanax."  In other words, as social media consultant Sarah Fader told him: "If you’re a human being living in 2017 and you’re not anxious, there’s something wrong with you.”

He notes that as many as 38% of girls 13-17, and 26% of boys, have an anxiety disorder, and that anxiety far outpaces depression on college campuses.  

This should not come as a surprise.  After all, since 9/11, the 21st century has seen a never-ending threat of terrorism, wars in Afghanistan and Iraq, the Great Recession, widening wealth inequality, and hyper-partisan politics the likes of which we may have never seen before.  To not be anxious seems like not paying attention.

Mr. Williams cites the fidget spinner "as a perfect metaphor for the overscheduled, overstimulated children of today as they search for a way to unplug between jujitsu lessons, clarinet practice and Advanced Placement tutoring."   A mindless activity like them has great appeal. 

He also references another new source of anxiety: #FOMO, or fear of missing out.  We have to keep up with Facebook, Twitter, Snapchat, texts.  Staying connected can be an overwhelming, 24/7 task.  Our obsession with -- one could say addiction to -- our smartphones shows how we constantly have to be busy with something.

No wonder it isn't just children who are playing with them anymore.

There's nothing inherently wrong with fidgeting.  The Washington Post interviewed Katherine Isbister, a professor at University of California Santa Cruz, who is studying the fidget spinner craze.

Dr. Isbister told the Post that we evolved doing things with our hands, but modern life affords us less opportunities to do many of them.  She speculates that our digital devices rob us of the kind of "interesting tactile experiences" that fidget spinners provide.

Professor Isbister and her collaborator Michael Karlesky believe that fidget spinners "may shape cognitive state to support a user’s productivity and creativity in their primary tasks."  OK, then. They're collecting other examples of how and with what people fidget (and finding some interesting items!).

Fidget spinners may not have broader implications for health care, as I've previously speculated that other seemingly unrelated things like e-SportsPokémon Go, or Snap's Spectacles might.  They might not tell us anything more about the times we may live in than hula hoops told us about McCarthyism or the Cold Way did about the 1950's.  They may just, indeed, be a passing fad.

I think I still want one, though.  How about you?

Tuesday, June 6, 2017

Robots for Everyone!

Ready or not, there are robots in your future.  And some of them will be for health care.

There has been growing concern that the rise of robots, along with artificial intelligence (AI), will create huge impacts on jobs.  Within the last few months both McKinsey and PwC have issued white papers on the topic.  The former found that nearly half of jobs have the potential to be automated (although most not totally), while the latter expects 38% of U.S. jobs at at high risk of automation within 20 years.
Health care is not high on most lists of sectors whose jobs are soonest to be heavily impacted by robots, but it is on the list -- and it will happen.

The Pew Research Center asked people for their predictions about robots and computers taking jobs, and found a curious dichotomy.  While two-thirds expected those technologies to take over most jobs within 50 years, 80% thought their own jobs were safe.  They were more worried about their industry declining or jobs going to lower wage workers.

Even the ones who happen to be right about their job may still feel the impact.  Recent research suggests that robots not only take jobs but also reduce wages for the remaining jobs.

If you are worried about your job, there's a website Will Robots Take My Job which allows you to calculate the odds your job will be replaced by a robot.  If you are a physician (0.42%), nurse (0.9%), or pharmacist (1.2%), you're probably feeling safe, but if you work on an assembly line (97%) or are a truck driver (79%), not so much.

And if you are a billing clerk (96%), pharmacy tech (94%), or personal care aide (75%), well, you might want to brush up that resume.

Robots are becoming more and more human-like.  China's University of Science and Technology have unveiled "super-realistic" robots that have facial expressions, can carry on conversations, even practice calligraphy.   A professor at Osaka University has created a robot named Erika that Bloomberg called the "creepiest robot ever built" because it is so lifelike.  

There are already hotels -- in Japan, of course -- that are staffed solely by robots.

Although sophisticated robots like in robotic surgery or nanobots are already here or coming (respectively), many see robots to assist with caregiving as filling one of the biggest health care needs.  Global Markets Insights, Inc. projects that the market for "healthcare assistive robots" will grow 19% annually from 2016 to 2024, and that's the early stages of the market.

Let's face it: there are a lot of shitty jobs in health care.  In many cases, literally.  Jobs that it is hard to find workers to fill, especially because they tend to be low wage jobs.  Taking care of people who can't take care of themselves is a hard job.  Doing it can be a calling, and thank heavens for the many people who do it cheerfully and tenderly.

There just aren't enough of them.

If you or a loved one has ever been in a hospital, you know that ringing for help rarely results in someone coming quickly.  If that stay is in a nursing home, the wait will probably be longer.  The staff isn't right there, there aren't enough of them, and there are often other people asking for help at the same time.  If you're in pain or simply have to go to the bathroom, the wait can seem interminable.

If only you had a robot aide, standing patiently next to you, ready to help...

An even bigger help would be robots you could have at home when you are disabled or incapacitated. Most people would prefer to stay at home instead of going to a hospital or nursing home.  Many Medicaid programs have worked diligently to try to keep vulnerable people at home instead of being admitted to nursing homes, but there's only so much having an aide visit a couple hours a day a few times a week can do.

But a robot aide living with you could be more effective, and might actually be cost-effective about keeping people out of nursing homes.

Think about it: they'd never need to sleep, go home to their family, or take a vacation day.  They'd never be in a bad mood or make a careless move.  Helping you would be their only mission.

We're not quite there yet.  There are some tasks that we're not quite willing to have robots perform, especially on already fragile individuals.  But if we're trusting robots to do eye surgery, helping with bathroom or other sensitive tasks is certainly achievable, in the not-too-distant future.

Bernadette Keefe, M.D., did a deep, deep dive on robots in health care (starting with what a robot is, their history, and their uses in other sectors).  She included several examples of caregiving robots, including:

  • Zora, a "personal caregiver" from Softbank, interacts, moves, and helps with rehab.
  • Robear, from Riken and Sumitomo Riko Company, can lift patients from a bed.  It is, however, still considered experimental.  
  • Softbank's Pepper, which is intended as a companion.  Softbank claims Pepper can perceive and respond to human emotions.   

In addition, Toyota has a family of "partner robots" which includes a personal assist robot, a care assist robot, and Robina.  Not to be outdone, Honda has their own family of robots, including ASIMO, which they bill as "the world's most advanced humanoid robot."

Half of respondents to a Futurism survey predicted every house would have a humanoid robot, although there was widespread disagreement on the timing, with some thinking we were still decades out.  That may be pessimistic.  There's already Catalia Health's Mabu personal care assistant and the Aido "next generation social family robot," among others.

We're already getting used to personal home devices like Amazon's Echo, Google Home, and now Apple's HomePod, all of which can do a variety of virtual tasks  It is not at all far-fetched that'd we'll similarly get used to personal robots who can do physical tasks for us, including ones relating to our health.

With AI doctors and personal care robots, technology can at least help fill in current gaps in care, and maybe help provide better health care generally.

Bring on the robots!

Wednesday, May 31, 2017

Building a Better Health Care System

Several Kaiser Permanente executives recently urged that we stop wasting patients' time.  They cited the ultimately tragic example of Jess Jacobs, who used her Six Sigma expertise to calculate that only 4.75% of her outpatient visits and 0.08% of her inpatient stays were spent actually treating her conditions.  They then outlined how they've re-engineered some of Kaiser's processes "to upend traditional paradigms and make saving our patients’ time a part of our standard quality measures."

That's a start, but, if we're going to re-engineer health care processes, let's really re-engineer them.  The future is patient-driven, on-demand, and just-in-time.

Hey: it's the 21st century.  We have computers and smartphones, we have unobtrusive sensors, and we're beginning to have meaningful artificial intelligence (AI).  The health care system shouldn't still be built around waiting or even on in-person contact.  It may still include those, but they should be the exception, not the norm.

Let's look at what it might look like:

  • You wake up in the morning and will already have more information about your health than your doctor does now, between, say, biosensors on your skin, ingestible sensors,  even smart toilets.  
  • All that data will go to your personal health assistant, such as Baidu's Melody or  It will know your norms, understand when something appears off, and listen to your (health) complaints.  It will give you a good idea what might be wrong and what you should do about it.  Perhaps most importantly, it will tell you when you need to consult which doctor.
  • The first stop will usually be to consult an AI "doctor."  It be available 24/7, and will have access to all your data and all the deep learning only AIs can accumulate.  
  • If you do see a human doctor, chances are it will be first via a screen (or VR/AR).  They will be the best available expert for your problem; not just locally, but in the world.  In-person visits will be reserved for the most urgent problems requiring hands-on care.
  • When you do have to visit an office or facility, it won't be like today, full of forms, waiting, and uncertainty.  It will be more like visiting an expensive spa, where you are treated like royalty.  They'll be ready for you, cater to your unique needs, and get you in and out efficiently.  
  • "Minimally invasive" will take on whole new meanings, from ingestible robot surgeons to reprogramming our immune cells to tweaking our microbiome.  
  • With so much of our care AI-driven or AI-supported, there will be much less reliance on hunches or outdated research, and more on data and evidence of efficacy, reducing the current "epidemic" of over-testing and use of unnecessary procedures. 

Sound optimistic?  Ray Dorsey and Eric Topel write about the future of office visits, and while they don't go as far as the above, they do assert: "Tomorrow’s office visit will increasingly take place everywhere but the office."
They include on-demand home visits and hospital-at-home models in their prediction, pointing out:
While most patients like their doctor, almost no one likes going to the doctor. By contrast, tomorrow’s office visit will offer patients unprecedented access to confidential, expert care that is delivered conveniently in the comfort of their homes.
The big question is less where or how visits happen, but who is making them.  I.e., whether AI can truly supplant the role of human practitioners for much of our care.

Newsweek recently proclaimed that AI will "cure" our health care system, and claimed, "we’re close to being able to build AI software that can at least supplant that first visit to a doctor when you’re sick—which, of course, is when you least want to travel to a doctor’s office."

Their optimistic prediction:
Add it up, and in these next few years we’re going to see a parade of tech applications that reduce demand on the health care system while giving all of us more access to care. Doctors should be freed up to do a better job for patients who truly need their attention. 
CNBC's Christina Farr, interviewed several doctors about AI's future.  She found that physicians were skeptical of sweeping changes -- but many agreed they hoped AI could free them of more mundane tasks, which would help them spend more time with patients.

Rasu Shrestha, chief innovation officer for UPMC, told Ms. Farr: "Health and health care is too human a notion for AI alone to cure it."  That is certainly true, and Newsweek's headline went further than the actual article did.  There will be human doctors, but they are likely to be doing different things and doing those things differently.  And they will almost certainly be supported by AI.

We have to remember that, by definition, most doctors are average.  Maybe 10-15% are great, maybe 10-15% are poor, and the rest are in the middle.  The law of averages is not good that the doctor you end up with is one of the great ones.  Even if you manage to identify one, getting to see him/her is often a challenge.

On the other hand, all it takes is for someone to develop one AI that is better than the average human doctor.   Unlike human doctors, such an AI is not limited by geography or patient load. It doesn't sleep or take days off.  It could, in theory, see all the patients who want to consult it.  It may or may not be better than great doctors, but it certainly would be more available than them, and would be better than the average doctor you might otherwise end up with.

And that's why AIs will ultimately prevail for most of our needs.

We used to expect other humans to operate elevators and dial phone calls for us.  We used to have personal relationships with our grocers and butchers.  Technology and convenience eroded or eliminated these and other kinds of interactions, and that will happen in health care as well.

We often talk about the importance of patient-physician relationship, but when you rush to the ER or suddenly get surgery, competence outweighs familiarity.  If AIs can help get us better, we'll use them, and that opens up many opportunities for change.

Many protest that "health care is different," and won't follow the patterns of other industries.  They're often happy to try to just make the current system less bad.  That's too low a bar.

Let's re-engineer our health care system to take full advantage of the available and the coming technology, and to truly respect our needs, preferences -- and time.