May I See Your Credentials...Oh, Never Mind

Chances are, your doctor is Board Certified.  Chances are, if you have gone to a hospital, it was accredited by The Joint Commission.  Many health care consumers look at these kinds of credentials as a proxy for quality, helping ensure that the people or institutions from whom/which they receive care are, in fact, well-qualified to provide. 

It turns out those expectations may be overly optimistic. 

Board Certification is overseen by the American Board of Medical Specialties (ABMS).  Following medical school, residency, and licensure, physicians can take a specialty-specific exam to obtain their board certification.  Following that, in order to remain board certified, they must follow a process called Maintenance of Certification" (MOC) in order to demonstrate ongoing competence, and it is MOC that has proved controversial. 

Credit: Association of American Physicians and Surgeons

In a recent survey from MDLinx, 65%  of physicians say MOC provides no clinical value, despite costing physicians thousands of dollars and significant time.  Only 4% felt it enhanced their ability to practice.  Seventy-seven percent also added comments elaborating on their frustrations.  One cardiologist told MDLinx, "These are people in a bureaucratic ivory tower who have the pomposity to state that these computer tests are going to help patients, when they're really helping themselves." 

Four internists have recently filed a lawsuit against their speciality board (ABIM), claiming the MOC process amounts to restraint of trade.  They'd like more acceptance of other certification options, such as offered through the National Board of Physicians and Surgeons.  This comes on top of an investigation three years ago that charged that the specialty boards -- and the ABIM in particular -- were using board certification and MOC to rake in huge windfalls for their organizations. 

The ABMS, for one, is not sitting idly.  It just released its draft report on its vision for the future of certification, trying to address some of the concerns raised and asking for public comment on their vision.  It's a good bet they'll get some.

Things aren't much better on the hospital side.  The accreditation process is costly for hospitals in terms of staff time and actual dollars.  Despite that, a new study found that patient outcomes were not really better at accredited hospitals than non-accredited ones, with no difference in mortality.  The authors were blunt in their conclusion:

...we found that hospitals accredited by private organizations did not have better patient outcomes than hospitals reviewed by a state survey agency. Furthermore, we found that accreditation by The Joint Commission, which is the most common form of hospital accreditation, was not associated with better patient outcomes than other lesser known, independent accrediting agencies.

It gets worse than that.  The Wall Street Journal reported that even when state or federal regulators find significant safety violations, hospitals rarely (e.g., 1%) lose their accreditation status. Professor Ashish Jha (who was one of the authors in the study above), told the Journal, "It’s clearly a failed system and time for a change,” and the Journal finding “shows accreditation is basically meaningless—it doesn’t mean a hospital is safe."  

Equally troubling, the Joint Commission actually has a subsidiary that provides consulting services to help hospitals with the accreditation  process, which creates potential conflicts of interest. The Journal's reporting caught the attention of CMS, which announced it was going to look into these.  CMS Administrator Seema Verma said: 

We are concerned that the practice of offering both accrediting and consulting services—and the financial relationships involved in this work—may undermine the integrity of accrediting organizations and erode the public’s trust.  

The Joint Commission, of course, defends its accreditation process and also insists it keeps a strict firewall between it and its consulting efforts.  

Credit: The Leapfrog Group

Meanwhile, the Leapfrog Group does its best to track hospitals' actual quality performance.  In its latest survey, of the 2,600 hospitals evaluated, only 32% received an "A."  A plurality (37%) only got a "C."  The results do not differ significantly from previous years, which should be worrisome.

All of this boils down to the same underlying problem: we don't really know how to measure quality in health care.  Sure, we have many quality measures and many ways of trying to gauge knowledge and/or processes that should lead to quality outcomes, but you still rarely know if you have one of the best doctors/hospitals, or one of the worst. 

And that is a problem.

I'm deeply sympathetic to physician and hospital complaints about the certification/accreditation processes.  They are expensive, take much time, and don't seem to have the desired results.  What I am not sympathetic, though, is the lack of meaningful options being proposed.

We already don't really understand the distinction between a certification from ABMS and one from NBPS, or between an accreditation from the Joint Commission and one from the Healthcare Facilities Accreditation Program.   We don't really know if graduating from Harvard Medical School makes someone a better doctor than graduating from Virginia Tech Carilion School of Medicine, or if doing a residency at the Cleveland Clinic matters more than where a doctor went to medical school.   We don't really know if a physician's performance is improving or declining over time.

What we need to know is, who is helping patients the most?  Who is harming them the least?  How much difference will it likely make if I go to this doctor/hospital versus that doctor/hospital? 

We should know these things, but we don't.  Physicians and hospitals should know them, and should use them to continuously improve their performance on them, but they don't and they can't effectively.  We can't entirely blame them: in today's litigious society, measuring and reporting on those kinds of specifics open the door to more lawsuits and higher awards.

The problem goes to the age-old debate: is medicine art or science?  Art is subjective; it can't be measured or easily compared.  Science thrives on measurement and proof.  We like to think of medicine as being scientifically-based, but human health is not only highly subjective but also highly variable.  So we tend to shrug at the problem, measure what we can, and use these kinds of pseudo-scientific accreditations to bridge the gap.

We have many problems in healthcare.  Much good work is being done on a number of them.  But until we can answer those three questions above -- for a specific doctor/hospital -- we're likely to keep risking our health, and wasting our dollars. 

What College Can Teach Healthcare

Mitch Daniels, the former Governor of Indiana and current President of Purdue University, gave an interesting interview to The Wall Street Journal about what Purdue has been up to during his watch.  Mr. Daniels -- who knows a thing or two about healthcare -- drew an explicit parallel to healthcare in the interview, so I wanted to take some time to talk about what he said, and to try to extend the parallels further.

Here's how he described the parallels: 

"You're selling something, a college diploma, that's deemed a necessity.  And you have total pricing power."  Better than that, "when you raise your prices, you not only don't lower customers, you may actually attract new ones."

For lack of objective measures, "people associate the sticker price with quality: 'If school A costs more than B, I guess it's a better school.'"  A third-party payer, the government, funds it all, so that "the customer -- that is, the student and the family -- feels insulated against the cost.  A perfect formula for complacency."  The parallels with health care, he observes, are "smack on."  

People in healthcare may quibble, especially about the "total pricing power," but "smack on" seems about right to me.

Credit: Purdue University

Higher education is one area where prices seem to be rising even faster than in healthcare, and both much faster than wages.  Student debt just hit a record $1.465 trillion -- yes, trillion -- and now trails only mortgage debt in size.  We're past the point of talking about "real money;" we're now in the stratosphere of healthcare money.

We spend a lot more -- nearly twice as much per student annually -- on higher education than almost any other developed country, according to OECD.  Some might argue that more spending on higher education is a good thing, but that may not be true.  "The U.S. is in a class of its own,” Andreas Schleicher, the director for education and skills at the OECD, told The Atlantic.  “Spending per student is exorbitant, and it has virtually no relationship to the value that students could possibly get in exchange."

Yep, sounds like U.S. healthcare all right.

Mr. Daniels is trying to change that.  For one thing, he's focused on holding the line on costs, such as by bringing Amazon in to help lower textbook prices.  Purdue had raised tuition 36 years in a row prior to his arrival, and now has not raised them since 2012.  “We’re able to say,” he says, “that the total cost in nominal dollars of going to Purdue will be less in 2020 than it was in 2012."

How many healthcare organizations could boast something similar?

While Professor Clayton Christensen, the O.G. of disruptive innovation, has famously predicted that half of traditional universities will be bankrupt within 10 years, in large part due to competition from online universities, Mr. Daniels led Purdue to buy Kaplan University.  He converted the online distance learning giant to a nonprofit, Purdue University Global, that enrolls 29,000 students nationwide and is extending the Purdue brand.  

It's as if Kaiser Permanente bought Teladoc.

Credit: Purdue University

But here's what really caught my eye.  Purdue pioneered the use of Income Share Agreements (ISAs), an idea attributed to economist Milton Friedman.  Students don't owe tuition during college, but six months after graduation they begin to pay a percentage of their income for a fixed number of years (e.g., 10 years).  Repayment is capped at 2.5 the initial funding.   Several other universities are now rolling out their own versions.  

Instead of students taking on debt, they are, essentially, selling a share of their future financial success.  Do well, and you'll end up paying more than the student loans would have been (but also have more income with which to pay); get lower paying jobs, and your repayments scale down accordingly.  

In a world where universities are starting to be evaluated more by their graduates' salary potential, ISAs are a way for universities to put their money where their marketing promises are.  

The application of ISAs to healthcare may not be obvious.  It's not about basing contributions/taxes for healthcare/health insurance on income, although that is certainly something we should be doing more of.  The healthcare system makes no promises about future income, nor should it.  It does, though, supposedly exist to try to help us be in better health than we would be without it, and that's where the parallels might be drawn.

In an earlier post, for example, I suggested treating our health as a capital asset.  We would seek to spend -- invest -- money on things that increase it, and avoid things that decrease it.  It would, admittedly, be hard to quantify any of this, but doing so would force us to measure and to track.  We measure a lot of things in healthcare, but too few of them tell us what we really want or need to know.  I.e., are we getting better or worse?  Are we spending our money on the right things?  

Perhaps a Healthcare Share Agreement (HCSA) would have a healthcare organization make a quantifiable prediction about your health, and what you pay each year would depend on how they do against that prediction.  We'd have to agree on how to measure it, over what period of time, but both the prediction and the measurement are feasible (e.g., QALY).   

Are all QALYs equal? www.joelcooper.co.uk

The payment could be in lieu of health insurance premiums or health care organization's charges.  The healthier-than-expected you are, the more you pay; the worse-than-expected you are, the less you pay.  It's value-based payment at the next level.  It could be done as agreements with individuals and organizations, or, say, between health plans and health organizations at a population level.

The key thing is for healthcare organizations to do what Purdue is doing: bet on their ability to actually make a positive impact in the lives of the people they serve.   

I don't know how it would work.  I don't know if it can work.  But I'd sure like for someone to give it a try, because the existing business models sure don't seem to be working.

If Mitch Daniels -- with no previous educational background -- can take a solid-but-not-top-tier university and bring about some real innovations that position it well for the future, where is the Mitch Daniels of healthcare?   

No Parking Here

Design firm IDEO published another thought-provoking blog, Owen Sanderson's To Transform Your Industry, Look At Someone Else's.  It talks about an example of what they call "analogous research;" as Mr. Sanderson describes it: "Analogous research is a form of exploration that takes a team outside of its industry to find inspiration in the ways others have tackled similar challenges."  As may be evident from my prior articles, it is a thought process I love to follow.

The example Mr. Sanderson discussed involved taking some clinicians and healthcare executives to the airport, to see how JetBlue handled customer service.  Personally, I think using any airline for examples of customer service is setting a pretty low bar but, well, healthcare has a hard time even clearing those.  Their clients seemed to get something from the experience. 

I want to try some analogous research too, and I'll pick an even more off-beat topic: parking. 

Jae C. Hong/AP and CityLab

Parking?  Parking is on many people's minds this time of year.  Perhaps you fought the crowds on Black Friday, or tried to avoid them by shopping on Cyber Monday.  Either way, at some point this month most of us will find ourselves trying to park at some shopping destination, searching for the perfect parking space. 

You might, then, be surprised to hear that many experts think we have too much parking, way too much.  CityLab reports we have 2 billion spaces for our 250 million cars.  They quote Donald Shoup, a professor of urban planning at UCLA: "The area of parking per car in the United States is thus larger than the area of housing per human."  That's pretty scary.

CityLab says that we have enough parking spaces not just for busy days like Black Friday but for "multiple" Black Fridays, something that Strong Towns pointed out two years ago.  The latter created #BlackFridayParking to help document the excess parking, "Because, even on a day that is supposed to be one of the biggest shopping events of the year, we've noticed that year after year after year after year, the parking lots are simply never full."

Credit: Sarah Kobos, Strong Towns

Much of this excess parking is actually prescribed by local zoning or retail merchant requirements that are based on, well, who knows what the required ratios of parking to retail/office/housing square footage are based on.  All of that parking, of course, comes with a cost -- not just the cost to build and maintain the parking, but also the lost opportunity costs of how else the land might be used. 

As Sarah Kobos of Strong Towns describes our obsession with parking: "It’s an inefficient system that hits municipalities–and taxpayers–directly in the pocketbook."

We know how we got here.  We started moving to the suburbs, which meant we needed more cars, because we didn't want to walk or take public transit.  Retail stores followed, as did other businesses, all of which then built parking lots -- the more, the better. 

Los Angeles, ironically, is one of the places looking at how it might end the madness.  Architectural form Woods Bagot did a study More LA, asking: "What if L.A.’s miles of parking could be unlocked for more productive urban uses?"  The firm believes converting unnecessary spaces could create housing for up to 1.5 million people while boosting retail spending and creating more green space.

The trouble is not just the current carrying costs of all that parking, but what future trends are telling us.  More people are going online to shop, work, or socialize rather than driving to them.  More people are moving back to more urban areas, fewer people of all ages are getting drivers licenses, and ride-sharing services like Uber or Lyft are on the rise.  In the not-too-distant future, personal ownership of cars may become passe, and much of our lives will be experienced virtually.

We've designed our communities around the car-crazy culture of the 2nd half of the 20th century, but we're now into the 21st century.  We need to rethink what that means for those communities, including but by no means limited to parking lots.

Healthcare has a lot of parking lots -- both literally and figuratively. 

Start with the literal.  All those health care facilities and all those medical office buildings, come with parking.  They have the same problem as the malls and other retail establishments; parking is built for worse-case scenarios, leaving those parking lots often significantly underutilized.  The costs for all that parking, of course, gets built into what we pay for care.

More troubling are the figurative parking lots.  Let's start with the easy one: waiting rooms.  There's almost no one who has had a healthcare encounter who doesn't have their own waiting room story.  The problem is both that we spend too much space on them, and that we make people spend too much time in them. 

Or my favorite example, hospitals.  They are huge capital sink holes, often far from full, and too often housing patients who, with some creative effort, could well be taken care of at home or in the community.  We need to rethink our concept of a "hospital" for the 21st century, not build more of them, much less more parking lots for them. 

Then there is telehealth.  It remains a hot topic, even if currently not widely used (as a recent special Health Affairs highlighted).  That's not going to remain true.  At some point -- as Kaiser Permanente has shown possible -- a majority of visits will be done virtually. 

We need to be planning for a healthcare system where a majority of health care happens virtually or delivered at home, rather than happening in healthcare facilities.  Those parking lots, those waiting rooms, and those hospitals are going to look awfully deserted. 

Urban planners and developers are starting to realize they need to plan for a world that needs less parking.  It will be a big shift, and won't happen overnight, but it will happen. 

Similarly, healthcare executives need to be planning for a healthcare system in which care is delivered very differently -- and where "care" itself will be redefined.  It will also be a big shift, won't happen overnight, but it, too, will happen.

Parking may be the least of healthcare's worries.

The Empire Strikes Back

It seems deeply ironic that a week after I wrote about how even giant companies eventually get surpassed, I'm writing about the resurgence of one such giant, Microsoft.  Last week Microsoft won back the title of world's most valuable company (as measured by market cap), passing Apple.  Apple had that distinction since 2012; Microsoft hasn't had it since 2002.

Admittedly, Microsoft was only able to pass Apple because a recent tech stock downturn dropped Apple from its record trillion dollar valuation, and, as of this writing, Apple has pulled back in front again, but the fact that it is a race again says a lot about Microsoft.

The moral of the story may be that big can stay big, but not by sticking to the same things or doing them in the same way.  Healthcare, pay attention.

CEO Satya Nadella is helping Microsoft fight back.  Credit: Business Insider

Apple was always the cool kid (especially post-iPods), while Microsoft was the nerd.  Apple was the charismatic Steve Jobs; Microsoft was Bill Gates, the King Geek himself.  Apple was elegant, integrated hardware/software, Microsoft was all-too-often kudgy software.

Google "Tech Big 4" and you'll most likely get Alphabet, Amazon, Apple, and Facebook.  Wall Street tends to focus on the stocks of FAANG -- Facebook, Amazon, Apple, Netflix, Google (Alphabet).  People in healthcare and in tech like to speculate endlessly about what Amazon, Apple, and Alphabet might do in healthcare (Prime Health, anyone?). 

Microsoft often seems like an afterthought, if thought of at all.

It's true that Microsoft has had its share of blunders.  It was famously late to the Internet; even now, its browser has less than a 3% market share.  It failed with its phone. then blundered even worse with its acquisition of Nokia.   Or there were failed products like Zune, Vista, MSN Watch, and Microsoft Bob, to name a few.

Still, once Satya Nadella became CEO in 2014, things have changed.  Its stock has tripled under his leadership.  Its cloud business is a strong second to Amazon.  Office has gone from a licensing model to a more attractive-to-investors subscription model (Office 365).  Its Xbox line is a $10b business, is growing rapidly, and an area in which Microsoft will continue to invest "aggressively."

It now makes its own hardware -- the Surface line of PCs, laptops, and tablets (which, by the way, started under prior CEO Steve Ballmer) -- that have generated largely position, sometimes rave reviews.  Surface is now a billion dollar business.

Microsoft has also made some key acquisitions, such as open source leader GitHub this year, business networking site Linkedin in 2016, and video game Minecraft in 2014.  Mr. Nadella preaches: "We need to be insatiable in our desire to learn from the outside and bring that learning into Microsoft."  

Meanwhile, its foray into virtual reality/augmented reality -- Hololens -- hasn't necessarily generated a lot of revenue yet, but it has generated a lot of buzz, including a just-announced $480 million contract with the U.S. Army.  More benignly, Hololens is also being used to guide surgeons. build cars, and train medical students (see video below):

As two of the Hololens examples illustrate, Microsoft is paying a lot of attention to health.  HealthVault, the personal health record it introduced over a decade ago, never quite gained traction, and Microsoft shut down its HealthVault Insights app earlier this year, although the platform itself remains.  

More significantly, in 2017 Microsoft launched Healthcare NExT, which it described as:

a new initiative to dramatically transform health care, will deeply integrate greenfield research and health technology product development, as well as establish a new model at Microsoft for strategic health industry partnerships

Healthcare NExT -- which is now just Microsoft Healthcare -- is betting big on the use of artificial intelligence (AI), through its Microsoft AI in Health Partner Alliance. and cloud computing.  One of their current areas of focus is using "executable biology," such as to combat cancer. 

Their collaborations include the Fred Hutchinson Cancer Center, St. Jude Children's Research Hospital, Adaptive Biotechnologies, the University of Pittsburgh Medical Center, and the British Columbia Cancer Agency in Canada.

Peter Lee, the head of the unit, described to Medscape his approach:

But when you think about doing that, the first question you ask yourself is, 'What right do we have to exist in healthcare at all?' And it's not uncommon for big companies to do that with maybe even some arrogance. So it's important to be grounded, and I would put it this way and ask the question, if Microsoft disappeared today, what potential would be lost for the healthcare world?

Good questions for any company thinking of getting into healthcare -- and for ones in it now.

Microsoft could have coasted along for a long time on Windows and Office, but they didn't.  They weren't even under Mr. Gates (Xbox) and Mr. Ballmer (Skype).  But its bets are really starting to pay off under Mr. Nadella. 

For tech or other companies thinking of getting into healthcare, I'd advise that they think long and hard about Dr. Lee's rubric: if you didn't get in healthcare, what potential would be lost?  E.g., would healthcare really miss what you might bring?  If you aren't sure, or if it is strictly a revenue grab, please -- stay away. 

For companies already in healthcare, I'd advise that they learn from Microsoft's own story: it's not enough to double down on what you are already doing.  You have to be willing to take risks, place some big bets, in areas that are not in your traditional areas of competency.  Some of them may -- no, will -- fail, but you have to try nonetheless.  The sure bet is that your future is probably not going to be defined by what you are doing today. 

If Microsoft can successfully reinvent itself, maybe there is hope for healthcare organizations as well.

The Big Get Bigger, Until They Don't

You may have missed it, but the Open Markets Institute released a report on what it calls "America's Concentration Crisis."  The report begins bluntly: "Monopoly power is all around us: as consumers, business owners, employees, entrepreneurs, and citizens."  As David Leonhardt wrote in his op-ed about the report, "The federal government, under presidents of both parties, has largely surrendered to monopoly power."

Their associated data set details market concentration within 32 industries, several of which are health related.  For example, in electronic health record systems, the top 3 firms account for 58% of the market, whereas in pharmacies/drugstores, the top 3 control 67% (and the top 2 alone have 61% share). 

This shouldn't come as a surprise by anyone who pays even minimal attention to healthcare, yet here we are. 

Credit: Federal Reserve Bank of Minneapolis

Perhaps due to the available data, Open Markets Institute did not look at hospitals, physicians, payors, or pharma, but a few months ago, Lindsay Resnick, writing in Becker's Healthcare, warned that we should "get ready for a future of rampant healthcare consolidation."  He cited the following:

• Five for-profit insurers now control 43% of the market. 
• More than 60% of community hospitals belong to a health system
• Less than half of physicians own part of a private practice. 
• Vertical integration mergers and acquisition deals topped $175 billion in 2017.

Even more telling, earlier this year the Commonwealth Fund released a report about market concentration of healthcare providers and health insurers, and found that 43% of markets were "super concentrated" for providers and another 47% were "highly concentrated."  For insurers, 55% of markets were highly concentrated and 37% were moderately concentrated. 

Credit: Commonwealth Fund

The argument is always that such consolidation leads to great efficiencies and more ability to reduce unnecessary care, but as far as I know, the research to support such claims does not exist.  To the contrary, study after study has found that consolidation almost always to higher prices and increased spending. 

The New York Times recently commissioned its own study on the matter, and found that: "The mergers have essentially banished competition and raised prices for hospital admissions in most cases."  In the 25 markets it studied, prices went up from 11% to 54%.  As one expert told them, "The puzzling part for many of us in the state is why anyone would allow these oligopolies to form."

Mr. Leonhardt and the Open Markets Institute could explain it.

Mr. Leonhardt attributes both income stagnation and a decline in entrepreneurship at least in part to what he calls this "corporate gigantism," and Dave Chase, among others, has been preaching for years that, specifically, out-of-control health care costs have been robbing workers of wages for years.   

We don't have an Alphabet, Amazon, Apple, Facebook or Microsoft in healthcare -- yet -- but, left unchecked, it's only a matter of time before local/regional monopolies become national ones.  

It would be easy to get discouraged about this trend, but the ever-optimistic John Nostra, writing in Psychology Today,  points out: "Giants are meant to die." He cites the work of Professor Mark Perry, who looked at the Fortune 500 in 1955 and again in 2017, and found that 88% of the ones in 1955 did not make the latter list.  Some had gone bankrupt, some had merged/been acquired, and some were just were no longer big enough to qualify.  Professor Perry refers to this as "Schumpeterian creative destruction."

Professor Perry sees this as a "positive sign of the dynamism and innovation that characterizes a vibrant consumer-oriented market economy, and that dynamic turnover is speeding up in today’s hyper-competitive global economy."  Mr. Nostra is similarly encouraged, noting: "The early movers in a marketplace can often become the dominant player, but commonly, they are also the ones who stumble."

It wouldn't seem that time-honored institutions like hospitals, physicians, pharmaceutical companies or health insurers are "early movers," but it may just be a matter of perspective.  It may be that our medical model of "health care" is the early mover, and will be replaced by other models that do not value those as highly. 

As I've written previously, healthcare's "monoculture of thought" limits its ability to come up with truly new ideas and approaches, thus creating opportunities for outsiders.

Take what's happening in banking.  Traditional banking is a huge industry, also time-honored and increasingly concentrated, but it is being challenged by "neo-banks" -- typically digital only enterprises without a bank charter.  Accenture says 19% of financial institutions in the U.S. are considered new entrants, largely what they term "digital disruptors."  The New York Times reports that U.S. neobanks received four times as much venture capital so far in 2018 as they did all last year, and ten times as much as in 2015. 

Credit: Australian FinTech

Chime, for example, has 2 million accounts and is adding more customers per month than Wells Fargo or Citibank.  Neobanks in other countries, including Australia, Britain and China, are moving even faster. 

World Finance asserts that the 2008 global financial crisis led to a wave of anger towards, and lack of trust in, traditional banks that has created the opportunity for neobanks.  Even so, though, "they will need to offer a positive alternative of their own that is more convenient, more secure and cheaper than what is currently available."

I don't know what healthcare's "neobanks" are going to be (for that matter, the financial services industry isn't yet sure what its own neobanks are really going to be).  Perhaps they will be AI personal health assistants or 3D printed-at-home prescription drugs.   Perhaps they will be something someone is still sketching out the idea for.  Perhaps we won't even recognize them as being such at first. 

If consumers' anger towards and lack of trust in an industry creates opportunities for outsiders, then healthcare certainly is ripe, perhaps even more than financial services.  We're going to see more market consolidation in healthcare before we see effective challenges to it...but we will see them.  Even giants die. 

Healthcare does have a concentration crisis, but that creates opportunities for the right challengers.  Who will they be? 

It's MY Data...I Think

Data privacy is hotter than ever.  We're all mad/upset/concerned about what tech giants like Amazon, Facebook and Google are doing with our data.  Indeed, a new Harris Poll found that data privacy (65%) tops our list of pressing social issues -- ahead of healthcare, supporting vets, or even job creation -- while we're pretty critical about how well companies are dealing with it.

It has been a few months since I've written about data privacy, but it's not out of lack of interest or because it's not important.  Neither is true.  It's that, the more I think about it, the more I wonder if we even understand the real issues. 

There has been a lot happening with controlling our own data.  In Europe, for example, GDPR was put into place in May 2018.  Is is one of the broadest attempts to restrict what data is collected about us and how it is used, but it doesn't fundamentally change who is collecting and using our data. 

Some are going further.  Hu-manity.co, for example, has asserted ownership of our data as the "31st human right," declaring:  "Everyone has the right to legal ownership of their inherent human data as property."  

The concept of data as property, and the corollary that we have the unique right to own that property, is a novel one that flies against the industries that have grown up around using us as the product.  Co-founder and CEO Richie Etwaru told TechCrunch: "We’re starting with the idea that your data is your digital property, and we are allowing you to have the equivalent of a title, like you have for your car."  

They've got a nifty app -- #My31 -- that uses smart contracts on blockchain to help manage this property, and are partnering with IBM's Blockchain Platform to achieve this.  Health data is one of their first areas of focus, in part because there are clear customers for such data; they estimate an individual's health data alone might be worth $200 - $400.

Then there is Health Wizz.  As reported by FierceHealthcare, they want to help consumers collect their health information in a "central, virtual depository," then be able to sell it to interested buyers like pharmaceutical companies.  They also use a blockchain approach to manage the data and any payments. 

Health Wizz will screen buyers, to help ensure that consumers know exactly how their data will be used, although consumers can sell it off-platform too.  People will have to be careful about who has their health data because protections like HIPAA primarily apply to health providers and health plans -- not, for example, to Facebook or Google.

In the interests of time, I won't go into other (blockchain-based) patient-controlled health data approaches like Citizen Health,  Gem, HealthBank, Iryo, Patientory,  Timicoin, or YouBase, any one of which deserves its own discussion.  Clearly, there is something happening here.

Some are skeptical about consumers taking control of their own data.  For example, Niam Yaraghi, a Fellow at Brookings, argues that data from an individual "has very limited value before processing. It is the aggregation, merging, and analyses of such data that creates value."  I.e., a lot of little data is needed before Big Data can produce value.

Moreover, he adds, "even if one could successfully assess the fair value of patients’ data, distributing the fair share of profits to patients would require a sophisticated tracking and accounting system," which would eat into any profits that might be shared with those individuals. 

Let's assume, though, that my data is my property, that I control it, and even that there are entities which would pay me for it.  The question I have is: what is "my" data?

Many would think about, say, the data gathered at physician visits or hospital stays.  It might include my vitals, my prescriptions, my diagnoses/symptoms, lab values, and any procedures or tests.  Those feel like data that are "mine," as they are about my health.

But they are also about the healthcare provider(s) who were involved.  The data is a record of things they've done, things they've observed, things they've recommended.  That's why healthcare providers feel such a sense of ownership about them, and why this kind of data is used in medical reviews and/or malpractice suits.  The providers aren't going to give up their "ownership" without a fight. 

Or take data gathered by a wearable, including smartphones.  Yes, it is a record about me, but is also a record of what the wearable was doing, and potentially how well it did that.  The manufacturer might argue that it has a "right" to that data as well, such as to ensure proper operation. 

Similarly, when I buy something on Amazon, Amazon, any third party vendors, and my credit card company all view that transaction as data involving them, to which they should have rights, if only as a business record.

Even a uniquely personal data like my DNA is not solely my own, now that "familial" DNA can be used to identify relatives, such as ones involved in a crime.  Yes, it's data about me, but it is also data that is also about others related to me. 

So what data, exactly, belongs solely to me?  If I want to collect and potentially sell it, who has competing interests to it that need to be considered? 

There is no question that many privacy laws are woefully outdated, especially HIPAA.  Most were engaged in a pre-Internet, pre-smartphone, pre-IoT, pre-Big Data time.  All those need to be considered in any updates to those laws.  GDPR is probably about as good as we have, but even it makes assumptions that I'm not sure are entirely valid. 

Data may be less like a piece of physical property than it is like the atmosphere.  I live in it, I partake of it, and I contribute to it, but it's hard to really say what piece of it is "mine." 

I don't have any answers to these issues, and I wish all these data start-ups success, but I suspect we're going to need a 21st century re-conceptualization of "data" before we can really come to grips with ownership of it.

Too Much Stupid Stuff

Melinda Ashton, M.D., has a great article in NEJM: Getting Rid of Stupid Stuff.   It describes a program her health system (Hawaii Pacific Health) undertook to do exactly that, with some promising results. 

That sounds like something everything in healthcare should put at the top of their priority list. 

The impetus of their program was to address the issue of burnout, specifically around documentation burdens.  Their EHR had been in place for 10 years, and they reasoned that some tasks might no longer be necessary or appropriate.  So, starting October 2017, they asked all employees to nominate anything in their EHR that was "poorly designed, unnecessary, or just plain stupid."

If that sounds unusually blunt, credit Dr. Ashton.  She explained to FierceHealthcare:  

We were going to call it ‘administrative simplification’ for a while and I sort of pushed back and said, 'You know, I really think we need to be clear on this.'  I just had a sense that calling it stupid stuff was going to resonate better.  

Dr. Ashton and her team reminded employees that: "Stupid is in the eye of the beholder. Everything that we might now call stupid was thought to be a good idea at some point.”  Fair enough.  They expected nominations to be in three categories:

• unintended documentation that could easily be eliminated;
• documentation that was needed but that could be collected more efficiently;
• documentation that needed better training to accomplish.

They ended up getting nominations in all three categories, and have already implemented a number of changes, as well as eliminating 10 of the most frequent 12 physicians alerts, because they were just being ignored.  Interesting to them, but not surprising to me, they got more nominations from nurses than from physicians.  

Credit: NEJM, Melinda Ashton MD

The program has now been extended beyond just documentation and beyond just the EHR because, as Dr. Ashton writes: "It appears that there is stupid stuff all around us."

Boy, put that one on our healthcare system's tombstone.  

It would be easy but short-sighted to take healthcare's collective frustration out on EHRs.  Many clinicians feel like EHRs were forced upon them, not designed for their ease, and ended up taking time and attention from actual patient care.  Nor have their fulfilled their promise of making patient records easily accessible across providers, improving care by more quickly identifying previous issues and reducing duplicate treatments.  

But let's not kid ourselves: EHRs are not the stupidest thing we have in healthcare.  EHRs may, in fact, be the smartest stupid thing healthcare has done, because at least there are significant upsides to having EHRs, even if we're not achieving them yet.  There are plenty of things we do in healthcare that are just plain stupid.

Admit it: if you work in healthcare, you see stupid stuff every day.  Some are things imposed on you from external sources, and some are things required by your own organization.  

As Dr. Ashton cautioned, some may have been a good idea at some point.  Some may never have been a good idea.  Some are things that just keep getting done simply because of habit/ tradition/rules.  Some are stupid things that someone, somewhere, still thinks is a good idea but, when push comes to shoving patient care, aren't. 

They're still stupid, and should be stopped. 

Maybe your healthcare organization has a process for taking suggestions (from employees and/or patients), but I'd question how often that results in changes that ease some of the worst pain points.  I love what Dr. Ashton and the team at Hawaii Pacific Health are doing, and think every healthcare organization undertake a similar effort to stop doing stupid stuff.  

That hard part won't be finding the stupid stuff: the hard parts are getting people to speak up about them, and making the changes needed to actually get rid of them.  Many stupid things are inter-organizational rather than intra-organizational, which makes it harder -- but not impossible -- to change them.  

A few months ago I wrote that healthcare should learn from Dan Gingiss and "do simple better," because "in healthcare we make the simple complicated, we make fast slow, and we make fun at best boring and worst scary."  I urged that we should strive to make healthcare simple, or at least simpler.  I still believe that, but now I think that before we do even that we should work to make it less stupid.  

We'll probably find that doing the one will help accomplish the other.

The program at Hawaii Pacific Health as aimed primarily at reducing daily frustrations for its employees, but we need to go much further.  These kinds of programs need to attack daily frustrations for all stakeholders, and especially for patients.  

If you are a healthcare leader, start a program like this.  If you work in a healthcare organization, advocate for one until your leadership puts one in.  If you are a patient or family member of one, don't wait for a formal program from the healthcare organizations you interact with; speak up about the stupid stuff you see and have to deal with, and make sure your thoughts get to those organizations' leadership.   

It's stupid to accept stupid stuff, especially with something as valuable as our health at stake.

In the meantime, if you want to report stupid stuff in healthcare, put it on the comments below, or on one of the threads about this article on Twitter, or on posts about it on Linkedin and/or Facebook.  It probably won't get it fixed, not right away, but we can at least get more of the stupid stuff out in the open.  

The Business of Healthcare Is Business

Hmm, that headline doesn't seem right, does it?  I mean, shouldn't the business of healthcare be, well, health?  Or, at least, caring?  Actually, shouldn't the business of healthcare be patients?  After all, everyone in healthcare says it's all about patients.  Everyone says they're patient-centered, whatever that means. 

But think about this: who in healthcare gets paid for you to be healthy?  Or, conversely, who in healthcare doesn't get paid when you get sick, or when you don't improve under their care?

Whether we planned it or not, whether we admit it or not, or whether we like it or not, our healthcare system is a business that has become about making money. 

We have a healthcare system that is like a bizarro world.  It operates unlike any other business, treating its supposed customers like second class citizens while violating most laws of economics that apply to other industries.

Let's look at a few recent examples:

• Kaiser Health News reported on a $48,000 allergy test.  The patient's insurer "negotiated" it down to a mere $11,000, leaving her with more than $3,000 to pay out of pocket.  As one billing expert told KHN, "That charge is astronomical and nuts."  The patient expressed her confusion: "No one cut into me. No one gave me anesthesia. I had partly open plastic containers filled with fluid taped to my back."  
• Denver's 9News reported on how patients are going in for what they assume will be in-network surgeries, and coming out with liens placed on their houses due to bills from out-of-network physicians involved in their care.  This despite Colorado having a law that is supposed to prevent balance billing.  As one patient -- no, let's call him what he is: one victim -- told 9News: "This whole system is crazy.  You have insurance. You have an emergency. It should be taken care of.”
• "Non-profit" hospitals continue to claim the benefits of that status, but often don't act like it.  As health economist Gerald Anderson told NBC News: "The tenor and the responsibility of hospital CEOs has now changed over time.  They focus on the bottom line and … they get performance ratings based on profitability."  
• Pharma keeps raising prices and coming up with new, always-more-expensive drugs.  Novartis, for example, is talking about a one-time dose for a gene therapy that they think is worth $4 million.  There are already other drugs that cost near $1 million a year.
• Yet another study confirmed that "serious illness often means financial disaster for Americans."   For example, nearly half of cancer patients spend their life savings in the first two years of treatment.  No wonder, then, that medical bills now account for 1/3 of GoFundMe campaigns.  
• The chief medical officer for the American Cancer Society just resigned in protest to some of the (lucrative) partnerships it has formed with businesses like Herbalife, Long John Silver's, or Tilted Kilt.  ACS is far from the only advocacy group with ties to companies with dubious health credentials, and KHN found that patient advocacy groups also take millions in from pharma.  

I could go on and on, but Elizabeth Rosenthal's An American Sickness covers this ground at greater length (and with greater eloquence). 

Bottom line: Healthcare. Should. Be. Embarrassed. 

Jesse Tinsley / The Spokesman-Review

Still, though, I would be remiss if I didn't include an example of  how technology fails in healthcare, as again reported by Kaiser Health News.  It seems that Epic, the largest EHR vendor, can't even handle the switch to/from daylight savings time. 

As one RAND researcher told KHN: "It’s mind-boggling.  We expect electronics to handle something as simple as a time change. Nobody is surprised by daylight savings time. They have years to prep. Only, surprise, it hasn’t been fixed."

No wonder, as Atul Gawande wrote in The New Yorker, 

Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Many believe they're so bad because they're neither about physicians nor patients, but about billing.  As seems all-too-usual in healthcare, it comes down to the money, not the care.

And, yet, we seem to want the healthcare system, bizarro though it may be, to take on ever greater responsibility.  Dhruv Khullar, MD, wonders if we've "medicalized everyday life," He worries: "But we may also be medicalizing much of normal human behavior — labeling the healthy as diseased, and exposing them to undue risk of stigma, testing and treatment."  

Dr, Khullar concludes:

More fundamentally, we need to reconsider where the upper and lower bounds of diagnosis should be. Many experts believe the pendulum has swung too far, such that much of normal human behavior now falls within treatment thresholds. This reassessment is particularly important because those with mild or borderline symptoms may be less likely to benefit from treatment than those with more severe symptoms.

It shouldn't come as a surprise, then, that an article in BMJ asks if "lifestyle medicine" should be a new medical specialty, or that we talk about getting "prescriptions" for exercise.  "Exercise for Medicine" is an actual initiative.  Honestly, should we really need a prescription for exercise, and should our lifestyle be under the purview of our doctor? 

Credit: American College of Lifestyle Medicine

Where is the line between our life and our medical care?  Who should be making money off of it -- and how? 

Healthcare is slow-walking its way to outcome-based payments and value-based purchasing, but we don't really know what either of those are and we're not really anywhere near ready to put anyone at major risk for them.  Let's be realistic about what they might accomplish, and when.

Look, I don't mind that healthcare is a business, or that people and organizations make money in it, even large amounts of money.  What I do mind is how we're treated by that business, and how little we seem to know about what we are buying with all that care it delivers. 

It's time -- way past time -- for the business, and the business model, to be about our being healthy, not about paying for what happens to us when we are not.