Of Moonshots and Priorities

I was planning to do a what-I-wish-for-in-2018 post, but I saw a headline that made me wish I'd written it.  It came from a Wall Street Journal story about the woeful state of the NASA moon program.  They headlined it: "If We Can Put a Man on the Moon, Why Can't We Put a Man on the Moon?

It immediately made me think of healthcare.

The U.S. takes the whole "if we can put a man on the moon..." thing as a point of pride.  President John Kennedy put the challenge out there in 1962, at a time the U.S. appeared to be lagging the U.S.S.R. badly in the space race.  It was audacious, it was implausible, it was daring -- the kind of thing that made people love J.F.K.

Not only did we meet that challenge, but we did so within the decade, as he'd demanded.  The effort forced us to take big leaps, invent new technologies, spend lots of money, and risk many lives, including the loss of several.  But we did it.

Since then we've used that precedent to say, gosh, we're so good at meeting challenges, certainly we can accomplish anything we put our minds to. 

So we read about "moonshots" in almost every walk of life, from self-driving cars to Big Data to neural networks to nanobots, not to mention NASA's own moonshot for aviation. Alphabet's X is trying to turn innovation into a "Moonshot Factory," with a long list of bold projects. 

In healthcare, we have Joe Biden's Cancer Moonshot, Startup Health's moonshot list, IBM Watson's health data moonshot efforts, GE's digital health moonshots, among many other calls for healthcare moonshots.  We have so many moonshots we'll need more moons.

It's all very inspirational, but, it turns out, maybe we're not very good at moonshots after all. 

We did land 6 Apollo missions on the moon, but the last of those was in 1972.  We haven't even attempted a manned moon mission since then, and neither has any other country.  A small but dedicated percentage of the population now even believe the moon landing was faked.   

The WSJ article covers a report that NASA commissioned that helps explain why we're not landing anyone on the moon.  Basically, NASA's bureaucracy and contracting makes everything take too long and cost too much, even if NASA had enough money, which it doesn't.  The report calls for more public-private partnerships, to take advantage of the burgeoning private sector space efforts. 

Even Alphabet's moonshot efforts are having a fair share of crashes. 

B.F. Skinner wondered about the difficulty of improving education versus putting a man on the moon, and we just as well could ask the same question about improving healthcare.

These are things we could do.  We just don't. 

We like to believe we have the best health care system, but we don't.  Its problems are well known.  The U.S. spends too much money, mostly because our prices are insanely high compared to other countries.  We waste too much money and have too much unnecessary care. 

Our outcomes are average or worse.  Our already mediocre longevity is getting worse.   Some 28 million people still don't have health coverage, which represents the lowest level in decades but which is soon expected to get worse.  Even coverage doesn't ensure affordability.   

We continue to invent new drugs, devices, and treatments, but usually at higher and often jaw-droppingly high prices, and without always offering much incremental benefit.  We allow physicians to get payoffs -- let's be honest about this -- from those drug companies and device manufacturers.  We tout competition but are allowing both hospital and health plan markets to consolidate at unprecedented levels, despite much evidence that such efforts are only most likely to further increase costs. 

It's as though our car is speeding towards a cliff, but, instead of braking or turning away, we're hitting the accelerator.  Or, perhaps, saying we want to get to the moon but aim for the ocean. 

So, spare me the moonshots.  Spare me the big goals.  Spare me the expensive innovations.  Let's get the basics right first. 

Too much of healthcare has become like NASA.  Its processes are too slow, its organizations too bureaucratic and too inwardly focused, and everything is much, much too expensive.  Its regulations are expressed designed to keep outsiders out, to make barriers to entry high, ostensibly in the name of patient safety but, in many ways, more to preserve turf. 

The analogy to the new NASA report, which recommended public-private partnerships, might be more partnerships with non-healthcare organizations.  Amazon is the one perhaps most expected, and feared, to shake up healthcare.  Jeff Bezos, after all, is famous for saying "Your margin is my opportunity." 

As if anyone can figure out what the margins really are in healthcare, with confabulated charges, "non-profits" that aren't, padded salaries and superfluous jobs, and an array of middlemen -- think PBMs -- who add costs but not much value.  It makes the defense industry look like a hyper-competitive, transparent industry. 

The thing that made the actual moonshot successful was that, from top to bottom, the goal was clear, and shared.  In healthcare, that's almost never true.  We say it's about the patient, always about the patient, but that's hypocritical.  There are lots of goals and lots of priorities, often conflicting. 

A healthcare system that was truly about the patient would not look or perform anything like ours does -- and a true system of health would look at health first, and care as a last resort, so "patient" would never be the center. 

We would be. 

One of the hidden secrets about healthcare is that when doctors become patients, they don't tend to choose much of the care they typically give to patients, such as with end-of-life decisions.   If all care was treated that way, well, it's hard to believe we'd keep doing things the way we do now. 

Want a moonshot?  How about this: everyone working in healthcare should treat every person they deal with -- directly or indirectly -- as though they were themselves, or their parent, or their child. 

It sounds like a slogan.  It sounds too simple, and too unlikely to accomplish anything.  But so was "I'm helping put a man on the moon."

It's not about the moonshot; it's about the priorities.  Let's make this one ours.