The Thirty Years Perspective

Thirty years is a long time.  I was reminded of that by two things: the 30th anniversary of Tim Berners-Lee conceiving the World Wide Web (March 12.1989), and a new report from the Pew Research Center asking Americans about our country in 2050.  Thinking about the former helps me think about the latter.

They make me wonder about healthcare in 2050.

Let's start with the birth of the World Wide Web.  The internet existed, but it was not widely dispersed.  Services like Compuserve or Prodigy gave glimpses of what online life might look like in the future, although dial-up speeds and the closed nature of those communities limited those glimpses.  Tim Berners-Lee (and a few others) imagined a different future, and, amazingly, his scribbled diagram came to fruition.

Tim Berners-Lee original sketch.  Source: w3.org

If you were alive in 1989, would you have expected that by 2019 you could always be in contact with almost anyone, find out almost any fact, read or watch almost any content, and buy almost anything?   Most of us would probably have to say no.

It certainly is no exaggeration that the advent of the World Wide Web, spurred by broadband and mobile, has greatly impacted the lives of most of the people in the world. 

What I find most striking is to think about the changes in largest companies in the world, and how the World Wide Web helped bring them about.  Back in 1989, 7 of the top 10 companies were Japanese, and most of those were banks.  As of the end of 2018, 5 of the 10 largest companies by market cap were internet-based companies -- Alibaba, Alphabet, Amazon, Facebook, and Tencent -- started after 1989 (and, in most cases, after 1999), while another two of the top 5 -- Apple and Microsoft -- used it to greatly boost their size. 

A new technology changed the landscape of our lives, and our economy. 

-------

Let's turn now to the Pew report.  It would seem that Americans don't have high hopes for our country's future.  For example:

• 87% are worried our political leaders won't be up to solving our biggest problems;
• 60% think America will be less important in the world;
• 73% think the gap between rich and poor will grow;
• 72% think older Americans will be less prepared financially for retirement;
• 65% think we'll be more politically divided;
• 59% think the environment will be worse;
• 44% think the average families' standard of living will get worse (only 20% think it will be better).  

We look to science and technology (87%) and education (75%) to help us solve our problems, but we don't list spending on science as a very high priority (34%) and about three-quarters worry about the quality of public education.  In other words, we'll need other countries -- or magic -- to help us. 

When it comes to healthcare, 58% think it will be less affordable in 2050.  Providing "high quality, affordable health care to all" is by far our top priority (68%) to improve the quality of life for future generations, although we aren't very confident we will. 

----------

Using the lessons of the last 30 years, here are a few predictions about the next 30 years:

New technology: As much as we worry about the size and influence of today's Big Tech, it is very likely that few, if any, of them will be the largest corporations in 2050.  Pick almost any thirty year period and it is amazing how much that list changes from beginning to end.

Some new technology will come along to revamp our economy.  Many of the new corporate leaders will use it.  Moreover, that technology probably exists, in formative or early stage development, right now.  The hard part is figuring out which one it will be, and the second hardest part is predicting how that technology will be adopted.

Healthcare system:  Thirty years ago we did not have universal healthcare.  Thirty years ago the biggest types of health care spending were on hospitals, physicians, and prescription drugs.  Today we still do not have universal healthcare, although ACA put a dent in the number of uninsured, and the biggest types of healthcare spending remain hospitals, physicians, and prescription drugs. 

A healthcare encounter today looks very much like a healthcare encounter of thirty years ago, although with more electronics -- and much more expensive. 

Given the level of political polarization, and our lack of faith it will get any better, I don't have much confidence that we'll have achieved universal coverage even by 2050.  That healthcare encounter, though, is something we should hope will radically change. 

Rethinking health:  Pouring more money into our current healthcare system is not likely to make us healthier.  Spending more on the traditional sources of care is not going to revamp our care or when we need it.  If we're still going to the hospital, going to a doctor's office, or taking a prescription drug in 2050 at anywhere near the rates we do in 2019, then we will have failed.

What we need are technologies that change the healthcare economy in the way the World Wide Web changed the global economy from 1989 to 2019.  Technologies that bring new entrants, doing new things.  Those technologies and the things that are done with them may be aimed directly at our health, or may just have better health as a nice side effect.

Credit: body>data>space

For example, the new health technology might revolve around the fusion of biology and electronics.  That might include the so-called "Internet of the Body," using DNA for data storage and computing, and cell-sized robots and devices. 

These kinds of technologies already exist; it just remains to see what we can do with them.

------

In 2050, I hope that healthcare is a much smaller portion of our economy.  I hope that by then we focus more on maintaining health than we do having the healthcare system fix health issues.  I hope that the next Facebook or Google or Apple has something to do with our health, in a way that delights us and on which we'll gladly spend our own money. 

What technology or technologies would make our current healthcare system seem as old-fashioned as the pre-World Wide Web world? 

Blurred Lines

You probably heard about the 6 year-old boy in Oregon who got tetanus after getting a cut; he hadn't had the recommended tetanus shot because his family did not believe in vaccinations.  He ended up having to be hospitalized for almost two months, racking up a bill of over $800,000.  His parents allowed the first round of the tetanus vaccine while he was in the hospital, but not the second round, nor any of other recommended vaccinations. 

Many people's response was "that poor kid," with many others thinking "those parents should be ashamed."  Me, I'm more cynical; my first thought was: hmm, I wonder who is paying that bill. 

That particular case actually happened in 2017, but was only recently reported by the CDC.  It comes at a time when the anti-vaxx movement has never been so widespread, nor as outspoken.  The United States is having measles outbreaks -- in 2019! -- such as the ones in Washington.  Those cases are tied to a tight knit community of Eastern European immigrants, who have very low rates of vaccination.  But, as the chart below from Vox illustrates, it's not now, it's not just them, and it's not just there.

As of March 14, there are 2019 outbreaks in 15 states: Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Michigan, Missouri, New Hampshire, New Jersey, New York, Oregon, Texas, and Washington.  This for a disease that was declared eliminated in the U.S. in 2000. 

It'd be easy to believe that the anti-vaxx movement is driven by religious objections or poor education, but it is way past that.  The beliefs that vaccines can cause autism have propagated widely, and now there are people who believe that getting measles can, at worst, be cured by antibiotics (measles is a virus) or, at best, that getting it can help prevent cancer. 

Seriously. 

People not letting their children get vaccinated not only put those children at risk, but others as well.  Schools can try to limit exposure by banning children without vaccinations from attending, but can also expect lawsuits.  There are, unfortunately, also reports of anti-vaxxers being vicious in their condemnation of those who follow the vaccine recommendations. 

What I am not clear on is who the anti-vaxx movement thinks should pay if someone in their family do end up with one of the diseases those vaccinations would have helped protect them against.  Unless they are in a community like the Amish that don't typically turn to insurance, I suspect they still expect their health insurance to assume most of the costs. 

That's something other people in that insurance pool might have some feelings about. 

It's easy to talk about holding anti-vaxxers accountable for not believing in vaccinations, but let's not stop there.  If we think we've got a measles outbreak, we have a far worse flu outbreak.  It's in more states, with more deaths, from more age groups.

There is a flu vaccine, but, as is usually true, it's effectiveness is not high.  The current one is estimated at about 47%, making getting it kind of a crap shoot.  Perhaps that is why rates of flu vaccination are fairly low -- for 2017- 2018 it was estimated at 37%. 

Should we similarly criticize people who don't get the flu vaccine? 

If we want to take this further, there are all sorts of personal responsibility we could hold people accountable for.  Are they getting their recommended preventive exams and screenings?  Are they following a recommended diet?  Do they get the recommended levels of sleep and exercise? 

If we're going to pick on anti-vaxxers for not following vaccine recommendations, we should be asking when we cross the same line for other recommendations. 

It doesn't help that it is often hard to know what the right recommendations are.  Eggs are bad for you...no, good...no, bad again.   Do 150 minutes a week of moderate exercise, or 75 minutes of vigorous exercise, or maybe just a few minutes of intense exercise.  Get an annual preventive exam...oh, maybe not.  Men should get PSA tests...umm, that's not so clear.  Women over 40 should get regular mammograms; really, who knows? 

The fact is that the basis for many of these recommendations is not as clear-cut as one might expect, nor do U.S. guidelines always agree with guidelines in other developed countries. 

If you are a smoker, it is permissible for your health plan to require higher premiums.  Employers are allowed to take that concept further, giving people who participate in the wellness program as much as a thirty percent discount in their premiums (which amounts, of course, to a 43% penalty for those who do not). 

Neither, though, impacts the level of coverage you get.  Fair?  To whom?

No wonder we usually just throw up our hands and agree to share in the costs even for people who (we don't think) are not doing all they could to maintain or improve their health.  Those anti-vaxxers are not as far out of the mainstream as we might like to think. 

There are lines here somewhere, but they're awfully blurred.  Not everyone who doesn't get a measles vaccination gets measles.  Not everyone who doesn't get a tetanus shot gets tetanus.  But, then, not everyone who smokes gets lung cancer, not everyone who is overweight gets diabetes, and not everyone who doesn't exercise has heart attacks. 

One line we could draw is whether your behavior is likely to impact others' health as well -- and whether it can be clearly shown that your doing/not doing something causes a clear risk to them.  E.g., measles and flu seem different -- the measles vaccine is close to 100% effective, the measles closer to 50/50, and measles is much more contagious than the flu.

But even that line is still arbitrary, and the step to financial responsibility is a big one. 

The thing is, we're going to be in a position to know.  Apple Watches, wearables, information from social media, etc. are going to track our behaviors, and Big Data is going to tell us what impact they have on our health.  It would be an natural next step to start expecting to hold people accountable for what they are doing, or not doing, to manage their health. 

It just won't be easy.

We shouldn't ignore the issue of financial consequences of personal responsibility, but knowing how and where to draw those lines is going to be difficult.

Let's Just Stay In

The Wall Street Journal has a fascinating series on "The Delivery Wars," which I'll get to shortly, but what makes me most interested in it is a concept I'd not previously heard of: virtual restaurants.

There will be a tie-in of both to healthcare, I promise.

Now what, for heaven sakes, is a virtual restaurant?  It's not, as you might guess, a restaurant in a videogame or virtual reality simulation where you might pretend to eat.   It's not even a restaurant making use of augmented reality (although those probably do exist).  It's not a place you go to eat, or where you go at all.

They are restaurants, and they do cook food, but they exist to support food delivery services, whose users don't really care where they are or if they also serve food to in-restaurant patrons.  NBC News recently profiled how Uber Eats using data on their users to identify what virtual restaurants are likely to be possible:

This is not actually a new concept.  You can find articles discussing it two years ago, and by November 2017 Mashable reported that DoorDash, Grubhub, and Uber Eats all were featuring virtual restaurants.  A virtual restaurant chain named the Green Summit Group started in 2013 and got a $1 million investment from GrubHub in early 2017.

By last fall Uber Eats had 1,600 virtual restaurant partners worldwide, according to Eater.  Jason Drodge, the head of Uber Eats, described them to Eater as follows: "They’re restaurant brands located in physical restaurants. And the brand only exists on Uber Eats," adding that they "don’t compete with their in-store menu, and so it can be completely incremental to whatever they’re doing in-store."

Restaurant delivery services are becoming the tail that wags the dog.  If valued alone, Uber Eats would supposedly be worth $20b, while Grubhub and DoorDash are each valued at around $7b.  WSJ says Grubhub has 105,000 restaurant partners.  They predict the online takeout ordering market will triple by 2022, to some $21b, and reach $31b by 2025.  Another estimate puts the growth as going from the current $25b to $62b in 2022.

Keep this in mind: a third of all "restaurant" meals are now eaten at home. 

It's not only food from restaurants, of course.  Online grocery services are predicted to go from $17b in 2017 to $86b in 2022.  John Mulligan. Target's COO, had this to say to the WSJ about such services: "From a pure relevance standpoint, you have to figure it out, because that’s how shoppers are going to interact with you."

Both restaurants and grocery chains are relying primarily on third party vendors, such as Grubhub for restaurants and Instacart for grocers.  

In something that healthcare would recognize well, the delivery services are seeking to find, and help create, "super-users," who use their services regularly, even daily.  WSJ says: 

Food-delivery companies instead need high-frequency, repeat customers—driven by force of habit at least as much as by bargains—as rivals race to amass the widest possible user base before focusing on making each individual order profitable

It's all about the data.  Who lives where, what their dining preferences are, how to maximize choices and minimize delivery time.  Get that right, then you win more users and start making them super-users.  Get that right, and you can persuade restaurant owners to create virtual restaurants.  Get that right, and all those growth figures look not only possible but perhaps even conservative.  

Meanwhile, healthcare...

Healthcare has plenty of data, of course, with more on the way all the time.  Unlocking all that data from their silos and figuring out what it all might mean are challenges that are recognized and being worked on.  Big Data and A.I. are going to be the killer apps that make the data information that the healthcare system can use, hopefully to make us healthier and not just to wring more dollars from us.  

But where is the healthcare app that is collecting and analyzing my health needs and preferences?  Where is the healthcare app that is using the data to ensure I have the right sets of services nearby, even helping healthcare professionals and organizations create new types of services in order to meet them? 

In other words, where are healthcare's virtual restaurants?

I'm not just talking about more use of virtual care, although my feelings on that are well documented.  I'm talking more broadly about data-driven products and services to target our specific needs and preferences, where and how we live.  It's happening for restaurants, it's happening for grocery stores, it's happening for online shopping, it's happening for streaming content services.  Where it is not happening, to any meaningful extent, is for healthcare. 

How do we match our individual health needs with the right services and the right professionals, in the right places at the right times? 

When it comes to our health and our healthcare, we like convenience.  We like choices.  We like affordability.  We like quick service.  We like high quality.  But we can't order those up, not like we can our favorite meals.  Some would say, of course not, that's like comparing apples and oranges (or, rather, apples and stethoscopes), but is that reality, or just tradition?

The NBC News report mentioned the issue of how virtual restaurants will ensure that healthy choices are offered along with people's less healthy preferences, and at least that is something Uber Eats and others are aware of and can help address (unlike some current food deserts).  We'd have to do the same kind of balancing to do a healthcare equivalent of virtual restaurants. 

Look, I've never used a food delivery service.  I like eating in restaurants.  But when I hear about concepts like virtual restaurants, and start to understand the forces that are behind them, I get why they might work.  And I can't help but feeling there are parallels in other industries, even -- or especially -- in healthcare. 

Virtual hospitals, anyone? 

WeWork Our Way to Health

Maybe you don't work in a WeWork office setting.  Maybe you haven't ever visited one.  Maybe you haven't even heard of WeWork.  In that case, then you'll probably be surprised that this audacious real estate start-up now has a valuation close to $50b, with over 400,000 "members" in 100 cities across 27 countries (and they claim to "touch" 5 million people worldwide).  Or that their plans go well beyond their unique twist towards office sharing. 

Who in healthcare is thinking about them, and who should be worried...or intrigued?

The 2009 vision for the WeWork ecosystem, drawn by co-founder Miguel McKelvey

Earlier this year WeWork rebranded itself as The We Company, saying its "guiding mission will be to elevate the world’s consciousness."  No one should be surprised by the lofty mission; WeWork was never just about finding people and companies office space: it wanted to "help people work to make a life, not just a living." It focused on building a culture in its spaces, complete with amenities and events to help build a community among its members.

The We Company has three main divisions: WeWork, the office space sharing division; WeLive, which tries to extend the WeWork culture to residential spaces; WeGrow, an early education effort.  The Wall Street Journal reports that WeGrow stems from a personal interest of co-founder/CEO Adam Neumann, as did investments in a natural food company and a wave pool maker. 

And WeBank may be coming soon. 

They've already made more traditional real estate competitors nervous.  Fast Company reported on how several real estate companies, such as Rudin Management Company, are beefing up their tech to better match WeWork's capabilities.  Georgia Collins of head of workplace experiences for real estate firm CBRE, told Fast Company: "As we’re building smarter buildings the idea of connecting the building technology to something that is user facing is much more real and appealing."

No wonder, when people in WeWork's corporate offices wear t-shirts that say "Buildings equal data." Huh -- buildings equal data?  Archinect News says: "It’s hard to overstate how essential data is to WeWork’s operations. Specifically, architectural data."  They use this data to drive analytics to help design and create better workspaces.  

Quick show of hands: how many health systems view data from their many buildings as an asset, much less a design tool?  

Just as Starbucks was never really about the coffee but about becoming "the third place," WeWork hass been about the culture their spaces try to create.  Gideon Lewis-Kraus did a deep dive on this for The New York Times recently.  It's not just the nice coffee or the yoga classes but it's also the community manager, who acts sort of like a super-charged concierge.  He describes the "relentless sociability" that serves as powerful personal and professional networking for the tenants/members. 

Dave Fano, the head of growth for WeWork, described (to Fast Company) WeWork as "infrastructure as a service," but Mr. Lewis-Kraus sees it differently: they're selling "office culture as a service."  They are selling their "CultureOS" not just to entrepreneurs but even to larger companies trying to gain/regain that entrepreneurial spirit, and maybe help recruit younger workers. 

Credit: WeWork

That is a powerful concept, way beyond simple office sharing.  Michael Schneider writes in Inc.:  

The WeWork model is a reminder that great cultures aren't a result of forcing predetermined values to unite employees under one flag, but instead focusing on fostering an ecosystem that allows the freedom to connect with others based on their own beliefs and interests. 

Whenever I think about culture and health, I can't help but think about Steve Downs' call to "build health into the OS."  I.e., make health part of our everyday lives, not an after-thought, and use tech to help accomplish this.  I think The We Company would get this. 

Credit: Rise by We

They've already seized on wellness, going way beyond on-site yoga classes to Rise By We, whose vision they state as "drive a cultural shift towards greater well-being."  It seeks to connect where people work and live with the same kind of community its work locations foster.  Its only current location is in New York City, but we can expect more to come. 

Other health initiatives include:

• "Collaboration hubs" for the Biden Cancer Initiative, putting together cancer researchers, patients, and oncology companies.  A WeWork spokesman said: "We believe this partnership is a step toward knocking down barriers that so often prevent the sharing of important information."
• Hosting space for Parsley Health, direct primary care practice, the only medical practice WeWorks hosts.  CEO Robin Berzin, M.D., told Forbes: "WeWork heard my story about what I was trying to start with Parsley Health, believed in it and made an exception [to their policy] — it’s been awesome."

Small steps, perhaps, but big enough to suggest that the possibilities in healthcare are endless. 

So, where is the company whose platform sells a "healthy culture" as a service?  Where is the company whose platform has a CultureOS built around health and wellness?  It is not The We Company, not yet, but it could be someday, and it most definitely should be someone.

Think about when you walk into a medical office building, hospital, or other health facility.  Do you get the feeling that the people working there are happy to be there?  Do you feel the atmosphere encourages them to collaborate and network?  Do you feel that the buildings and the spaces in them are designed to encourage health and wellness?  

I didn't think so.  

Don't think about the buildings, think about what the buildings are intended to help accomplish, and how we can continuously "learn" from them to make them better.  Don't think about just housing healthcare professionals, think about enriching their professional and personal lives.  Don't think about having places to treat patients, think about them as spaces that help foster their health.

Tech has gotten big by reliance on platforms, and many have questioned where healthcare's platforms are.  The We Company may be giving a hint about what they could be.