Time Really Can Be Money

If you are not an IKEA fan, or haven't been spending any time in Dubai, you may have missed the chain's marketing campaign to help promote its second store in the area.  Titled "Buy With Your Time," customers got store credits for how long they spent getting to the store.

Gosh, that's something that should make any self-respecting critic of the U.S. healthcare system perk up.  Count me as intrigued.

The campaign involved checking the customer's Google Maps' Trip tab to determine how long it took them to get to the store.  IKEA benchmarked the average hourly wage in Dubai, and converted the travel time into how much credit they'd generated.  It works out to about $29/hour, or $0.48 per minute.  Spend long enough getting there and you could get a free coffee table or even a bookcase.  Prices in the store include the equivalent time currency.

An IKEA spokesperson explained:

Before the birth of this campaign, we realized two things: time is precious today, and many loyal IKEA customers spend a significant chunk of it visiting our locations, which are sometimes away from the city center.  We think it’s only right to reward our customers’ efforts by repaying them for the time spent reaching us. It’s our way of helping the Dubai community make the most of every minute.

 It is believed to be the first time a retailer is letting customers use their time as a means of payment.

The campaign depends, of course, on Google Maps' ability to track users' movements, and for customers to allow IKEA to use that data.  On the other hand,  Google is tracking those movements anyway, so the least we should get for that tracking are some free meatballs.

Jason Aten, writing in Inc., was impressed:

I think the promotion is brilliant--even if it is just a marketing campaign to promote a new store. Any time you can turn one of your biggest challenges into a win for your customer, that's still a win. And it's also a very creative use of technology.

Simon Chandler was more skeptical, warning in Forbes: "the promotion is another step towards normalizing the idea that it's okay to be watched wherever we go so long as we receive 'free stuff' in exchange."  Still, he concedes: "this promotion opens the door to a significant and profound change in how consumers purchase goods, and in how they relate to brands."

The program seems to have been a success:

I love this campaign for a couple reasons.  One is the concept that it recognizes that, yes, our time is valuable, and not just in a lip service sort of way.  The second is that "money" is a broader, more elusive, concept than the formal forms of currency that we usually use.

Healthcare should be thinking about both of those.

Travel is often not a prime consideration in healthcare, with medical tourism and centers of excellence still not achieving mainstream status.  We like our healthcare local, failing to recognize that, for most of us, local is far from the best care we could get.  But what if, taking a page from Ikea's campaign, the time we spend traveling to -- and taking off work for -- sources of higher quality care translated into credits that we could use to pay for that care?

More important than travel time is the waiting.  I have railed before about how the healthcare system often treats our time almost contemptuously.  As I put it previously, we wait to get appointments, we wait at appointments, we wait during appointments, we wait for results after appointments, and, if we're in a hospital or nursing home, we spend most of our time waiting.  Plus, of course, we spend inordinate amounts of time enrolling in our health insurance plan, waiting for claims payments, and, should you ever need it, on hold in customer service queues. 

Healthcare should be valuing the time we spend in the system waiting for something to happen.  Some parts of the healthcare system seem to track and report waiting time -- e.g., urgent care centers or emergency departments come to mind -- but they don't seem to do much with that information.  E.g., a three hour wait at an emergency room doesn't give you any credit off the big bill you'll get for that experience.  

The healthcare system values the time of the people and things in it, not the people using it.  Imagine how the incentives would be different if our time cost them money.   Note, for example, Nicos Savva and Tolga Tezcan propose in HBR that payments for emergency room visits be tied directly to wait times.

We shouldn't just be looking at giving wait times monetary value, but also explicitly valuing the kinds of behavior that keep us out of the healthcare system.  This has been the goal of "wellness programs" for several decades, despite near-universal evaluations from objective observers (e.g., Rand or Song and Baicker) that they are not really effective.  

It boils down to the fact that we have an illness system, not a system of health, and so all the monetary rewards revolve around dealing with how we treat those illnesses.  In the ideal health-oriented system of the future, payment should be oriented to activities and people who keep us healthy, or return us to the best health most effectively.  

Imagine instead of paying health insurance premiums we accrue credits for our good health behaviors, which can be redeemed when we need some sort of intervention to maintain or improve our health.  Ikea couldn't have done its campaign without Google Maps, and we're getting close to the kind of 24/7 tracking options that would allow for us to determine and manage such credits.  

The problem will be that no existing entities in the healthcare system are really equipped (or incented) to administer such an approach, opening the door to new types of market entrants.  Maybe we should ask the people at IKEA...

IKEA's effort may just have been a clever gimmick to promote a new store in an isolated location, but there are lessons to be learned from it nonetheless.  As Mr. Aten suggested, turning pain points for the customer into a win for the customer is, in fact, a win.  If there is something that we can all agree on, it is that healthcare has too many pain points for its customers.  The question is: how can we turn them into wins for those customers?  

Who's in YOUR Supply Chain?

Tesla is now, by market cap, the second largest auto manufacturer (after Toyota).  Its market cap exceeds U.S. auto makers Ford, G.M., and Fiat/Chrysler -- combined.  This despite selling less than 400,000 vehicles in 2019, a figure that is more than the prior two years combined.  

Tesla has made its bet on the future of electric cars.  It didn't invent them.  It isn't the only auto manufacturer selling them.  But, as The Wall Street Journal recently said:

Investors increasingly see the future of the car as electric—even if most car buyers haven’t yet. And lately, those investors are placing bets on Tesla Inc. to bring about that future versus auto makers with deeper pockets and generations of experience.

 A recent analysis suggested a big reason why, and its findings should give those in healthcare some pause.  Tesla's advantage may come, in large part, from its supply chain.

Nikkei Business Publications did the analysis, a "teardown" of Tesla's Model 3, the cheapest car in Tesla's lineup.   The teardown found that Tesla's integrated central control unit -- aka, its "self driving computer" -- had capabilities that were six years ahead of the rest of the industry.  That's six years ahead of auto manufacturers with long histories, huge research departments, and millions of vehicles sold, not to mention sizeable investments in their own electric vehicles.

Nikkei quoted a "stunned" engineer from a Japanese rival who examined the computer: "We cannot do it."   

Tesla integrated central control unit.  Credit: Nikkei xTech

The engineer admitted that technological hurdles were not the reason for the gap, but, rather, the automakers' concern "that computers like Tesla's will render obsolete the parts supply chains they have cultivated over decades."

Tesla's computer required fewer electronic control units (ECUs) than other manufacturers.  If those manufacturers followed suit, it would drastically impact their suppliers of those units.  As Nikkei put it: 

So big automakers apparently feel obliged to continue using complicated webs of dozens of ECUs, while we only found a few in the Model 3. Put another way, the supply chains that have helped today's auto giants grow are now beginning to hamper their ability to innovate.

Tesla developed its integrated central control unit itself, and Nikkei found that to be part of a pattern: 

"Most parts inside the Model 3 do not bear the name of a supplier. Instead, many have the Tesla logo...This suggests the company maintains tight control over the development of almost all key technologies in the car."

And, of course, Tesla updates its software "over the air," giving existing models the advantages that traditional auto manufacturers might have required buyers to purchase a new vehicle to benefit from.  

In other words, no one knows.

Brian Johnson, a Barclay's analyst, has suggested that the market is acting as though Tesla will be the "sole winner" in the shift to electric vehicles (although he also has warned Tesla may be overvalued).  Another analyst, Adam Jonas of Morgan Stanley, wrote: "If Tesla proves to be profitable…we think this removes one of the biggest impediments for why legacy [auto makers] were hesitant to go ‘all in’ on EVs."  

Tesla didn't have existing vehicle models to build from.  It didn't have legacy technologies.  Nor did it have millions of vehicles, hundreds of thousands of employees, or scores of existing suppliers.  For better and for worse -- and Tesla's journey has encompassed both -- it started essentially from scratch, and bet big on its sole objective, rather than hedging its bets across numerous markets using varied technologies.

Last fall, Nathan Furr, a professor at INSEAD, called Tesla's strategy "brilliant."  He pointed out:

...a long research tradition underscores that when incumbents face a new technology architecture, they struggle to understand and adapt...

Although incumbents may imitate the new architecture, they have a hard time overcoming the way they have done things in the past and to match the superior performance of the new, purpose-built architecture...

It’s always the little things that get in the way – such as the fact that most vehicles built by other manufacturers have up to five separate software systems rather than a single integrated system like a Tesla, which gives a performance advantage.

Professor Furr believes Tesla is competing at a high risk, high reward, system level, not a product level:

The truth is that consumers don’t want products, they want solutions. Most car makers deliver products. But Tesla tries to deliver a complete experience: car, upgrades, charging, insurance – the whole bundle.

Meanwhile, of course, healthcare is the industry that still relies on the fax and CD long after most other industries have moved on, that views sharing data as anti-competitive, that finds disclosing prices (or quality results) too difficult, and that literally uses a still-in-use 200 year-old technology (the stethoscope) as its symbol. 

And yet...

In healthcare hospitals, doctors, and pharmaceutical companies account for essentially the same shares of spending that they've had for at least fifty years, old school vendors Epic and Cerner dominate the EHR market, and healthcare is patting itself on the back for efforts to "reinvent" primary care and to deliver "digital health." 

It's always the little things that get in the way... 

Healthcare is different, pundits claim.  Health care depends on the doctor-patient relationship, they preach.  Healthcare is maddeningly complex, full of visible and invisible middlemen, they complain.  Health care must "first, do no harm," making innovation both harder and for higher stakes, they warn. 

Maybe. 

But healthcare also seems to rely on doing more things to more people for more money, without necessarily ensuring that the results are worth it.  Lots of people are making money in healthcare, and they like it that way.  There is ongoing debate about what portion of our spending is unnecessary, how much of our care is ineffective at best and harmful at worst, or how many of us suffer or even die from medical errors.  But whatever the exact numbers, most people would agree that each is too high. 

Who in healthcare is six years ahead of the rest of the industry, in anything?  Who in healthcare is less concerned about disrupting its existing supply chains of healthcare professionals, facilities, and manufacturers, and more concerned about patients' experiences and outcomes?  Who is inventing and delivering "new, purpose-built architecture"? 

Tesla may be wrong.  We may never go fully to electric vehicles.  Self-driving vehicles may be a pipe dream.  Its build-it-here approach may blow up or might never prove profitable.  But, gosh, you have to love the chutzpah, and how it is moving the huge auto industry. 

Where's healthcare's Tesla? 

Healthcare Has a Moral Injury

The term "moral injury" is a term originally applied to soldiers as a way to help explain PTSD and, more recently, to physicians as a way to help explain physician burnout.  The concept is that moral injury is what can happen to people when "perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." 

I think healthcare generally has a bad case of moral injury. 

Maria Fabrizio for KHN

How else can we explain physicians practicing surprise billing, hospitals suing patients, health plans refusing to pay for pre-authorized treatments, or pharmaceutical companies charging "skyrocketing" costs even for common, essential prescription drugs?  There are people involved in each of these, and countless more examples.  If those people haven't suffered a moral injury as a result, it's hard to understand why. 

Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians.  One physician decried how "the real priority is speed and money and not our patients’ care."  Another made a broader charge: "The health system is not set up to help patients. It’s set up to make money."  He urged that physicians seek to understand: "how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right."

David Oliver, a British physician, has an example of doing that: hospital gowns.  In The BMJ, he argues that "there's no dignity in hospital gowns," noting:

There are sometimes entirely legitimate reasons for using gowns—for example, in critical care or surgery or for some imaging or interventional procedures, where easy access to the whole body is vital. But that’s not the case for most patients for most of their stay. Yet still we use the gowns, or we keep people wearing them well beyond that immediate need.

 Dr. Oliver compares the process of being admitted to the hospital to being jailed -- "people having their possessions bagged up and being forced into standard prison clothing, symbolising the transition from citizen to inmate" -- and pleads "we surely want patients recovering from acute illness or surgery to spend more time in day clothes and shoes to help them regain their independence."

He doesn't want physicians to be part of this moral injury, urging: "Most of all, we as health professionals should be asking why people are wearing them at all."

U.K. physicians have, as a result, launched a #downwiththegown movement, urging the NHS "to put dignity first, and stop humiliating patients at a time when they are vulnerable."  That sounds like something that shouldn't just be limited to hospital gowns, nor only to the U.K.  

In other words, stop inflicting moral injuries on the people who work in healthcare, and start treating the people who receive care with more empathy and in more ways that allow them maintain their dignity.

There are, for example, more dignified hospital gowns available, but they have not become the norm.  Dr. Bridget Duffy, who had been the Cleveland Clinic's first Chief Experience Officer, explained why to NPR two years ago: "Hospitals are not designed for patients."

Think about that: hospitals are not designed for patients.  No wonder what happens to patients in them, and in other healthcare settings, result in moral injuries to the people working in them.  No wonder people receiving care continue to suffer various indignities.

Let's not get caught up in gowns alone.  For example, a new study found that twenty percent of commercially insured people who underwent elective surgeries ended up with surprise bills.  These are patients who have chosen their surgeon, chosen their hospital, yet are still stuck with out-of-network bills, most commonly from anesthesiologists and surgical assistants.

As Karen Pollitz of the Kaiser Family Foundation told Olga Khazan of The Atlantic, "you don’t pick these people. You don’t know them,  You learn their name when the bill comes," referring also to pathologists and radiologists.  

Dr. Karan Chhabra, the lead author of the new study, lamented to Ms. Khazan: "The way we set the system up is really putting patients last.”  In other words, in ways that end up generating moral injury to well-intentioned people.  

Or in the case of those pesky retrospective denials of pre-certificated care, Martha Grimes, director of the Center for Patient Partnerships, asks: "How broken can you get?  How much more laid bare can it be that our health care insurance system is not about health, nor caring, but just for profit?"  It would be hard for anyone involved in issuing those denial to not suffer moral injuries.

And, of course, anyone involved in suing or sending to collections patients who can't pay their share of healthcare charges, no matter how outrageous, must be suffering moral injuries, or must not have a conscience.  

Estimates are that as many as 50% of physicians experience burnout symptoms, and given all of the above and more, I don't understand why it isn't higher.  And I suspect it is at least as prevalent for others working in healthcare.  

If our healthcare system can't even give vulnerable patients something better than the traditional hospital gown, much less refrain from hounding them for money when they are still recovering, well, it has lost its way.  We as patients shouldn't stand for it, and the people working in it should no longer be complicit in the practices it has resulted in.  

Things don't always go well with health care.  Sometimes people don't get better, treatments don't work, mistakes are even made.  We should always, though, seek to allow patients their dignity.  At the very least, we should not allow practices that inflict moral injury to those involved in them.

If we're not careful, our healthcare system's moral injury could prove mortal.

For Your Eyeballs Only

There's so much going on.  There's the coronavirus: It's now a pandemic!  China can build an entire hospital to treat coronavirus patients in under two weeks!  Or there's primary care: One Medical's IPO boomed!  Amazon, Humana and Walmart are testing their versions!  People are flocking away from primary care!  Or, on a completely unrelated note, Tesla wants to disrupt auto insurance too.

As interesting as all those are, it's augmented reality (AR) that I want to talk about.

Bosch smart glasses display Credit: Bosch

Stop thinking about Snap Spectacles or Pokémon Go as what you think of when you think about AR.  Stop thinking about the supposed failure of Google Glass.  Start thinking about AR being ingrained in our daily lives.

Facebook CEO Mark Zuckerberg believes "at some point in the 2020s, we will get breakthrough augmented reality glasses that will redefine our relationship with technology."  He went on to elaborate:

Instead of having devices that take us away from the people around us, the next platform will help us be more present with each other and will help the technology get out of the way. Even though some of the early devices seem clunky, I think these will be the most human and social technology platforms anyone has built yet.

Not surprising, Facebook is rumored to be working, in conjunction with Luxottica, on its own (AR) smart glasses project -- code name Orion -- that is expected to become available sometime between 2023 and 2025.  CNBC reported: "The glasses would allow users to take calls, show information to users in a small display and live-stream their vantage point to their social media friends and followers," and have an accompanying A.I. voice assistant.

Apple's Tim Cook agrees.  "I'm excited about AR," Cook said, reports Silicon Republic. "My view is it's the next big thing, and it will pervade our entire lives."  Apple's AR headset is expected to launch as early as this year.  Bloomberg reports: "The glasses are expected to synchronize with a wearer’s iPhone to display things such as texts, emails, maps, and games over the user’s field of vision."

Samsung is also expected to launch AR smart glasses this year, among others, and, of course, Google Glass never really went away, just changed focus.

But what excited me lately about AR was a report from CES 2020 by Evan Ackerman about what Bosch is doing.  Instead of projecting the AR on a screen or in front of you, it "paints an image directly onto your retina."

Now we're talking.

Here's the Bosch promotional video, featuring a number of interesting use cases:

Mr. Ackerman was fitted with a customized set of smart glasses, as is necessary, and marveled:

It’s definitely true that for the first 10 or so minutes of wearing the glasses, your brain will be spending a lot of time trying to figure out just what the heck is going on. But after that, it just works, and you stop thinking about it (or that’s how it went for me, anyway.) This is just an experience that you and your brain need to have together, and it’ll all make sense.

Bosch is reportedly less interested in producing consumer products itself than in licensing its Smartglasses Light Drive to other manufacturers as "a complete, ready-to-use solution for smaller, lighter, more stylish smartglasses."  Mr. Ackerman says "The earliest any such product might be available would likely be 2021. The light drive technology is not inherently super expensive, though, so any consumer smart glasses made with it should be available at a cost comparable to (or cheaper than) other smart glasses systems." 

Because the image is projected directly into your retina, it is always in focus and works under all lighting conditions.  Others not only can't see what you are seeing but wouldn't even know you are seeing anything at all. 

We've all experienced being with people who can't tear their eyes away from their smartphone or other screen.  It is often particularly felt in the healthcare setting, where patients often feel that their physician spends more time looking at the EHR than they do looking at them, and physician burnout is often tied directly to all that screen time.  

The Bosch approach could at least diminish the patient perception, even if physicians are still looking at other information as they talk to them.  

Tim Cook, for one, think this is something AR can help with.  "I think it’s something that doesn’t isolate people," he said. "We can use it to enhance our discussion, not substitute it for human connection, which I’ve always deeply worried about in some of the other technologies."  And he is "extremely excited" about tech helping healthcare, noting: "I’m seeing that this intersection has not yet been explored very well."

A survey by E-Commerce Times found that only 12% of consumers (actually, heads of U.S. household that have broadband) consider themselves "familiar" with AR, although that is true of a quarter of Millennials and a third of Gen Z households.  Despite the low current familiarity, more than 60% expressed interest in getting information via AR.

Right now, consumers still think of AR as through smartphones, but as smart glasses get both sleeker and smarter, that should change.  I'll go a step or two further: just as I've long viewed smartphone and other physical screens as transitional, in a world of ubiquitous computing I believe that even smart glasses are transitional. How what devices might be "painting our eyeballs" in such a world, I don't know, but I'm sure that in twenty or thirty years we won't all need to be wearing physical smart glasses. 

Healthcare is usually late to technology innovations.  It kept paper-based business records long after other industries, it continues to fail on sharing/transmitting customer information, and usability is often at best an afterthought.  It is dipping its toe into both AR and VR, with some experts predicting AR will grow much faster over the next ten years, but in the case of AR I hope healthcare is a leader, or at least a very fast follower, instead of a laggard. 

Don't blink or AR might pass healthcare by. 

Towards a Quantum Theory of Health

We're pretty proud of modern medicine.  We've accumulated a very intricate understanding of how our body works, what can go wrong with it, and what are options are for tinkering with it to improve its health.  We've got all sorts of tests, treatments, and pills for it, with more on the way all the time.

However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along. 

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don't have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We're fooled into thinking our macro view of the universe is true, but our perceptions are wrong. 

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health. 

Two articles in Science illustrate how we're still just scratching our understanding of their impact.  The first, from Rodrigo Pérez Ortega, reports on two new studies.

The first study found that the genetic structure of gut microbiome was more predictive of health than one's own genes.  It was especially better for "complex" diseases that are attributed to both environmental and genetic factors.  Gut microbes are impacted sooner by environmental factors and thus serve as better predictors for such diseases.

The second study found that a person's microbiome could be used to predict their death 15 years later.  Presence of a certain family of bacteria led to a 15% higher mortality rate in the next 15 years.  Whether the bacteria are the cause of the mortality or a side effect of other factors is not clear.

Credit: Finlay, et. al, Science Magazine

The second article was a study from B.B. Finlay, et. alia, that speculated that so-called non-communicable diseases (NCD) might actually be communicable, via the microbiome.  I.e., "we propose that some NCDs could have a microbial component and, if so, might be communicable via the microbiota."

The authors looked at obesity, Type 2 diabetes, cardiovascular disease, and inflammatory bowel disease as possible examples.  "These observations suggest that the microbiota could be a causal and transmissible element in certain diseases that have been traditionally classified as NCDs," the authors conclude, further noting: "Additionally, only gut bacteria have been considered in this discussion, yet viruses and fungi may also contribute to NCDs, as well as microbiota at other body sites such as the skin and oral cavity."

Their paper concludes:

These findings could serve as a solid framework for microbiome profiling in clinical risk prediction, paving the way towards clinical applications of human microbiome sequencing aimed at prediction, prevention, and treatment of disease.

Dr. Finlay says: "If our hypothesis is proven correct, it will rewrite the entire book on public health."

Microbiome researcher Samuel Minot, PhD, who was not involved in the studies, is told Mr. Ortega, "I am hopeful and enthusiastic that the community will reach a point where we’re able to develop microbiome-based therapeutics and diagnostics.  I think that this is within the realm of possibility." 

Professor Harry Sokol of the Paris Center for Microbiome Medicine agreed, telling Gut Microbiota for Health: "I am convinced that some microbiome-based tests will become biomarkers in many clinical situations in the future."  

There is much work going on in the field.  For example, The Cleveland Clinic has the Center for Microbiome and Human Health, the Mayo Clinic has the Microbiome Program, Stanford has the Stanford Microbiome Therapies Initiative, UCSF has the Benoff Center for Microbiome Medicine, the University of Pittsburgh has the Center for Medicine and the Microbiome, and the University of Wisconsin has the Center for Microbiome Sciences & Therapeutics.

Still, it is too early to get overly excited.   Everyone agrees more research is necessary.  Timothy Caulfield, the Research Director of the Health Law Institute at the University of Alberta, warns: "Gut hype is everywhere."  He acknowledges that this is an exciting field with great promise, but cautions "it is still early days for microbiome research." 

Think of modern medicine, with its germ theory of disease and its understanding of our body's biomechanics, as classical physics.  See a germ, kill a germ.  Monitor our bodily functions, test our blood, even sequence our genes; all the answers lie within us.  Newton would approve.

Our recent discoveries about our microbiota are upending our notions about what disease is, what causes it, and how we should best deal with it.  Our supposed precision in medicine is illusionary. Heisenberg would understand. 

Credit: KATERYNA KON/SCIENCE PHOTO LIBRARY, VIA GETTY IMAGES

Modern medicine loves its antibiotics, despite the devastating impact they wreak on our microbiome.  It is fascinated with our genome, despite the fact that our microbiota's genes greatly outweigh our own, and have more diversity.  Our microbiota change in ways that we don't understand and, as yet, can't even really track, much less predict the effect of.  

We need the equivalent of a quantum theory of health. 

I don't mean literally applying quantum physics to healthcare, although, of course, we are a collection of quantum bits.  I mean recognizing that our human-centric picture of health is much too narrow, and fails to predict what actually drives our health.  I mean admitting that "our" health is really a consequence of "their" health, and that only figuring out how to incorporate both will yield us a true picture of health. 

Modern medicine is in the stage physics was in the early part of the 20th century, when the concept of quanta was known but the consequences of it were yet to be discovered.  Physics struggled for many years to accept quantum theory, and medicine will have a similar struggle to accept whatever the theory that fully incorporates microbiota will be. 

Modern medicine has had its Newtons, maybe even its Einsteins, but now it needs a new generation of scientists to develop more accurate theories of our health, no matter how counter-intuitive they might be. 

Welcome to a quantum theory of health.

Your Wealth Is Your Health

We've been spending a lot of time these past few years debating healthcare reform.  First the Affordable Care Act was debated, passed, implemented, and almost continuously litigated since.  Lately the concept of Medicare For All, or variations on it, has been the hot policy debate.  Other smaller but still important issues like high prescription drug prices or surprise billing have also received significant attention.

As worthy as these all are, a new study suggests that focusing on them may be missing the point.  If we're not addressing wealth disparities, we're unlikely to address health disparities. 

It has been well documented that there are considerable health disparities in the U.S., attributable to socioeconomic status, race/ethnicity, gender, even geography, among other factors.  Few would deny that they exist.  Many policy experts and politicians seem to believe that if we could simply increase health insurance coverage, we could go a long way to addressing these disparities, since coverage should reduce financial burdens that may be serving as barriers to care that may be contributing to them.

Universal coverage may well be a good goal for many reasons, but we should temper our expectations about what it might achieve in terms of leveling the health playing field.

The new study, by Paola Zaninotto, PhD, et. alia, in The Journals of Gerontology "examined socioeconomic inequalities in disability-free life expectancy."  It compared cohorts from England and the U.S., looking not just at life expectancy but also how healthy those lives were, as measured by presence of disability -- the "disability-free" life expectancy.  Long study short:

people in the poorest group could expect to live seven to nine fewer years without disability than those in the richest group at the age of 50.  

The study looked at men versus women, at different ages, by disability level and wealth status.  Most importantly, it compared results for those in England versus the U.S.  The authors found that: "we showed that within each country, there was a consistent advantage for people in high socioeconomic groups, particularly for wealth and education, so that they could expect to live a higher number of years without disability."  

Source: Zaninotto, et. alia, The Journals of Gerontology

Dr. Zaninotto told Yahoo:

We were not surprised.  In fact, the reason for looking at wealth and not income is that we know how important a socioeconomic indicator it is. This measure of wealth is based on housing, savings, investments — something that takes a long time to accumulate. It’s a measure of past and present circumstances.

Still, when it came to the similarities between the two countries, Dr. Zaninotto admitted: "It was surprising to find that the inequalities are exactly the same."  

It was surprising because, unlike the U.S., England does have universal coverage.  The National Health Service provides access to care to everyone, without financial burdens.  There may (or may not) be access issues with the NHS, but they are not, for the most part, financially-driven.  And yet the differences of the impact of wealth on health between the two countries are similar.

One could speculate that the wealthy in England are somehow buying their way into better care -- perhaps jetting off to Switzerland or even the U.S. -- but that is unlikely to account for those seven to nine extra years of disability-free life they are getting.  

It's about the money.  

There has been much furor about the obesity crisis in the U.S., with the childhood obesity crisis presenting a ticking time bomb for future health care problems.  Same for diabetes.  But what we're not paying enough attention to is that a wealth crisis is looming for younger people as well, which the new findings suggest will result in major health implications.  

Economist Gary Kimbrough has been studying the upcoming wealth gap, with some alarming results:

Millennials are way poorer than previous generations at their age, burdened by student debt and stagnant wages.  Christopher Ingraham, writing in the Washington Post, warns:

It’s a hole they’ll never truly be able to dig out of, given the way that money draws other money to itself via the gravitational pull of compound interest: The less money you start out with, the less you’ll make during the rest of your life.

 Some argue that it will all be OK, they'll eventually inherit significant wealth from their parents --"the Great Wealth Transfer" -- but that assumes that those parents won't end up spending that inheritance on their own health care and other financial needs. 

Equally as worrisome, it ignores the adverse health impacts that the reduced wealth is already having on their health.  Lack of wealth is not the only hole that you may never be able to dig out of; poor health is at least as hard. 

Dr. Zaninotto thinks the results should be a call to action, telling Yahoo: 

We really think this inequality should be addressed much earlier in life.  When people are older, you can’t give them an education — it really should start much earlier in life. It’s looking at improving opportunities across community and education much earlier and trying to help younger people to buy a house. It seems it is quite important.  

The U.S. could, and should, move to universal coverage.  It is the right thing to do.  We could, and should, find ways to lower costs, both for coverage and for care.  It is the right thing to do.  But we shouldn't expect that those actions would level the unequal playing field that wealth creates.  

We need to address affordable housing.  We need to reduce student debt burdens.  We need to ensure people are paid living wages.  We need to provide parents with affordable child care options, such as  day care, preschool, after-school programs.  

Arguably, these are more important than universal coverage, or at least their long-term impacts on health will be greater.  

We can't, and shouldn't, try to equalize wealth.  That's not what America is about, and not what most Americans want.  But there are some aspects of life where wealth should make less of a difference.  It shouldn't determine opportunity, and, as these findings suggest it does, it shouldn't dictate health.    

Healthcare Might Look Good in Plaid

I don't really follow FinTech -- I can't even keep up with HealthTech! -- but it caught my eye when Visa announced that it was acquiring FinTech company Plaid for $5.3b; a 2018 funding round valued the company at $2.65b.  A 100% increase in valuation within a year suggests that something important is going on, or at least that people think something is.  

I suspect there may be some lessons for healthcare in there somewhere.  

For those of you who are equally as unfamiliar with FinTech's terrain, Plaid has been described as the "plumbing" that supports many other FinTech companies.  Launched in 2013, one in four people with a U.S. bank account are now believed to use Plaid to connect with 2,600 FinTech developers connected to more than 11,000 financial institutions.  Its customers include Acorns, Betterment, Chime, Coinbase, Gemini, Robinhood, Transferwise, and Venmo.  Plaid claims it connects with 200 million consumer accounts.  

What terrifies Visa and rival Mastercard is that the future may be less card (credit/debit)-centric.  In 2015, only 18% of internet-connected consumers worldwide had used a FinTech app to move money; in 2018 75% had.  Plaid is one of the services that allow for such movement.  

Rival Mastercard hasn't been sitting idly; it had previously acquired FinTech companies VocaLink for $1b in 2016 and Nets for $3.2b in 2019, and had been an investor in Plaid.  It has been trying to describe itself as a "multi-rails payment company."

In a call with analysts, Visa CEO Al Kelly admitted:  

We are increasingly trying to move from being strictly focused on payments, to being focused on the movement of funds for any purpose around the world.  As big as Visa is in terms of the bank accounts that we can reach, we’re not as big as we need to be if we want to be a formidable player in money movement around the world.

Techcrunch says that what Plaid's APIs do "is akin to what Stripe does for payments, but instead of facilitating payments, it helps developers share banking and other financial information more easily."  It adds that, with the acquisition, Visa "now has a view into scads of high-growth, private companies that are reinventing the world in which Visa operates. Buying Plaid is insurance against disruption for Visa, and also a way to know who to buy."

CEO Mr. Kelly praised the acquisition, noting: "Plaid opens up new market opportunities by significantly expanding Visa’s network capabilities.”  Mr. Kelly predicted that the acquisition would "expand a new financial data network” and  add “new growth in core, as we work more closely with fintechs."  

Similarly, Visa President Ryan McInerney told Fortune:  "Fintechs are clearly reshaping financial services, and Plaid is unquestionably the leader in this space...It’s something that positions Visa for the next decade and beyond."  

Meanwhile, healthcare struggles to share our data even between healthcare institutions using the same platforms, can't seem to uniquely identify us, and is always trying to figure out who to chase for how much payment.  It's slow, inefficient, inaccurate, and very expensive.  

There are companies like Noyo that are trying to change that.  It describes itself as "modern architecture for health insurance," and "the first API integration platform for health insurance."  Crunchbase even went so far as to say Noyo is "a sort of Plaid for health insurance data," which Noyo liked so much that it quotes that description on its home page.  

Founded in 2017 by veterans of troubled benefit software company Zenefits, Noyo has raised $4 million, and is still in the early stages of partnerships with carriers.  Similar to Plaid's strategy, Crunchbase said "Noyo wants its service to become a platform upon which other companies can build, but it doesn’t want to write all the apps."  

Healthcare doesn't talk much about platforms, or at least it didn't until the Mayo Clinic made a splash this past December by hiring the well-known health tech guru John Halamka, MD, as president of the Mayo Clinic Platform.  Mayo describes its platform as "a strategic initiative to improve health care through insights and knowledge derived from data. The technology platform will elevate Mayo Clinic to a global leadership position within digital health care."

Mayo just announced its first platform initiative, the Clinical Analytics Data Platform, "a strategic initiative to improve health care through insights and knowledge derived from data."  As part of the announcement, Dr.Halamka said: 

Platform business models have been a force of disruption in many sectors, and the rapid digitalization of health care is affording us an unprecedented opportunity to solve complex medical problems and improve lives of people on a global scale

Mayo is certainly thinking globally, and it recognizes the opportunities that digital health affords, but I'm not sure that either it or the rest of healthcare see the threats, and opportunities, that platform models present.  I'm not even sure that many in healthcare even understand what "platforms" in healthcare might look like, Noyo notwithstanding.  

There certainly don't seem to be many established healthcare companies that are as determined to be part of disruption in the same way that Visa and Mastercard are.  

Credit/debit cards are well-entrenched in most consumers' lives, especially in developed countries.  Mastercard and Visa are huge, profitable, and seemingly indispensable.  Despite that, FinTech solutions have sprung up to reach more consumers and reduce dependencies on networks like Visa and Mastercard.  They're not waiting to be toppled; they're buying "insurance against disruption."

Healthcare has a data problem.  It is too fragmented, too siloed, too complicated, and too difficult to use and to move.  Its volume is growing exponentially, with more types coming from more sources.  At the same time, more of the payment burden is falling directly on consumers, and they're not happy about it.  

In other words, it is ripe for disruption.  

Disruption in healthcare won't be easy, and it won't come quickly.  Then again, credit/debit cards aren't going away anytime soon either, but Visa and Mastercard are preparing for a future in which they might, or at least in which their role is greatly diminished.  

Healthcare organizations better start buying insurance for disruption that doesn't look much like the current system.  The platforms are coming.