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. 

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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. 

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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.

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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.  

Lost in the Signal

I finally got around to reading Bryan Caplan's The Case Against Education: Why the Education System Is a Waste of Time and Money.  In it, Dr. Caplan, an economic professor at George Mason University and self-avowed libertarian, argues that, aside from basic literacy and numeracy, our educational system serves less to educate and more as a way to signal to employers who might make good employees. 

Oh, boy, did this book make me think about our healthcare system. 

Credit: UCLA Health

Dr. Caplan's views on economic signaling are by no means out of the mainstream, although his application of it to education may be.  Think of it this way:

• how many of the courses you took in high school and college have actually proved useful to you in your career?
• Indeed, how much of what you learned in those courses do you still remember?

Dr. Caplan cities a raft of statistics to support his point-of-view, including ones about adults' dismal knowledge of most subjects after they graduate, how few college majors actually train many people for jobs in those fields, and even how the "learning to think/learning to learn" arguments are not well supported by data.

He believes that employers prefer people who get a college degree (or at least a high school diploma) because the degrees signal that graduates are "intelligent, conscientious, and conformist."  That is, if you are willing to endure the boredom of all those years of classrooms to the end, you're not only at least moderately smart but also are more likely to be willing to endure the tedium that their jobs will probably have.

E.g., if you are hiring and have two candidates with similar grades and courses, but one of them didn't finish a class in their senior year (and thus could not graduate) versus one who stuck it out for the diploma, how likely are you to risk hiring the dropout -- even though, in terms of what they supposedly learned in college, they were almost exactly the same?

Dr. Caplan notes from his own experience how many students search for easy courses and easy professors, and often fail to even show up for classes -- not behaviors one would do if trying to maximize their learning.  He argues that it has never been easier to find great education: you can audit classes for free at many universities, and take online classes from some of the world's best teachers.  But neither will be recognized by employers in their hiring. 

Dr. Caplan offers drastic remedies, such as cutting all government funding to education, making college more expensive, cutting most majors (he does like practical majors such as statistics or engineering), and more vocational training.  He also supports child labor, as he thinks it is better that kids at least learn how to work instead of wasting time in school.

I suspect Dr. Caplan staked out an extreme position to make a point, but that does not mean that his point doesn't have validity.  Most people would tend to support ever more spending on education -- free college for everyone! -- but, at some point, there have to be diminishing returns, and it is certainly possible that we have passed that point.  It's not like we're doing better on most measures of knowledge or skills. 

Credit: Lown Institute

We spend over a trillion dollars annually in government (federal, state, and local) support for education, which is more than we spend on defense but way less than we spend on healthcare.  As with education, most of us would probably acknowledge that healthcare is full of waste -- not just excess administration but also unnecessary/inappropriate care. 

Even worse, all that healthcare spending seems to buy us declining mortality increasing morbidity, and an array of quality outcomes that rival some third world countries.  Perhaps over-reliance on signaling is one of the reasons for this. 

For example:

Degrees: The gold standard in healthcare is the M.D. (or D.O.).  We look for it, we rely on it, we have faith in it.  And we expect physicians to spend more time in training than other countries, and spend more money on it.   

But we don't really know which medical schools (or residency programs) are better than others.  We don't know how individual physicians did in those programs.  We don't know the relationship between excellence in training and excellence in practice.   

Even worse, we don't know which physicians are good at what they do, much less who the best are.  Having a license or even board certification not only does not guarantee basic competence, it doesn't necessarily mean a physician isn't impaired, has lost their license elsewhere, or even has sexual assault charges. 

We like the degree signal so much that we're increasingly expecting nurses to have B.S.N.s (or Master's), and Ph.D.s for nurse practitioners, pharmacists, and physical therapists.   

Does any of this necessarily make healthcare professionals better?  How would we know?  Or are they just signals to reassure us?

Reputation: You know the Cleveland Clinic.  You know the Mayo Clinic.  You know the most prestigious medical institution in your region.  But you probably can't say why they are more prestigious, and they probably can't really prove that they should be.  

We base these views a lot on faith, on word of mouth, on anecdotes, on which have newer/fancier buildings, and, increasingly, on advertising.  On signals, in other words. 

Latest: We like the newest drug, even though it usually is (much) more expensive and may only offer slightly, if any, improved efficacy.  We like new tools like gamma knives or robotic surgery because, well, they are newer and must be better, expensive be damned.  We get MRIs even when CT scans or a simple X-ray might suffice.  

Given a choice between older treatments/technology or newer ones, who among us wouldn't prefer the latter, even when the latter has not demonstrated its superiority, especially in cost/benefit?  The fact that it is the latest is our signal that it must be better.

I don't go as far as Professor Caplan and say that most of our healthcare spending is wasted and should be cut, but I do think we spend more than we should, and too much on the wrong things.  We'd get a bigger bang for our buck by investing more in public health and less in direct medical care. 

We've gotten lost in healthcare's signals, and aren't focusing enough on what they're actually supposed to be telling us. 

The End of Health Insurance

Paul Tullis has an interesting article in Bloomberg about how self-driving cars might kill auto insurance "as we know it."  After all, if human error is responsible for 90% of auto accidents, and those humans are taken out of the equation, what's left to insure?

Many people don't think much about autonomous vehicles, but Mr. Tullis reports that Michelle Krause, an Accenture insurance expert, says that their impact on auto insurance "...comes up in every strategic conversation" within insurers.

It made me wonder: what would it take to kill health insurance...as we know it?

I.U. professor Rodney Parker told Mr. Tullis: "Liability is likely to migrate from the individual to the manufacturer and the licensers of the software that drives the AV."  This means that, as David Ross Keith, an MIT professor, also told Mr. Tullis: "It’s foreseeable that insurance is a much less consumer-facing industry in the future."

The experts that Mr. Tullis talked to see closer relationships between auto makers and auto insurers; as for potential mergers between the two, Ms. Krause told him "those conversations are going on as we speak."

It makes healthcare mergers like CVS-Aetna or Cigna-Express Scripts look far-sighted.  After all, UnitedHealth's non-health insurance subsidiary, Optum, has already become a powerhouse for the company. 

CVS prototype Health Hub.  Credit: CVS

Let's think about what health insurance is for:

• Averting losses: Like every other form of insurance, health insurance was originally about protecting people against unexpected, catastrophic losses.  It still serves this purpose, and should you ever have the misfortune, say, to have a premature baby or to go through a long program of cancer treatments, you'll appreciate this aspect.  
• Budgeting: Americans somehow came to expect that their health insurance should protect them even against expenses that were moderate and predictable -- most notably, preventive care.  It's not that most of us could not afford these services, we'd just rather finance them via our health insurance premiums rather than budgeting them ourselves, which is a crazily inefficient way to do so.  
• Subsidization:  ACA instituted a program to subsidize cost-sharing for lower-income people via insurer payments (although the Trump Administration has been trying to end them).   As a result, health insurance has become the de facto mechanism to transfer money for health expenses to lower-income people not on Medicaid/Medicare.

I'll take these in reverse order:

Subsidization 

Health insurance is not the right mechanism to do wealth transfers.  It's not what it is designed for, and it is not what it is good at.  Such transfers are a social problem, and should be dealt with via the tax code and/or social welfare payments (as we do, for example, with payments for food or housing).   

Budgeting

It's a failure on our healthcare system's part, that we feel we need financial incentives to get preventive services.  Either we've failed to convince people that getting such services is in their best interests, or we've been promoting services for which that case is unclear.  Neither of these is good.  

We need to stop expecting health insurance help us budget for expenses that, in any other aspect of our lives, we'd be paying for ourselves.  

Averting losses

Even if we accomplished both of the above, health insurance would still probably not look too different than it does now.  Our healthcare system would still have catastrophic expenses, and we'd be looking for protection against them.  We'd still have networks, negotiated prices, and tensions between those who deliver health care and those who pay for it.

Credit: WSJ

We have to attack the root problem, which is not just the prices, but also the costs.  Some examples of how this can happen:

Virtual care will allow us to get advice and even treatment where/when we want it, and increasing reliance on A.I. rather than human expertise will both cut direct costs and, hopefully, unnecessary treatments.  

DIY health is a trend that has promise to greatly impact costs.  Whether it is hearing aids, insulin pumps, or "biohacking," we're starting to move away from reliance on expensive solutions from traditional healthcare sources to cheaper, even home-grown solutions.  

Robots, right now, fall within the "more technology, more expensive" ethos of our current healthcare system, but that cannot last.  Robots will get smarter and more versatile, we'll get better at building them, and they'll allow us to take costs out of healthcare in the way they've taken costs out of manufacturing. 

Hospitals, are, as I've stated previously, "19th century institutions operating under 20th century business models in the 21st century."  

We need to move to a future that is not institutional.  We need to move to prevention, to addressing root causes of health problems, and to delivering more care at home and in the community.  With better real-time monitoring, we can do this cost-effectively.

Prescription drugs are one of the biggest pain points for consumer healthcare spending.  Part of this looks a lot like greed, such as seemingly exorbitant increases for previously affordable drugs (e.g., insulin), part of it is the U.S. not negotiating prices as other countries do, and part of it reflects the long pipeline for drug discovery and development.  The former two are more price issues than cost ones, but the latter one is one 21st century technology can help address.

Credit: Chemistry World

For example, we are already in the era of 3D printed prescription drugs, and this will rapidly advance, even to the point of printing your own drugs at home.  This will have huge impacts on manufacturing and distribution costs.

We are also early in the era of using artificial intelligence to aid the drug development process.  A.I. can sort through vast amounts of data to identify likely combinations and monitor side effects, among other things.  The FDA is encouraging such uses.  Novartis, for example, sees itself as a data company, according to Business Insider, seeing A.I. as its "next great tool" in drug development.  

Long story short: take the big costs out, as is possible, and the need for health insurance goes away, or greatly lessens.

We shouldn't accept the status quo; not in how care is delivered, not in how much care costs, and certainly not in how it is financed.  If auto insurers are discussing merging with automakers, Apple is thinking about its post-iPhone era, Ikea wants to become the "Amazon of furniture," and Amazon's own future may be more about cloud computing than retail, then certainly health insurers should be looking to a very different future. 

Virtual Docs.for All!

There are lots of big ideas being pushed these days, in partly reflecting the run-up to the 2020 elections.  There is the Green New Deal that aims to move the U.S.to a "secure, sustainable future," including (but by no means limited to) moving away from fossil fuels by 2030.  In healthcare, there's the evergreen "Medicare for All," which didn't secure Bernie Sanders the 2016 Democratic nomination but which is popping back up (although skeptics point out it is more like Medicaid for All). 

We'll see how either of those play out, especially with our divided, hyper-partisan elected officials, but instead I'll propose something that is potentially more achievable: let's ensure that every American -- at least, those with access to a smartphone or computer -- has access to their own virtual physician (both human and A.I.).

Baidu's Melody.  Creit: Baidu

Healthcare reform in the U.S. in recent years has tended to be about improving the number of people with health coverage (even ACA left some 27 million without coverage) or using more "value-based" payment mechanisms, which have yet to really shake-up our fee-for-service system.

We are a long way from getting consensus on covering everyone, or on revamping the methodologies for the incomes of all healthcare professionals/organizations, but virtual care for everyone is something we can achieve now, at a reasonable cost.

Andy Kessler, writing in The Wall Street Journal, says "it's time to fire your doctor!"  He lists many of the ways consumers can use technology to track their own health, as well as seek medical advice through "several smartphone-based platforms now function like Uber for doctors."  (He is quick to note though, that when you're really sick you'll still want a specialist).

Mr. Kessler points out: "Doctors don’t scale, so the real future of medicine is digital diagnosis...The revolution is coming.  But not from your doctor."  

Credit: Accenture

A.I. has been looming for healthcare for a few years now, with uneven results.  Babylon Health, for example, pitched its chatbot in the U.K., but ran into concerns from physicians about the advice it was giving.  In China, Baidu has been using its chatbot (for both consumers and doctors) for a couple years.  China views A.I. as an essential component of its future healthcare system.  

Meanwhile, A.I. continues to get better. A new study (from China, not surprisingly) demonstrated an A.I. that was highly accurate in diagnosing several common diagnoses.  It's accuracy rate challenged the highest accuracy rates of human physicians.  The thing to remember, as Mr. Kessler noted in his article, is that "The best doctor sees one patient at a time, but a clever piece of code can be used by countless people." 

Studies have also found that A.I. can detect heart disease and lung cancer more accurately than human physicians, and in diagnostic imaging.  There have already been FDA approved AI tools for ophthalmology and stroke detection.  

Healthcare Bot use Credit: Microsoft

In a recent Insights, Forbes cites study that indicate private sector investment in healthcare will reach $6.6b by 2021, with AI generating potential U.S. annual savings of $150b by 2026 (Accenture) or $269b (McKinsey).   IBM (Watson) and Google (Deep Mind) have invested heavily in A.I. for healthcare, and Microsoft just rolled out its Healthcare Bot Service to help spur creation of chatbots and A.I. personal assistants.  

As for virtual care from humans, it is not entirely clear that virtual visits do replace in-person ones, nor are most physicians involved in providing them, but the promise remains.  Kaiser Permanente, which has also long been an advocate of using A.I., claims over half of all visits are virtual.  Many, perhaps most, large health plans/employer health plans give their members the choice of virtual visits.   

Rock Health's 2018 Digital Health Consumer Adoption survey found continuing increases in the percentage of consumers using such services: 75% have used at least one telemedicine channel.    

If we think about it, it is crazy that when we have a health problem, the thing we are expected to do is to call our doctor for an appointment, then drive there (or to the ER/urgent care) to find out what is wrong.  This is why we end up sharing our germs with a room full of other sick people, waiting for our turn to be seen, and worrying the whole about what might be wrong and is going to happen to us (not to mention how much it will cost). 

There are too many unnecessary visits, resulting in too many unnecessary tests/procedures.  Everyone agrees on the problem, but few healthcare professionals think they are the problem.  They're just as happy to have those in-person visits, regardless of the time and money they cost their patients.  That is not putting the patient first, and that is not patient-centered care.

In most cases, the first step should be an AI-based triage to determine what is most likely to be wrong, if I need to communicate with a human physician immediately/virtually, or if I need to seek in-person care -- and, if so, from whom/where, taking into account any health plan network restrictions. 

The U.K's National Health Service reportedly pays Babylon Health about $80 per patient annually, which would equate to around $26b.  That sounds like a big number, but it's probably more like a CHIP-sized bargain.  It's much cheaper than Medicare-for-All or the ACA premium subsidies.  The cost could most likely be reduced by economies of scale, tougher competitive bidding, and, most substantially, passing off costs by requiring health plans to cover it. 

Such coverage would also let the U.S. set the standard in "licensing" AI for healthcare and end the crazy-quilt licensing of human telemedicine physicians we have now.  Both would be boons for the U.S. healthcare system. 

We're already (finally) getting more worried about China's efforts in A.I. -- as demonstrated by President Trump's recent A.I. order -- and this initiative would help us keep pace with their A.I. healthcare efforts.

Giving everyone access to a virtual physician is a good thing to do.  It's the right thing to do.  And it's not only something we can afford to do; it's something we can't afford not to do.