Why Price * X = Healthcare Value is Unsolvable- X, Quality remains an unknown

Price x Quality = Value a the fundamental question for almost every buying decision. You pay a little less, you get less quality.  You pay more, you get more.  So why can't solve this equation for healthcare? 

I had the opportunity last week to host a panel on price transparency at Health 2.0. This meeting has been advocating for patient empowerment through technology for many years.  Several companies including Vitals.com, Healthgrades, HealthSparc & 
BetterDoctor presented.

For the insured, price transparency is relatively easy with a little effort. The cost of the procedure can be defined based on certain parameters -in or out of network, whether you have the procedure done at a hospital or an outpatient center all go into the price calculation.

Quality is much harder to define. To date, companies have relied largely on patient ratings of physicians.  However, with the new release of the Medicare database, other factors being are being considered. How often a physician is doing a particular procedure, how good are the other physicians referring to that particular physician, and what is the hospital rating where the procedure is being done are all being incorporated into the websites. 

Although this makes sense, this process is only surrogate for quality. For example patient rating (patient satisfaction) largely reflects the buying experience, how much the patient liked the doctor or their office staff rather than their outcome.  In fact studies have shown that sometimes satisfaction negatively correlates with outcome.  Patient satisfiers such as prescriptions for narcotics and unnecessary surgeries (often easier for the doctor), are not good for your health. Physician’s may be particularly attentive (another patient satisfier) after there has been an error. Physician volumes may be indicative of a truly good practitioner, or may relate to their affability or availability.

These websites should be a concern for healthcare practitioners.  Without real patient outcomes data, ratings run the risk of becoming a popularity contest rather than a rating system for good care.  During the Health 2.0 an audience member asked the panel what physicians, particularly recently trained physicians, should do. Panelist recommended physicians pay attention to their profile and patient feedback about their care early in their careers. Perhaps med schools should have classes in web marketing?

My personal bias would be to give physicians the information regarding their own referral networks first.  This would tend to shift referral pattens.  I may refer to a friend, but if they finished 3rd out of 4 colleagues in the same geography, I might reconsider my decision.  This decision would also be contextual.  Doctors tend to know why results from a colleague may not be as good as other practitioners.

I don't mean to be negative. In fact, I applaud these efforts. However, we are at the beginning of our journey to better understand the “value” in healthcare.  Having price transparency is a good start..  Ultimately, to solve the equation better measures of quality need to be determined.  Until we can this type outcome information (likely a mixture of data from providers and patients months after treatment) ratings will remain more about personality than value.  Until then, let the buyer beware.

There's a wide chasm between wellness and healthcare

There's a lot of talk about shifting our focus from healthcare to wellness. Great idea. After all, it's far cheaper to prevent disease rather than treat it. If only it were that simple.

Wellness conjures up visions of youth, spas, and sunshine. Wellness is for the healthy and the privileged. Wellness is for the super-fit, all those kale eating triathletes Silicon Valley millionaires looking to optimize their health.

Healthcare is something else entirely. It brings up visions of doctors and hospitals, cancer and pain. Nobody wants healthcare. It's not fun, sunny or desirable. It requires an admission of frailty and mortality, all things most of us look to deny.

It's almost as if the 2 words are ying and yang, an us and them, the well and the diseased. This misperception has lead to stupendous market failures. I've seen countless healthcare entrepreneurs suggest their product is the next big thing, something everyone will want only only to hear a resounding thud, a small niche market with little or no adoption.

The fact is most people who need care... have failed wellness. Challenged by either socio-economic, genetic factors, or attitude, wellness might as well be a foreign language for many people suffering with chronic healthcare issues. And the people who care about wellness, aren't typically sick.

If we are really going to impact on those who need it most, we need to have an honest discussion around the issues related illness, & the often associated feelings of helplessness and depression. This means not simply masking disease with quick fix pills and surgery, nor seeing people as weak if they don't cheerfully adopt the wellness lifestyle. Rather, we need to address deep rooted (and expensive) psychosocial co-morbidities that co-travel with the reasons for healthcare.

I'm all for wellness. But to truly have an impact we need to have an honest conversation around  what it means to be "them," the majority of Americans living with chronic disease.

What if Don Draper had to Sell Wearable?

I'm a big fan of Mad Men.  Unfortunately, I'm old enough that it feels like my youth.  But beyond that, it’s an interesting window into another culture, America in the 60's.  I'm also intrigued by Don Draper's ability to sell anything, to make products that might kill you have emotional stickiness.

Why Google Glass.....
when you can put monitors right on your eyeball

Watching the show I've often transfixed by the technological changes in the last 50 years.  They use cord phones as their only way to communicate.  If Don wasn't in the office or at home, he couldn't be found.  In a recent episode, a computer was introduced to the office.  One of the characters was literally driven mad by the incessant hum emanating from the control room.  In contrast, we are constantly connected, always available, and soon to be, always monitored.  My question, how would Don Draper sell wearable technology?  How would he make it sticky?

I want to live forever, but I won't.  No matter what I do, my time is finite.  Ultimately it comes down to what I'm willing to give up today in terms of personal freedoms and additional anxiety (yes, the decision to monitor brings my frailties to my consciousness), in exchange for some benefit tomorrow. Ideally I would live an stress free world and then drift off in my sleep.  Unfortunately most of us spend part of our lives with a constant companion, a chronic illness, in our later years.

In order for wearable to truly take off, it will need some message, something that addresses our base instincts rather than simply offering something cool.

I don't want to be monitored.  I want to live without worry as long, and as comfortably as possible.  If he were to sell me on wearable, what would Don say?

Portals Are for Cattle, Personal Health Records (PHR) Should Be for People

There seems to be confusion around the term Portal and Personal Health Records (PHR) in healthcare.  Let me explain.

Portal displays or communicates with a practice or network

Portal is a hospital's attempt to improve customer service.  A typical portal allows you can log on to your hospital, see your records, schedule a visit, or possibly message your in network provider.  Compared to the days of fax and phone it’s clearly a step forward.  And it works as long as this is the only place you go for care.  However, unlike cattle, most people don’t tend to stay inside hospital fences.  People wander from hospital to hospital, clinic to clinic, sometimes going to a doctor in network and sometimes going to one out of network. Portal is limited tool for a single hospital or network.

PHRs are something else entirely.  Fundamentally, they are owned by patients.  The record collects all care, irrespective of the health system.  It is not a tool for marketing, tethering you the patient to a particular set of providers, but rather an organized way to tell others about you.  Ideally, a PHR would leave room for patient self report.  Healthcare systems seem to forget that most of health occurs at home.  Hospital records leave no room for patient self report.  Personally I feel how patients feel about themselves day to day, whether their happy or depressed, has far more to do with their health and outcome then whether they took their medicine or lost weight.  A true PHR would collect information across the continuum- from hospital to home, across all providers.

An ideal PHR would gather all information for the patient
and put it into the cloud

Without an effective digital tool, many patient’s literally resort to a shoebox for their PHR. Particularly for those with a chronic disease, there is a clear need.  So why hasn’t the market provided one?  Attempts have been made.  Both Google (Google Health) and Microsoft (HealthVault) literally spent hundreds of millions of dollars in what were largely failed efforts.  In part, this was do to a failed business model based on…. advertising.  Hospitals initially looked to leverage Microsoft’s HealthVault, but got stuck in their old ways of thinking by reverting to “portal” built on top of HealthVault.  For all their outward mission based altruism, in the end hospitals are businesses.  They have a hard time thinking beyond I win/you lose mentality and tend to look for market differentiators rather than collaborative strategies to deliver better care at a lower cost.  Too bad.  Can you imagine the first hospital to offer a true PHR?  Sure it would help their competitor by collecting records for the patient, but do you really think it would work equally well across providers.  The first hospital would do well by doing good.

With the new federal mandates it’s time to stop spending on fences (portals), and start thinking about continuum (PHR).  Grabbing patients via insurance plans or Accountable Care Networks will only go so far.  To actually improve care at a lower cost a true PHR, a patient owned record managed by a hospital would provide huge value for all stakeholders.  At the very least, we should stop referring to portals as PHRs, something they’re not.

What if HIPAA and Medical Malpractice Were Evaluated by Double Blind, Randomized, Control Studies?

The recent Dallas Buyer’s Club told the story of Ron Woodruff, a cowboy infected with the AIDS virus early in the epidemic.  The story revolved around his inability to get access to drugs based on FDA safety requirements.  Whenever a new drug, device or procedure is introduced, the question is asked- does this benefit the patient or is it a risk?  Often it takes years of double blind randomized controlled studies to arrive at the answer.  Occasionally  the medical  community doesn’t respond fast enough, but at least there is a process in place.  The same can not be said for medical legislation and the tort system where there has been something of a free pass.  Although both processes influence patient care, decisions are made by consensus rather than information. 

Take HIPAA.  Although designed to protect the patient’s privacy, there are adverse consequences that may actually hurt the patient by limiting access to critical medical records.  Personally, I would prefer to opt out of HIPAA, or at least have certain records freely accessible, rather than risk the chance of a bad outcome.

Medical malpractice poses similar issues.  Although the American tort system is designed to protect us, it actually ends up hurting more people than it helps.  Tort brings a adversarial element to the doctor-patient relationship.  In response some physicians change their practice patterns (CYA medicine) to defend themselves against the potential of a lawsuit.  In many cases, additional tests and procedures with no reasonable benefit for the vast majority of patients are ordered.  This promotes the opposite of what most double blind studies hope to achieve- exposing thousands of patients to risk for the benefit of the few.  Although safe guards are needed to avoid substandard practitioners, other countries implemented safeguards with better results at far lower costs.

Our government often looks to intervene- to help & protect us from the adverse effects of care.  However, indiscriminate use of regulation & process without a process of validation may lead to worse outcomes for the majority.  If we are truly serious about a better healthcare system through outcomes and transparency, shouldn’t all aspects of care be evaluated?  Legislation and legal process should not be given a free pass.

Is Obamacare Good For Innovation?- It’s All in What You're Asking For

In a recent Forbes article (http://www.forbes.com/sites/robertpearl/2014/03/06/malcolm-gladwell-on-american-health-care-an-interview/)  Malcolm Gladwell sat down with Robert Pearl to discuss healthcare.  Although not thought of as an expert in this area, I’ve also found Gladwell to be one of the most creative minds in America.   One of Gladwell’s books on innovation (Tipping Point) is something of a roadmap for a new paradigm, showing how the crowd can be delivered to solve problems; it also outlines a role as an accelerator for the individual.  I’ve written (pleaded) about this call to action (http://alanpittmd.blogspot.com/2012/12/why-i-use-linkedin-and-hope-you-do_20.htm). In the interview Gladwell asks where Obamacare is good for innovation, and how to “nudge” the system forward.  For me, innovation responds to a problem.  Obamacare has redefined the ask for innovators.

Since the last great change in healthcare (Medicare/Medicaid in 1965), America embraced something of a losing battle, a war on death.  Like every country, our healthcare reflects our traditions, We value the trailblazer over the settler, the surgeon over the internist, heroic care over chronic care.  We’ve paid for ever increasing breakthroughs at the margins (end of life) while largely ignoring less costly, and less sexy gains in quality of life.  This has left us with the most expensive system in the world with limited success for the average citizen.  We don't live longer than other developed countries.  And one could argue whether a country that ruins their citizen's fiscal health when they get sick is not very civil. 

Obamacare is a required shift.  The current system, something of a snowball of stakeholders, is not sustainable.  We are moving from volume (fee for service) to value based care, from heroic to chronic care management.  As with many transitions we are now moving through the 5 stages of Kubler Ross's scale, caught somewhere between anger and depression.

In terms of innovation, it's all in what you ask for.  This is one of the most chaotic times in American Healthcare.  However, in chaos there is opportunity.  We are seeing the beginnings of innovative strategies focused on new forms of care delivery.  Both large and small opportunities are nudging their way forward.  Americans are the world's greatest innovators.  Fear not Mr. Gladwell.  We are processing the new rules of the game.

Dear Doctor, Which one are you?- Patient, Physician, or Specialist?

We are all patients at some point.  Rich or poor, when sick we are worried and vulnerable. We’d all like a cure but at a minimum we want care, reassurance that all can be done, is being done.  Ideally we’d like to have confidence in the person watching over us. This can be a tall order.  As a senior physician, I remember the feeling of helplessness when my mother became a quadriplegic.  I became an increasingly passive participate as she went from hyper-acute ICU care, to inpatient care, to chronic care in a nursing home to home (http://alanpittmd.blogspot.com/2012/08/the-apex-of-care-i-am-successful.html).  Each step “forward” felt like a step back as her care became increasingly fragmented.

For some, healthcare experiences become a calling to serve.  They elect to become a physician, nurse or other healthcare professional.  Having interviewed many potential medical students, many have a naive, idealized view of the profession.  Now in mid life, with longer hours and a much less certain financial future than when I started, I had a somewhat jaded view until recently when my daughter Taylor elected to go into medicine. We had many discussions about a her choice.  Finally, she turned to me and asked what I recommended she pursue in these chaotic times- business, law, research? As a physician she was pursuing a worthy profession.  I couldn’t disagree.

After medical school most physicians specialize. In part, this is financial.  American specialists tend to make more than generalists.  However, this is also a result of the Darwinian selection process. Successful medical school candidates tend to be type “A.”  They want to be right.  Specialists train to know more about less (occasionally to the obscured) than their generalists counterparts.  However, over time, specialists are socialized to think of themselves as specialist first, then physician and then as a patient.  Some forget they were ever young doctors with calling.

The Accountable Care Act (aka..Obamacare) has come as a surprised.   Several provisions ask for coordinated care and a team approach, in essence asking for a cultural change for healthcare providers.  With a loss of income and control, many specialists are understandably frustrated, anxious and angry.   Although I don’t expected sympathy from many American’s for the plight of the specialist, earning less every year for the same (or more) work is never easy.  Although most in healthcare recognize the need for change, each group hoped the change would come from someone else’s piece of the pie. 

For many in my profession, Obamacare has become a rallying cry, representing of all that is bad with big government.   However, if you were President, what would you do?  The bills for decades of over utilization are coming due.  Although it remains to be seen whether care will improve for the average American, the current system is simply not sustainable.  Decisions have to be made in the best interest of the patient and the population, not the profession.   My daughter's choice has been a bit of a pause for me.  It has helped remind me healthcare is a noble pursuit, and that specialty care is a by-product of the business but not the purpose of the medicine.  Ultimately, we are all patients first.