Wristwatches and knowing your neighbors; so out they’re in?
I recently gave my daughter an old watch I found while cleaning out a drawer. It was a plain-looking Bulova, with a small face and a black strap. “Cool!” she said. “You know, it’s so convenient, just looking at your wrist when you want to know the time, rather than reaching for your phone.”
Whether you find that funny or not depends on your generation. In my generation, we find that ironic and humorous, because it seems so obvious. But for my daughter’s generation, it’s a novel thought. Everything old is new again.
It occurs to me that geographically-based communities might be similar, so retro that they become cool again. The great American obsession with mobility as a measure of status seems to be waning for my daughter’s generation. I was sitting next to a flight attendant “deadheading” on a flight back to Denver recently, and she lamented that the glamor days of air travel are long gone. She missed the days when people dressed up to fly, replaced now by folks in shorts and flip-flops. For my generation like so many before it, transportation implied luxury, the more exotic the better.
I also recently stayed at a resort that had a car museum on site, and an exclusive car club where members could store their expensive toys in an arid climate. I would bet that most members are older (as are many of the cars!). But for my daughter’s generation, many don’t intend to own a car, and getting a driver’s license, once a rite of passage for the American Graffiti generation, is now simply a hassle reluctantly undertaken. Car2Go and Uber will do just fine, thanks, until driverless Google cars come around!
What does this have to do with health? The car was once a symbol of independence, and the ability to control one’s own time. But as it became commonplace, the downsides of that device have come to light. Many in their 20s are viewing it as a commodity, to be consumed as needed, and not more than that.
Similarly, the Internet allowed us to find others by interest and worldview, irrespective of geography. Once association was limited by an inability to travel; that faded with cars and planes. Then that trend accelerated with the ability to exchange information, even form community, without having to be in the same place. How cool! Today Skype and similar applications link us to others around the world, allowing us to see strife in the Middle East up close, and visit with our loved ones around the globe daily if we so choose. For a while, it seemed to me that geography was becoming irrelevant.
But the recent literature around health tells us that geography, when it comes to health, is anything but irrelevant. Indeed, one of the raging debates in my wonkosphere is whether to pay differently and/or to have different quality standards by neighborhood. The social determinants of health seem to be greatly influenced by what others around us are doing. Those with healthy lifestyles tend to seek out others with healthy lifestyles, and vice versa. Who you hang out with is more and more recognized as a large influence on behaviors, including those that affect health.
So maybe the geographic community, once so passé in the uber-mobile American society, maybe, just maybe, it’s making a comeback, like that old Bulova watch. Once thought to be obsolete, maybe it’s cool again to have neighborhoods where people know each other. Once the novelty of instant communication wears off and becomes something of a hassle like owning a car (I think I’m already there), maybe we’ll realize again that one of the best things for us is knowing the people next door. The studies certainly seem to imply this. It may turn out that in the end that gadgets are cool, but ultimately we crave those things that just work: the time on our wrist, or communities where we say hi to one another on our morning walk.
Physicians Leading the Effort to Contain HC Cost
I had the privilege of attending the Physician Leadership Summit at Stanford University recently. The conference was put on by the Network for Regional Healthcare Improvement (NRHI) and was hosted by Dr. Arnie Milstein of the Clinical Excellence Research Center. NRHI selected physician leaders from five states to come together and discuss how total cost of care information might be used to improve quality and reduce cost. Now for most people, this is a pretty arcane topic, and you might expect that this was a two day snoozer. In fact, it was anything but.
I worked with my fellow NRHI staff on this for many months, and not without some trepidation. Would physicians get what total cost of care means? Would they feel responsible for it, or would they just feel overwhelmed? And how would they take to the communication challenge, the part for which I was responsible? I worried about all of these things.
In retrospect, I shouldn’t have worried. The physicians I met were without exception profoundly intelligent and decent people. They immediately grasped the potential of understanding total cost of care, and understood how they, as primary care physicians, could reduce cost and improve quality simultaneously. More than that, they understood the leadership challenge of swimming against the prevailing culture for something that is hard to do, but right. They understood it because they have been doing it, each in his/her own sphere, largely unaware there were others laboring in the same vineyard, a few rows over. I am profoundly grateful to have met them, and that they got to meet each other. If you’re going to be digging and planting in the hot sun, it helps to have company.
Pragmatically we will need hundreds and thousands of the kind of physician leaders I met at Stanford if we are to change the way we take care of people for the better, and not just change the way we pay for care. There are many reasons for this rooted in sociology, psychology, and neuroscience that we will go into another time. But to date I haven’t found a way to cultivate such leaders except one by one, and face to face. And so, from this small beginning, I have hope that these leaders will bring others into this field, and that we might bear fruit for the communities in which we live. Salue!
Retooling for the information glut age: five things physicians should do to lead
In the last post, I talked about what physicians should stop doing if they wanted to have a leadership position in the rapidly evolving healthcare world. In the spirit of bringing solutions and not just problems, today’s list is five things that I think we as physicians collectively should start doing.
1. Start looking at medical care as a shared and finite resource. With the best of intentions, we have mostly looked at health care as an infinite resource, i.e., inexhaustible. As long as patients had insurance, we could order whatever we wanted, with little or no consideration of cost/benefit ratios. Even if something was very, very unlikely to work, so long as it didn’t harm patients in some obvious way, we got to do it. But pooling finite resources doesn’t make them infinite, just finite and bigger. And that’s exactly what we do when we create insurance pools. We’ve never had to think, “If I order expensive test for patient A, there might not be resources available for patient B.” But no less an authority than Don Berwick said, “Cost is the moral dimension of our times.” This is because he correctly identified health care as a limited resource. And, he also realized that if there’s a limit to what a society can pay for health care, then efficiency and efficacy matter, because anything spent ineffectively on one person can’t be spent effectively on another. This matters because there are only a couple of ways a group of people can keep spending within a budget: cutting out waste and inefficiency is one, so there’s enough to go around; reducing the number of people we are concerned with is another. Most of us in the medical field are pretty uncomfortable with the second way.
2. Start partnering with people who understand finance. If we are going to deal with care as a finite resource, it’ll be helpful to have partnerships with people who know how to manage money. This would be CFO types, whether they’re in our organization or someone else’s. Now in our historical physician culture, anyone who was fluent in money was viewed as prioritizing profit over patients’ well-being. Bean counters, we called them. But that view is an oversimplification. They got the t-shirt with the BAD COP logo on it, which made us look really good sporting the GOOD COP logo. In fact, many health care CFOs I have known feel a serious moral obligation informs their management; often they went into health care rather than some other field for many of the same emotional reasons we did. I think many of us have an irrational fear that if we actually understand the finances we’ll be influenced to view money to be more important than patient care. In essence, we feel ignorance is protective. I question the wisdom of employing this strategy.
3. Start thinking beyond health care to health. An inconvenient truth is our healthcare system is largely a rescue system, like the fire department: we don’t prevent fires, we just try to put them out once they start, mostly. It should not be surprising therefore that the healthcare system only affects about 10% of health outcomes. The rest? Genetics, environmental factors, and behaviors. Included in the environmental factors seems to be factors that are specific to neighborhoods, like resilience and social support. So while we would never get rid of fire departments, we also shouldn’t think that all firefighting and no fire prevention is our best strategy. Prudent communities do both, funding the fire department and clearing brush from around their houses in fire-prone areas. If there are ways to reduce the need for emergent interventions like fire department runs and emergency room visits, wouldn’t we want to do that? The hard truth about that is with the exception of those of us who went into pediatrics and/or public health, we received very little education and training in affecting those other factors. That brings me to the next thing.
4. Start acknowledging that we can’t win the health game without lots of other professional types, because we can’t affect lots of the other determinants. Social workers, housing organizations, social organizations—many of these organizations that have no way of dropping medical bills have their success expressible in medical outcomes, like drops in ER visit rates and hospitalizations. Producing health care by ourselves, no problem. Producing health by ourselves, big problem. Arguably it can’t be done. Now I don’t know about you, but I went into this because I wanted to fix things, and I was willing to work really hard to gain the skills to do that. So it’s something of a disappointment that I quickly found I was ill-equipped to fix lots of the problems that generate the symptoms I saw in my medical practice: health-destroying habits, ineffective stress management mechanisms, unstable housing and/or relationships, early childhood trauma. The list goes on and on. The good news is that there are lots of other professional types who by training and temperament are better equipped to address these factors than we are. The bad news is we have to ask them to help us, since we can’t fix what they can fix. That requires real humility and openness, and too often we left medical school thinking we could get through an entire career without invoking either one of those things. These days, that turns out to be wrong.
5. And while we’re at it, start acknowledging that the most important partner we have in winning the health game is the patient himself. I am nowhere near as eloquent on this topic as others like my friend e-Patient Dave, but his message that I agree with is, “I’m your patient and partner, and I’m here to help. Just ask me.” It reminds me of that bumper sticker, “If you think education is expensive, try ignorance.” If we think partnering with patients is time and resource-intensive, that’s nothing compared with not partnering with them. Judy Hibbard’s work on the patient activation measure is pretty clear on this point. Highly activated patients get to effective strategies and treatments way faster than their less activated peers. This results in lower cost, and higher satisfaction for both the provider and the patient.
These five points are probably necessary and not sufficient, but they are a decent start, and hard enough all by themselves. I was on the phone a little while ago with a friend who also works in this field of health care transformation. He was telling me about all the cool things he was doing, from moving care out of clinics and into homes and “hubs” (places with high concentrations of patient need) to redesigning benefits for large companies personalized to individual patients. It struck me that he’s part of the vanguard of physicians that is willing to turn the traditional model on its head: little bricks and mortar, go where they are rather than make them come to us, use social media to meet them in their cyber environment rather than make them meet us in the physical world, etc.; all faster, cheaper, and more convenient than the status quo. But these innovations don’t even occur to us until we start thinking total dollars, total populations, and health rather than health care. Once we do, though, all kinds of possibilities pop into our heads, and we can help move things forward.
Five things physicians need to stop doing if they want to lead
In my last post, I talked about the need for physician leadership in the massive amounts of re-engineering necessary to get to a sustainable American health care system. This time around I want to talk about what we need to do differently, because the old saying is true: if you keep doing what you’re doing, you’ll keep getting what you’re getting. Here are my suggestions for physicians:
Stop thinking money will compensate you for an unsatisfying work life. This is a popular misconception, that you can put up with anything so long as someone pays you lots of money. It doesn’t work that way. There is ample evidence in broken relationships, drug abuse, alcoholism and other expressions of distress in our profession to prove this. Money is a decent proxy for food, shelter, and security, but it doesn’t get you to the top triangle of Maslow’s hierarchy of needs, and piling up more of it has very little marginal benefit to happiness. Doctors in the era of the third party payer have become wealthy materially while taking pay cuts steadily in respect and relatedness. And guess which way professional satisfaction has gone over the same period? Corollary: income preservation isn’t the thing that’ll make you happiest. Finding meaning in your work life will help make you happier. If we want a sustainable system and a sustainable place in it, we need to work for more satisfying lives over more spectacular livings.
Stop thinking that the solutions to our problems are to make other people behave differently while we stay the same. If only health plans would stop hassling us. If only the government would stop regulating us. If only, if only, if only. The heads of those entities are like leaders everywhere: there are days where they would give anything for someone to bring them a solution rather than a problem. Problem generators are abundant. Problem solvers are scarce. Which do you think stand a better chance of getting a meeting with these people?
This means that those who wish to have others change what they do, have to understand those others’ problems. And, they have to genuinely want to help solve those problems. Anything less, and you look like every other appointment on their calendars. I once met with a congressional staffer who picked my brain for an hour, and at the end said, “That was great!” I asked why, and he said, “Because you didn’t ask for anything. Everybody else always has something they want us to do for them.” Man, there’s a tough job.
Change most often begins with how we are going to change ourselves. And interestingly, that internal change often fosters change in those around us. We are hard-wired to respond to each other’s social cues, and neuroscience has found structures in our brains that are on automatic to sense and interpret those cues. Mirror neurons and the limbic system are parts of what Dan Kahneman calls System 1. It runs in the background while we are doing rational work in System 2, like math or logic. But as the older and more primitive portions of the brain, System 1 overrides System 2 in times of distress. These days, that’s a substantial portion of people’s days.
Stop thinking that we’ve paid our dues, and our living is compensation for suffering through school and training. It doesn’t work that way anymore. Actually, in most other areas of society, it never did. Once, before we were able to measure complicated things like medical outcomes, society basically gave us a magic key called a medical degree and said, “Death scares the bejeezus out of us. We did our best to pick agents in our fight against it, and we picked you. Please, please, please do a good job, because we have no way to know whether you did or not. We’re trusting you with our lives, literally.” We were honored by their selection of us, and we promised to do good the day we graduated.
But these days, people can measure doctor’s performance, and they are increasingly dissatisfied by what they’re finding. Seventeen years to adopt obviously good medical practice? Wassup with that? Today the boards and hospital privileges are no longer the Good Housekeeping Seal of Approval they once were. So what if you passed a really hard test a few years ago? Today, people who buy medical stuff want proof, and they want it on an ongoing basis. That’s been happening for people who build stuff like cars and dishwashers for a long time, since those are simpler tasks. But computing has caught up with measuring complex tasks, like hip replacements and chemotherapy.
Stop seeing everyone else as them, instead of us. This one is going to take a while, because we are products of a selection and training process that did nothing if not tell us that we were different than other members of the species. Smarter. More hard-working. More tolerant of sleep deprivation. And then we were inculcated into a subculture that extrapolated that (much of which wasn’t true) into the fatal delusion, “Not subject to the normal failure rate of human beings.” Think about it. Who are the heroes of our lore? Osler, DeBakey, Starzl. People who never admitted an error in their lives, ever. And yet, they all made mistakes. They weren’t a different species. But we share a comforting delusion with the larger society that we are error-free, because all of us want to believe that our error rate in life-and-death stuff can be reduced to zero by individual will and effort. It can’t.
We need to reclaim our own humanity, including the error part. We compensate for that in other industries by having redundant safety features and procedures, such as those in operating commercial aircraft and nuclear power plants. But we can’t compensate for an inherent human error rate until we acknowledge it. And we can’t do that so long as we claim we are innately exempt from errors. We can’t rejoin the human race until we acknowledge we are part of its imperfection, and ask for help in minimizing the impact of that imperfection on our brothers and sisters. To borrow from a recent bestseller’s ironic twist on Shakespeare, the fault lies in our stars, and in our selves. We should stop purporting that we have no part in what goes wrong with the way we treat our fellow human beings. We do, not because of bad intent, but because of our underlying humanity.
Stop hoping that it’ll all work out in the way we want without our having to lead the change. As if. “The best way to predict your future is to create it,” wrote Abraham Lincoln. It’s still true today. The future of medicine is being created today, and not necessarily by people who took the Hippocratic Oath. Nature abhors a vacuum, and that’s nothing compare with what it thinks about a power vacuum. When you’re talking about a $2.7 trillion industry, there are lots of people who want to make the rules for a modest commission on that $2.7 trillion.
But you all took an oath to help and not to harm people in the most vulnerable moments of their lives. The way I see it, that still applies, whether you do your work in the exam room or the board room. At the very least, I want you at the table to express that value. But you won’t get there so long as you continue to do the five things above. Here’s hoping you’ll stop.
Next time, what I think we should start doing.
Physician Leadership: An Idea Whose Time Has Come?
Lately there have been articles in journals like JAMA and Health Affairs discussing the need for physician leadership in reshaping the system. It isn’t that there hasn’t been this need before. Because of the central role granted to physicians by law and by culture, we have always needed physicians to agree, explicitly or implicitly, to changes to the delivery system. Indeed, I call the last model of physician accountability for health care the “infinite power for infinite responsibility” model. Because we had no way of measuring physician performance in the last age, how else were we going to deal with matters that were literally life and death? If you are dealing with a phenomenon that frightens us all, you want to give your agents all the power you can.
But in the Age of Information That Is Cheaper Than Zero and massive computing power, suddenly we can measure physician performance. With the knowledge that all physicians are not created equal (much less perfectly), we are left with a disturbing reality: physicians, like everyone else, need to be engaged in continuous improvement, simply in order to stay even with consumer expectations. I realized the other day that one reason this is so is that we are increasingly expecting human performance to be like computer performance. Computers are performing highly complexity and nuanced tasks, and doing them with greater reliability and reproducibility than humans can. What do you think is more reliable, asking a stranger for directions to a restaurant in a strange city, or Google Maps? Me, I like the app. So is it any wonder that we get annoyed when someone can’t remember if it’s ten or twelve blocks to the Café Boeuf?
Meeting ever rising requirements requires change and change management, and lots of it. Some theories of leadership state that leaders are really only necessary when dealing with change. When everything is stable (I remember a time once when I thought things were), leaders have limited utility. If I can get by doing tomorrow what I did yesterday, who needs leaders? I’m on autopilot. But in a time when people are radically changing what they want, how they pay me, with whom they expect me to work, and most importantly, how they judge my work? Yikes. And thus, physician leadership is the topic of the day.
I personally think physician leadership is a hot topic now because we’re quite simply out of other options. As Jerry Garcia said, “Somebody has to do something, and it’s just incredibly pathetic that it has to be us.” We’ve tried every option that doesn’t involve physician leadership and buy in, and none of them work. Health plans and mother-may-I managed care failed. Why? Because studies show that 40% of physicians admit to lying to get services for patients. That’s 40% who admit it; who knows how many it really is? Hospitals acquired physician practices thinking buying accounts receivable is almost like buying buy in, but find out, not so much. Way back when in the 1990s, practice management firm like Phycor did the same thing, and with the same disastrous results.
Okay, to brass tacks then. What will it take for physicians to do the Nixon-to-China about face, and actually embrace the Medicine of Limited Resources, the end of society’s blank check, and the upward slope of increasing accountability? Here are some suggestions:
- First, embracing limits cannot be primarily about making people money, even for the docs themselves. Fundamentally docs have to look themselves in the mirror in the morning, and no one likes to see someone who hurts other people for money looking back. If money is the sole appeal to changing to a population health approach, it will not be sustainable as a motivator.
- Second, there must be a positive reason to learn new skills and engage in the process. These positive reasons are different for different people. For some, it is the recognition among peers that they are the highest value provider in the land. For others, it is the sense that by making the system more efficient, they are preserving resources that allow other patients to get decent care. But for the largest proportion of providers in my experience, it’s when they see that things like coordinated care are actually better for patients. When someone comes back to the office and says, “My mother looks so much better with the additional help that Karen (the care manager) is giving her. Thank you so much for getting her that.” How do you stop doing that, even if it is a little more trouble for you as the doc? How do you refuse to offer it to every patient out there whose life is strung together with baling wire?
- Third, docs are like other humans. We like things like a sense of our own competence, autonomy, and relatedness. In many ways, external coercion works against these basic human sources of satisfaction. But if docs can feel like they have the tools to lead well, the ability to really make a difference, and the support of peers, this is a much different proposition that the bad old days of managed care. It reminds me of the saying, “People don’t resist change—they resist being changed.”
In essence my hope is that in order to avoid being changed, we physicians will own the change ourselves. None of this is easy or simple, because nothing involving humans and emotional processing is. But now is the moment we must test these theories, and as a physician community, either own this challenge or turn over the reins to someone else. I know which option I prefer.
More on the invisible power of computing: how it affects the way we interact with one another
I’ve written before about the major influence of Moore’s Law on modern life in general, and health care in particular. Moore’s Law states that the number of transistors on a chip doubles every 18 months, and therefore the cost of computing power halves in that same interval. Result: simple information has become cheaper than zero, and ever more sophisticated information is becoming cheaper daily. I am old enough to remember when four-function calculators came out, replacing the old adding machines that worked mechanically, and spit out tapes that resembled grocery store receipts. The calculators were originally priced in the hundreds of dollars.
But even sophisticated information has gotten cheap. Think of all the functionality on your smartphone. Although we each generally use a very small percentage of its potential, just think about what it does do for us. On it is a GPS that used to be a couple of hundred dollars by itself. I access TripAdvisor in strange cities and come up with great hotels and terrific restaurants, and directions to them as well as online registration and reservations. And now that I’m three models behind, my model, brand new, costs about $200.
While all of this is wonderful, there are some unintended consequences. First, what we used to think was hard is now easy, especially if you have some money. Ads cater to what we’re thinking, because of the powerful ability of vendors to infer what’s attractive to us by looking at our online data. Our GPS devices reroute us around traffic jams, and some new car models anticipate accidents by tracking the data being generated by the car two cars ahead of us.
I wouldn’t want to go back to the time when I had to go to AAA to pick up a TripTik, or customized route map, before a vacation trip. (Young people: I’m not making this up.) But the interface between humans and the computer-based environment isn’t static, for either party. As I said earlier, Moore’s Law gives us more and more computing power more cheaply on an exponential curve, so things like standalone GPS were hot Christmas items five years ago, and have now been overtaken by apps on our phones. I doubt you can give away your old GPS today with its static maps and slow processors. Ditto your old 5 MP digital camera.
Perhaps the more germane accelerated evolution, though, is on the human side. Humans are an amazing species, because of our adaptability. This allows us to take virtual trips to different planets, summit Everest where there is almost no oxygen, and probe the sea floor three miles down to search for Malaysia Airlines’ MH370. During this latest drama, the most common complaint I saw online: why is this taking so long? Think about that: a decade ago this search might have been practically impossible. Now we are complaining it’s taken too long. We just assume that of course we can do that, and somebody must be bumbling the job, otherwise we’d have found it by now.
This applies not only to the rational parts of our brains, but also the emotional parts as well. Scientists call this hedonic adaptation, and it essentially allows us to become happier in miserable circumstances. Again, this is a really good thing. But the same mechanism also causes joy to become routine, and reset our happiness to near its baseline after good things happen.
It might be obvious by now where I’m headed. As Moore’s Law makes information cheaper and cheaper, allowing us to search and find what we need in milliseconds, we as humans adapt to that hedonically, and we very shortly come to expect that which we found previously miraculous. We expect answers to questions instantaneously, exhaustively researched and sharpened by crowd-sourced opinions. We have evolved into a species that checks its smartphones while waiting the two minutes for our lunches to heat up in the microwave.
This might be okay if we were just dealing with computers. But we’re not. Our worlds are populated by lots of other humans, and the lines blur pretty quickly between performance we expect from machines, and performance we expect from humans. For example, I went into my local hardware store recently for some paint to touch up a wall in my house. I couldn’t believe how long it took to shake up the paint to mix the colors. I first stood there for ten or twenty seconds, and then I went to find something else interesting to look at while it finished. And, I realized I was expecting my hardware guy, Billy, to somehow make the thing go faster!
The upshot of this is we are increasingly holding humans to inhuman standards. No errors, instantaneous execution, and replace the human if it proves faulty in any way. We see this in our politics, our corporate life, and our culture overall. You just need one mistake to prove any politician isn’t worthy of his current or future office, or that a CEO has failed. We hold Congressional hearings to prove that the problem isn’t that error is inherent in human decision-making, it’s we just had bad people in the wrong places, and if you just elect people from my party, all will be well. Never mind that those people are also, well, people. We are increasingly tempted to treat one another as processors that wear out, and need to be replaced quickly, before whatever circuit that blew can disappoint us again. And because we have instant access to information, we have an opinion about everything, as if we are and have always been experts on deep ocean surveying, or other things we knew nothing about a couple of months ago. Our media have become a festival of second-guessing and I-told-you-so. Heck, our online chats are almost nothing but that. We are used to perfect computer-based execution as the rule, with delay, error, and lack of me-centricity the detestable exception.
I am not a Luddite; I don’t think there’s any way to go back to human-based execution with its inherent error rate as the norm. But I do think we are losing many things, as we have hedonically adapted to the kind of performance powerful computing enables: forgiveness, empathy, and the presumption of good faith are among these. Computers neither need nor want any of these things. But in a world where fear and alienation seem to be the prevailing affliction, I think we humans all need some of these things, some of the time. I know I do. Not only do we need to receive them, I’m afraid we’re making our lives worse by forgetting to give them. Good studies show that gift-giving, whether tangible objects or simply empathy and understanding, are at least as good for the giver as the receiver. And that, I think, is what we paradoxically risk losing by expecting inhuman performance of humans, like you and me. By condemning the inherent fallibility of our humanity in others, we risk disowning the same in ourselves.
Market failure and rural health care
For decades, the theory of American health care reform has been to introduce market forces and make them effective enough to control pricing and utilization, ideally at rates no greater than general inflation. This has been true since before the failed Clinton era reform effort, and its core thesis of managed competition developed by Stanford economist Alain Einthoven.
But what happens in locales that are too sparsely populated to support at least two competitors for a given service? What if it can’t really support one competitor without outside subsidization? Much of Colorado’s geography fits this description. In the absence of market competition, what forces will match supply and demand?
The issue is more complicated than it seems. From a purely technical standpoint, one might advocate for the decommissioning of facilities in such areas. “Look, if the market can’t support them, then I certainly don’t want to use my tax dollars to do it,” some might say. “If people choose to live there, then they have to pay their own way. Many things are more expensive in rural areas, and health care is no exception.”
But health care services aren’t like others, in that people take “care” as a sign of “caring”. If we stand by while their hospital fails, some would interpret that as a sign of neglect at best, and hostility at worst. Recently in Boothbay Harbor, Maine, St. Andrew’s Hospital became St. Andrew’s HealthCenter, with no capacity to admit people overnight. Despite the economic realities, the hospital seeing few emergent patients, and losing money because of expensive but underutilized staff, local residents were appalled that there would be no local hospital beds.
Someone at a local Maine foundation explained this to me. She told me, “This isn’t just a matter of economics. Many have contributed to their local hospitals over the years. In some of our towns, it’s the largest remaining employer. People identify with their local hospital, and its loss is a blow to civic pride.”
What this tells me is a lesson I have learned over and over again: the hardest problems aren’t technical, they’re cultural. (This has to do with the American drive toward individual empowerment, but that’s a whole other post.) Assuring adequate service to rural communities in the information age can be achieved, more cheaply and in many cases with an improvement in patient experience outcomes. Sanjeev Arora in New Mexico is a pioneer in telemedicine through a program he started called Project Echo. He’s demonstrated outcomes in many specialties in rural areas of New Mexico that are as good as those he achieves in his own specialty clinics in Albuquerque. He does this by bringing nurse practitioners and other primary care providers on to his team remotely, through telemedicine. I think he’s demonstrating that a static body of knowledge isn’t the main determinant of good care; it’s local relationships and the ability to stay current in an area through ongoing discussion with a team focused on the same kind of patient. It tells me that the best repository of clinical knowledge isn’t single human brains last intensively programmed years ago, but a living human “cloud” intelligence supported by the actual computing cloud. Both should continually update themselves.
Important questions loom in Colorado and other states with rural regions: how do we maintain adequate services for sparsely populated areas, at a price that is sustainable? How do we need to start thinking about services differently in order to widen the possibilities to solve the set of equations that define this problem? How do we honor the contributions of those who built these rural facilities that were once relevant, even vital, but before travel and information transfer were so easily available? How do we keep up with residents’ expectations that rise as fast as those in urban areas, but whose infrastructure cannot?
Complexity theory says that for complex problems with multiple independent actors, it is impossible to master plan solutions. The independent actors respond unpredictably to attempts to change the system. What can be done, though, is to plan interventions, measure results, adjust the intervention, measure, adjust, measure, etc. Rural health care system redesign is likely one such complex problem. Solutions to such a problem may involve innovative systems like telemedicine, mobile apps, and the local Walgreens being the main health care facility in town. But as a cultural problem, surely anyone outside of communities suggesting any of these things for communities will fail. Complex solutions cannot emerge without the leadership of the people affected by the problem. The external pressures in communities are not under their control; their response to those pressures is.
Synthesis, systems, and relationships
Recently I have been pondering whether my daughter should try to become a physician. She’s expressed some interest, but remains undecided. I am ambivalent about the prospect.
We overestimate things that have produced benefit in the past, and underestimate things that will produce benefit in the future. I think that often, as I am coming to understand more and more that we are the product of emotional decision-making, and not rational decision-making.
When I was growing up, there was no question that becoming a physician was a good thing to do. I think that our parents were absolutely convinced that education was the way to a better financial living, and therefore of a happier life. And indeed, I got a degree in medicine, and that improved my standard of living over theirs. Whether that makes me happier or not, it’s hard to say. I look at my 86 year old mother, and think that she looks pretty happy. And indeed, she has lived a life that allows her to appreciate the relative economic security she now enjoys. She has been dirt poor, living in New York’s Chinatown, next to the Bowery. She experienced living with a rich physician uncle in her childhood, on a large estate. And she experienced living in the middle class, as a draftsperson in the suburbs of Chicago. She has seen the gamut, and I think it helps her be grateful for where she is today.
The research on wealth and happiness says that my mother did a lot for her happiness once she advanced from living hand to mouth in Chinatown to a lower middle class existence. This happened for my family when my father took a job with a cousin in his laundry in Fort Wayne, Indiana. The data say that once worrying about food, shelter, and clothing is no longer the prime concern, we rise in happiness. But becoming more wealthy after that doesn’t seem to add much to our happiness.
What does seem to make us happier is relationships and experiences. This seems to be especially true when you combine the two, experiences that create and deepen relationships.
Against this backdrop, I see my daughters’ generation as struggling to find the kinds of jobs that would allow them to exceed my standard of living, to enjoy an economic security comparable to my own, just as my parents invested in my education to better my economic security.
But it seems that our economy is plateauing, from the booming growth that characterized the half century following World War II, to the Internet boom and bust, to the relative stagnation of the last ten years. It is not surprising that this era of relative stagnation followed the Internet boom. One of the major consequences of the increased productivity that came with computerization is the elimination of jobs that could be done by computers, faster and with near zero errors. A whole class of jobs that dealt with the classification, storage, and recall of information was eliminated. In the beginning, these jobs were obvious: filing clerks, typists, newspaper writers and editors. Remember what my mother did in Chicago? She was a draftsperson. Ask anyone under 30 what that is, and you’ll get blank stares. That job was obliterated by computer-added drafting (CAD).
But increasingly, other jobs that involve knowledge management are finding the same fate. These include what we call professions now, ones that took advantage of knowledge scarcity and obscurity. This includes attorneys, physicians, architects, professors, consultants, and others. Any field that relied on years of training to store masses of information in the imperfect repository we call human memory is now under fire for the cost of that process and the imperfection of its recall. Remember an obscure court decision that could bear on the current situation and bring it to bear in a lawsuit? Google will do that in a millisecond, and recall it more perfectly than any human brain. Cost to do that search? Even calculating in a contribution to fixed cost, it’s pretty close to zero. (This is why search is such a lucrative business: once you set up the infrastructure, marginal cost is almost zero, making marginal profit almost 100%. It’s a highly scalable business.) Search and recall is cheap.
Which brings me back to my daughters’ generation. In my college days, most of the smart kids aspired to be doctors, lawyers, and professors. But these days, the business advantage of acquiring the body of knowledge to enter any of these professions is eroding at a steady rate. Watson, the IBM computer that became Jeopardy champion a few years ago, is now being purposed to practicing medicine. While Martin Kohn, the scientist who is responsible for its development reassures us that it will simply be a tool that humans use to deliver better care, it seems highly likely that it will suggest better decisions than the unaided human doctor will be able to render alone. So what is the marginal value of the human in this equation?
I think the answer to this may be in the emotional decision-making I talked about at the beginning of this piece. Recent neuroscience tells us that our default mode is social. From mirror neurons to the ventrolateral prefrontal cortex, we are hardwired to detect and react to other humans in our environment. First we assess whether they are an outright threat, but then we do more subtle calculi, estimating what their motives are, and how we might either harmonize with or oppose those motives.
This means that the professional roles I’ve talked about that rely on information storage will likely transition into information interpretation and counseling. The first part of this is the incorporation of right-brain subtleties that might not be easily conveyable through data (although this domain may be shrinking because of Big Data); the second part is the building and maintenance of trust channels to through which the data flows. In medicine we term this “the doctor-patient relationship”. This is archaic as this dyad doesn’t begin to describe the complexity of this interaction, based in the future on terabytes of information.
What are the implications of this for my daughters and their friends?
- Professions as the royal road to prosperity will probably underperform. If professions were a stock, we would probably be rating them as “underperform”, or likely to be worth less in the future relative to the broader market of jobs that currently exist. The barriers to entry remain high and are getting higher (Google “average medical student debt”), and the marginal benefit of their certifications is diminishing (Google “percent of law graduates who get jobs requiring bar passage”). Cost/benefit ratio is getting worse steadily.
- Many of the middle class jobs that remain will require tech literacy. I actually think that tech is the new English, a knowledge domain that underlies all other areas. The ability to understand how tech makes your ideas known and your effort valuable to the market will be critical in this generation. Even jobs that we think of as blue collar, like truck driving and heavy machinery operation, are now requiring some understanding of the computers that are increasingly built into those jobs.
- Schumpeter’s creative destruction will require them to reinvent their value proposition every few years. You say to-may-to, I say to-mah-to. What you call proprietary knowledge, I call a market inefficiency waiting to be commoditized. Remember when the iPhone was the “It Girl” of gadgets? Now Apple’s stock is flattening out because of Google’s Android platform and the various manufacturers who are producing hardware to exploit it. They in turn will be disrupted by someone else with a better mousetrap, say a neural interface device that will make touching icons just so first-decade-of-the-twenty-first-century. The point here is that the cycle time of the destruction of perfectly good knowledge caches is shortening, so that obsolescence that used to take a generation takes a few years now. So what makes us think that the ideas that we base our livings on are somehow so special that they won’t be disrupted in the same way?
- If teamwork skills were a stock, it would be a “buy”. The skills that come from a well-developed social brain will be increasingly important. This is because being able to work in teams that match the complexity of the task/service experience required by purchasers will be more and more prized. The machines have linked together vast amounts of left brain inputs, to draw inferences about very complex systems. Now the challenge is to match that complexity in our social systems to improve outcomes. Content knowledge? Sure, still valuable. But relative to relational skills that allow teams to perform at a high level, that latter are appreciating in value.
- If search and synthesis were a stock, it would also be a “buy”. The ability to find the right dirt cheap content knowledge on the Web and then reassemble it in ways that bear on specific circumstances someone with money will pay you to understand, this will be big. Recently I read a book that says that some people see numbers as colors, and have other unusual sensory experiences. This is because they have connections in their brains the rest of us don’t have. This variant is overrepresented in creative professions by a factor of eight. Synthesis is the essence of creativity and innovation, and as translating ideas into reality becomes easier, the thinking of the ideas gets relatively more important.
So how should this inform how we shape society going forward? What it says to me is that the following skills are going to drive the next phase of our development: information recall and restructure, rather than information storage; teamwork skills vs. solitary production; and synthesis/creativity vs. static mental model care and maintenance.
See the pattern? All of the obsolete characteristics above are present in our current mental models of professions. Think about the small group family medicine doc, hopelessly trying to keep up his knowledge with the unaided human brain, and working detached from a system of knowledge management. That person works according to obsolete protocols, engages in little continuous learning, and uses a largely static knowledge base. While they may work in teams, most of the time those teams aren’t about generating new and improved management systems continuously, they’re more likely unidirectional vehicles for physician knowledge implementation, knowledge that can be decades old.
Medicine, law, and other professions based on information storage are in the process of changing to recognize the value they actually produce. A good deal of that value has been eroded by the massive power of computing to make information storage and recall amazingly cheap. What’s left will be about synthesis, systems, and relationships. And if my daughter can be good at those things, then she can probably make any profession work for her.
CVS stops selling cigarettes
CVS/Caremark announced last week that it will no longer sell cigarettes in its drugstores, which has been widely hailed as progress in the war against tobacco. Many now expect its competitors to follow suit, and potentially make it less convenient to buy cigarettes overall. This remains to be seen, as cigarettes remain widely available through other very convenient outlets, like grocery stores and gas stations. So why is this a big deal?
First, this represents a real amount of revenue for CVS, about $2 billion annually. With that amount of money on the line, you know they didn’t make this decision lightly. Ultimately deciding to stop selling something with such a reliable stream of customers has to have a real purpose behind it.
At first glance, that purpose might be to be/appear to be more moral than its competitors. While this might be the case, the more revealing reason might be this: the public feels health care companies shouldn’t create their own business. Imagine what people would say if the Cleveland Clinic had cigarette machines in its lobby, or a bar in its cafeteria. You get the picture: it wouldn’t go over well.
What this reveals about CVS is its intent. CVS is trying to morph from a provider of drugs to a provider of care. CVS has nearly 7,500 drugstores, but more importantly, owns Minute Clinic, the largest walk-in chain of clinics in the U.S., with 570 locations inside its drugstores. In a classic disruptive innovation, Minute Clinic is providing basic primary care an aisle over from the ibuprofen and cough syrup. Staffed by nurse practitioners, this care can be provided more cheaply and conveniently than its status quo competitors can, the primary care physicians. Think about it: which did you visit last, your PCP or your drugstore? How many visits do you make to your PCP a year? How many to the drugstore? For availability and convenience, its hard to beat something that close to where you live and work, and that’s in some cases open 24/7.
I’ve had this conversation many times with PCPs, many of whom continue to poo-poo Minute Clinic and its peers as “a flash in the pan”, or “inferior care”. They can do that, but they should also be nervous. The 40th largest company in the world just gave up $2 billion in revenue annually, because it’s betting that Minute Clinic is the future, and that unless traditional primary care changes radically in the next few years, it’s the past. And CVS is polishing its image to accomplish just that.
Debt, data, and deciders
A version of the following first appeared in Colorado Medicine earlier this month. It was directed at the physicians of Colorado, but I think has wider applicability:
It’s a privilege as a representative of the Center for Improving Value in Health Care (CIVHC) to write this article about the changing landscape in American health care, and how it affects us here in Colorado. Just for anyone who still doubts that health and health care in Colorado will be different in the future versus the past, a few facts, from a recent article in JAMA1:
-In 2000, 53% of physicians practiced independently, and 18% were hospital-affiliated. In 2010, the proportions had almost completely reversed: 23% independents, 48% hospital-affiliated. The macro trends favor further vertical and horizontal integration, for reasons I’ll go into later in this piece.
-The trend toward consolidation affected many health care sectors in the last decade, including insurers, pharmacies, and office-based physicians. The proportion of office-based physicians practicing in groups of six or larger rose from a third to nearly half.
-Nearly three-quarters (72%) of physicians today practice on an EHR, as do nearly seven hospitals out of eight (87%), as of 2012. Contrast that with earlier in the last decade when less than half of both groups were on an EHR.
The big question is: why is this happening? And how should physicians in general adapt?
At CIVHC we talk about three major trends in American health care, three tsunamis of change that are affecting every aspect of American life, not just health care. These are debt, data, and deciders. Let’s look at each of them.
Debt
Debt is at every level of our society today. As a generation, we Baby Boomers were raised in an environment where we could always count on future growth to bail us out of unreasonable debt obligations today. Big mortgage? Don’t worry, you’ll get raises later on that will make it affordable. Student loans? No problem, good jobs available upon graduation.
But then the Great Recession hit, and the Big Reset is taking place. People in my daughters’ generation are working at Starbucks while looking for work in the field of their choice, often to no avail. We’ve gone through a series of asset bubbles, from technology to banking to housing. Credit, which fueled the illusion of Infinite Growth That Hides All Sins, is only now starting to become available again, this time on more disciplined terms.
Debt, and particularly debt that prevents further borrowing, drives a search for value. As long as you think you have infinite resources, you care little about value, or more specifically, you are insensitive to the cost of things in order to get the benefits you want.
But once we perceive resources to be limited, it’s a whole different ballgame. Now suddenly, we are looking at price tags, and ratings by other consumers, others like ourselves. I notice this difference when I travel. If someone else is paying my expenses, I tend not to shop for my hotel, but to stay at the conference hotel for convenience. If I am paying with my own money (which I perceive correctly to be limited), I go to TripAdvisor and try to find a lower price for a similar hotel, close to the meeting. I read carefully about the pros and cons of that particular hotel, to predict whether I’ll like it.
What’s this got to do with health care? Before, nothing. Now, everything. Because of insurance, before we acted like the traveler with the expense account. We didn’t have to pay more to stay in the conference hotel, someone else did. We didn’t comparison shop for medical services, because it didn’t make a difference to us financially. We didn’t experience costs (much), only benefits. So why wouldn’t we metaphorically try to stay at the Ritz vs. La Quinta? If we stayed at La Quinta, we’d be saving money for someone we don’t like (the insurance company) and in doing so, worry that we shorted ourselves. Who does that?
I like to say jokingly that being out of money has an amazing clarifying effect on thinking, but there is truth in that. And being out of money on so many levels as Americans is clarifying our thinking about health care costs. It’s making us ask for the first time, “What are we actually getting for $2.7 trillion, and 17% of our economy?” And it is our debt, personally, corporately, and nationally, that is compelling us to do so.
Data
Remember what I did when shopping with my own money for a hotel? I went to TripAdvisor. Why? Sociologic studies show that the aggregated opinions of others in the same situation more strongly predict my satisfaction with a product or experience than I can alone. But that’s only possible because I can read their ratings and opinions online. In essence, massive computing power has allowed people to compile data about many experiences they have daily, and to make choices about those that involve giving other people money. Which brings me to a guy named Gordon Moore.
Moore was an engineer at a company called Fairchild Semiconductor, a strange name in the 1950s when people we just discovering uses for transistors. He figured out something cool working there, and it was this: Moore’s job involved making microchips, and cramming more and more transistors onto chips as fast as he could. He noted that he could double the number of transistors on a chip about every 18 months, effectively halving the cost of computing power. This became Moore’s Law, and the exponential trend he noted then continues today, half a century later. Moore also went on to found another little company with a funny name: Intel.
Why should you care? Think about how you picked a hotel in a strange city before TripAdvisor. You asked around at work, or got a recommendation from your spouse’s cousin who lived there ten years ago. Pretty hit or miss. But now, with TripAdvisor, finding a hotel in your price range that people love is a snap. Technology, and in particular, Moore’s Law, makes this information cheap, nearly free in fact, and cheaper every year from now until forever. Data makes shopping effectively really, really cheap. Which brings me to deciders.
Deciders
Okay, now we’ve got the average American family of four deeply in debt, with no additional help from their employers or governments coming any time soon, and massive and growing amounts of data available to them on their smartphones. Their employers are providing health plans to them that have $10,000 deductibles, so they’re spending their own money for anything beyond preventive care. Some health plans have reference pricing as a feature, in which when the plan does pay, it only pays the lowest price offered by a good quality provider, and you the patient get to pay the difference between that amount and what your chosen provider charges.
Remember TripAdvisor? There are companies that are starting to do the same thing in health care. Sometimes employers are giving their employees subscriptions to these companies so the best value in knee replacement shows up on their smartphone when they click the search button. So what will the average consumer think? “I’m spending a lot of my own dollars and I have access to information to choose the best bang for the buck. While I still worry about making good choices, I can read online what people just like me think of the doctor and hospital I’m about to choose. Hey, remember when I used to have to ask my spouse’s cousin who he chose when he had the same operation ten years ago? That was so twentieth century.”
There’s more to this story, but these three trends, debt, data, and deciders are bringing to health care what already existed in most other sectors of our economy: functional markets. Markets are places where consumers can compare prices and benefits, and choose for themselves where to spend their money. And for arcane reasons, they’re just now catching on in health care, because of these three forces.
And consumers these days don’t buy products so much as experiences, complete experiences where they can. That means they don’t like buying the parts of the car and assembling them themselves; they like buying the fully assembled car off the lot, and expect to be able to drive it without a lot of training. So the thought they’d have to pay for and assemble a surgeon, a hospital, a rehab center, physical therapist, etc., and manage them because they don’t really talk to one another? And get separate bills for what seems like the same thing? That’s not how people will shop for this stuff in the future.
Implications
Now we’re to how this plays out for you. Despite a massive trend over the last half century toward equating specialization and segmentation with expertise, increasingly consumers are going to recognize that this segmentation makes them buy pistons and catalytic converters separately, and hope the parts fit together in a way that makes the car run in a predictable way. Because teams that communicate and coordinate action well can create coherence for patients and consumers, they have a definite advantage over depending on, say, the random chance that all the players in a care plan will all do the right thing at the right time in the right way. I pointed out at the beginning of this article a growing trend toward doctors working for hospitals. This is because hospitals believe they need to control every phase of a patient’s experience to be successful in the future. They believe this because people who buy their stuff are starting to tell them that. While for many physicians this is anathema, and there is no rule that says hospitals have to be in control of the combined enterprise, there is no question in my mind that any entity that can actually create whole, coherent, and successful experiences for patients at a competitive price will be winners in the next decade. Personally I hope those entities are provider-led, but the hard truth is that value-driven consumers with good information will buy the better car at the better price, no matter who built it.
At CIVHC we are helping people get their teams together, measure their performance, and then improve it so they can sell a higher value experience. Currently my colleagues there are working on helping people construct bundles of care; increasing discharge reliability and thereby reducing readmissions; creating reports out of the All Payer Claims Database to inform providers of the cost and the quality of the experiences they create for patients; and many other things that we hope will enable providers to create greater value. And that will be good for everyone–except those who insist that delivering care in a disorganized way is the best we can do.
This, therefore, is the choice before you. You can either continue to contend that disorganized care is best, or you can acknowledge that you and others will do a much better job for people as teams that communicate well. You can continue to see only your piece of someone’s care, or you can try to understand how you fit into that patient’s total experience, from their perspective. And you can continue to imagine that we as a state get to spend from someone else’s infinite health care expense account, or you can acknowledge that in this area as in all others, the money is limited, and we need to find ever increasing value to make health care sustainable again.
At CIVHC we hope that Colorado’s providers will choose to find their place in teams dedicated to better clinical and financial outcomes for patients; to understand their own performance though others’ eyes; and to work in those teams to deliver value for people who have not a dime more to spend on care, and who increasingly know what they’re getting when they check into the health care system.
1The Anatomy of Health Care in the United States, JAMA, 2013; 310(18):1947-1963.
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