BY DAVIS LIU, MD

The future direction of American health care is unclear.  Certainly the cost trend as it exists is unsustainable with health care costs being a major concern of the private sector, the government, and individuals.  How does the nation manage costs while ensuring high quality medical care, access, and service?  Proposals include increasing competition among insurers, providers, and hospitals to drive down prices or giving more financial responsibility to patients via higher deductibles and co-pays with the belief that they will demand price transparency, shop around for the best price, and as a result slow health care costs.

What if both ideas are wrong?

While it is possible these plans might work, I cannot help but notice the similarities in the challenges for patients in navigating the health care system and consumers figuring out how to purchase and use technology.  Walk into your neighborhood electronics store.   Individuals are overwhelmed with the number of product choices, manufacturers, differences in technical specifications and features.  In the majority of situations, consumers are unsure of what they are purchasing.  They want something that just works, whether surfing the internet, making home movies, or being connected with loved ones.  The gap in knowledge between an expert and a consumer is great and often unintentional and unapparent.

Within the technology world, there are two groups of thought.  The first group offers technology in a closed system, like Apple, where the focus has been on just making things work.  There are a limited number of product types and designs.  For example, its current smartphone, the iPhone 4 comes in only two types.  Aside from the base memory of 16 GB or 32 GB and two different prices, the phones are otherwise identical in features with the same apps, cameras, and ability to record video.  Although the specifications are available for anyone to see, the focus is rarely on the technical elements of the products themselves and more on what they can do for you.  Walk into any Apple retail store and the products are situated by function.   Staff ask not how much computing horsepower, storage space, or CPU speed one needs, but what one plans on using the smartphone or computer for.

In contrast, Google’s sponsored Android platform, which runs smartphones from a variety of manufacturers gives consumers maximal choice.  Companies like Motorola, Samsung, HTC, and LG offer a variety of combinations of styles, features, and ironically even different software versions at various price points.  Verizon and AT&T wireless offer no less than 10 different Android based smartphones.  The amount of choice and options could be intimidating.  While potentially an Android smartphone could be cheaper than a comparable Apple iPhone, people often fail to account for all of the time and energy spent on researching, thinking, and also potential worry and buyer’s remorse that the right choice was made.  The time and energy spent does cost, either monetarily or emotionally.

Which one would you choose?  A system which just works, gets the job done, and has been designed to fulfill most of your needs?  Or alternatively, a different system which provides more choice, more options, and in many cases, requires more time to research and become an expert to make the best decision?

If you look at proposals and trends in health care, it appears many are advocating for Android.
To manage costs, consumer driven health care, where patients have more financial responsibility via the addition of deductibles and higher co-pays are felt to be the answer.  The patient is the party accountable to having the right tests done, finding the right doctors, reviewing and maintaining their medical chart using personal health records, and shopping around for the best price when it comes to imaging and other procedures.  After all, who has the most motivation to make the best choice but the individual who’s life depends on it?

Increasingly there is research that shows people are decreasing health care costs.  Unfortunately it is not the behavior of avoiding expensive excessive care (opting to see a primary care doctor rather than the emergency room for non-emergent evaluation) but skipping preventive tests, prescription medications, follow-up evaluations to treat chronic conditions at the early stage to prevent future complications.   If true, the implications of these small inconsequential choices by patients could be problematic years later.

Also similar to Android philosophy, others argue for more competition.  With the consolidation of insurers and in some case providers and hospitals over the years, understandably many are concerned that prices are driven higher through monopoly power. Instead, the belief is that having many insurers, providers, and hospital networks will improve health care as they compete for patients on areas of service, quality, and access.  The market will reward those who are best in providing all three.  With the large number of competitors, groups will be unable to have pricing power and therefore costs will be managed.

Providing patients plenty of choices is proposed as the key to fixing the health care crisis.  Perhaps this is the reason for the creation of insurance exchanges in the recent health care reform legislation.  Patients will have the opportunity be to select health insurance plans which are not tied to their place of employment.  Let them figure out which insurance plan is the best.  Have them figure out which doctors take their insurance and are the best.  They can select from their menu of different hospitals and determine the best one for their needs.

Is there another way?  Would patients prefer a different system which is integrated and seamless and where patients can focus on simply getting better and not spending time and energy trying to figure out where to go and who to select?

One example might be where I work, at Kaiser Permanente in Northern California, a vertically integrated organization with health plan, hospitals, and doctors working together to provide care that is convenient, simple, and personal for our members.  Dr. Atul Gawande in his June 2009 New Yorker piece, the Cost Conundrum noted places like Grand Junction, Colorado, were able to provide high quality care at lower costs when doctors worked together.  Other organizations which were physician led and accountable also had similar outcomes.

Grand Junction’s medical community was not following anyone else’s recipe. But, like Mayo, it created what Elliott Fisher, of Dartmouth, calls an accountable-care organization. The leading doctors and the hospital system adopted measures to blunt harmful financial incentives, and they took collective responsibility for improving the sum total of patient care.

This approach has been adopted in other places, too: the Geisinger Health System, in Danville, Pennsylvania; the Marshfield Clinic, in Marshfield, Wisconsin; Intermountain Healthcare, in Salt Lake City; Kaiser Permanente, in Northern California. All of them function on similar principles. All are not-for-profit institutions. And all have produced enviably higher quality and lower costs than the average American town enjoys.

Perhaps this is the reason for the creation of Accountable Care Organizations in the health care reform legislation.  Whether the legislation and regulations can foster and replicate similar organizations and outcomes remains to be seen.  What I can tell you is that within my organization, doctors, nurses, and support staff are working hard to improve how care is delivered to our members much the same way I suspect software engineers and designers at Apple focus on their technology to make it intuitive and so it just works.

Perhaps there is no illustration better of the potential of American health care than the words from a patient.

Here’s why I chose Kaiser for my medical needs at age 25:
1.    I liked their Web site.
2.    It was easy to set up appointments over the phone and via the Internet.
3.    They have a 24-hour Advice Nurse phone line which is helpful if your parent is not “just a phone call away”.
4.    Through the Web site you can choose a primary care physician and OB/GYN by location, gender, and bio. If you don’t like your choice you can always change it later.
5.    You can email non-urgent messages to your doctor through the Web site and your doctor has to respond within 48-hours.
6.    The Kaiser Web site will send you an email when test results are available online.

At age 29, here’s why I know Kaiser was the best decision I ever made:
1.    When I was brought to the Kaiser emergency room after my first seizure the staff was able to retrieve my complete medical history, which aids staff in making decisions about my care … even when I’m unconscious.
2.    After scans revealed I had a tumor in my brain, the head of neurology came down to see me and had me admitted to the hospital that night.
3.    My newly acquired neurologist arranged for my transport to the neurosurgery center for the Sacramento region.
4.    Once I got there I worked with Kaiser’s neurological equivalent to Dr. House, except this doctor was way nicer.
5.    My neurologist, neuro-surgeon, oncologist, neuro-oncologist, OB/GYN, primary care practitioner, orthopedic doctor, and physical therapist are all informed about my medical status.
6.    I never have to seek, or wait for, a referral. If a new specialist is needed for my care I get to see him/her as soon as I’m able to get a ride.
7.    I can get lab work done at any Kaiser facility and the test results are sent electronically to the requesting doctor within minutes/hours (or a few days if it’s analysis of brain tissue).
8.    Kaiser specialists network with peers from other medical institutions and often seek second and third opinions for you. They’ll even tell you who disagreed with them and why. If you want to get the second opinion yourself they are respectful of your decision and make sure you get all required materials to make this happen (e.g., charts, scans).
9.    After my most recent brain surgery, my tissue was analyzed by pathologists in Sacramento and Oakland, then sent to Kaiser in Redwood City, who sent it along to UCLA.
10.    While my friends and I did a lot of our own research, Kaiser made it easy for us to get treatment. We never had to figure it out all by ourselves and my doctors/nurse practitioners answered every question I had … even the silly questions.

The future of American health care is unclear.  Do Americans what Apple or Android for health care?

Let’s let them decide.

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27 Responses for “Does America Want Apple or Android for Health Care?”

  1. Jason Lander says:

    Although I realize this article is primarily debating the merits and differences in devices, I would posit that if healthcare focuses on the web – they won’t have to worry about devices so much. Building tools focused on specific OS’s and/or devices is a long term loss. If healthcare applications and websites are built for the web, the devices won’t matter. Go mobile web!

  2. steve says:

    I have a Droid. My wife has an Apple. I am willing to hassle with the complications, but my wife is not. When it comes to patients, a lot of people do not cope well with the complexities imposed by our fractured system of many private carriers. People make bad decisions because they thought they understood their plan, but they did not.

    As a provider I dont like it much either. When I take call later tonight at out trauma center I am nearly guaranteed to get a critically ill patient who has never been treated at our facility. I will have to guess about their medical history.

    Steve

  3. kim says:

    “Increasingly there is research that shows people are decreasing health care costs. Unfortunately it is not the behavior of avoiding expensive excessive care (opting to see a primary care doctor rather than the emergency room for non-emergent evaluation) but skipping preventive tests, prescription medications, follow-up evaluations to treat chronic conditions at the early stage to prevent future complications. If true, the implications of these small inconsequential choices by patients could be problematic years later.”

    Can you cite some of this research? That is not consistent with the research I’ve seen.

    As for the central point of your post, the important thing is that the government doesn’t decide FOR consumers whether they get Apple or Android, or their analogous choices in health care financing & delivery. Both should be available.

  4. Peleus says:

    Healthcare actually choose Windows XP for advanced workstations, Windows 2000 for everyone else and whatever Microsoft supports that was made by a healthcare software vendor or runs on their old IBM mainframe-type machine.

    If you actually noticed what’s happening in technology, then you would see that Apple is leading with an integrated and efficient environment and everyone else is chasing with a fragmented and copy cat set of products which they hope will help them keep some of their current customers. That’s the analogy. Why healthcare also doesn’t see this is the very heart of the problem.

  5. I have an iPhone. I don’t use apps and I don’t use games. I make phone calls and check email. Once in a while I get on the web to check the latest on THCB :-) . The iPhone drops calls with alarming regularity. The quality of the calls is average or below. The battery lasts about one day with average use (maybe 5-10 calls and the same for email). Any call that lasts more than 20 minutes makes the phone as hot as if I placed it in the oven.
    Yes, it is user friendly and pretty on the outside, but the quality of the phone (it is a phone after all) is par or below. It is also expensive and has a fixed price no matter where you buy it.
    I am waiting for Android to create something better, and I know they will, at which point I will gladly toss the iPhone in the trash.

    Now to health care. Kaiser may be great, but Kaiser is NOT cheaper than any other insurance plan in spite of being an integrated system. How do we explain that? If Kaiser realizes so many efficiencies, where is the money going? The same is true for all other systems of excellence mentioned in the post.
    I would argue that our primary focus should be on reducing cost of care without compromising quality of care. Apple hasn’t done that for technology (quite the opposite), and Kaiser has not done that for health care either.

    I don’t believe in integrated systems to the extent that the payer and the provider of care are one and the same (ala NHS). The temptation is too great for mere mortals.
    I would prefer single payer, or single collector, coupled with specific benefits regulation across the board, and let providers of care stay independent and do the best they can for patients.

    Not quite Android, and definitely not Apple.

    • Agree health care should be more affordable. People however confuse price versus value. In general Kaiser is less expensive than other comparable plans. Additionally, other plans do not have all of their doctors connected via a common and robust EHR which has drug-drug interaction safety checks and clinical decision making support. As a result, care can be coordinated and provided in the office, telephone, and secure email. Patients cannot email all of their doctors, book appointments online, or review their lab results. With the majority of doctors still using paper charts and requiring office visits as the only modality for providing care, looking at price alone, though important, does not actually reflect what patients are getting.

      Although it appears the iPhone isn’t adequate for your needs, it appears Android isn’t able to fulfill your needs at this time. When Android finally does make something better, undoubtedly Apple will have as well. If you look at what Apple has accomplished using its vertical integration of software and hardware, they created a completely new consumer electronics category, the iPad, a technology yet to be matched by any competitor. Apple has done that for technology. It’s not just the price, but the value and the experience.

      Finally, just to clarify your last point, the doctors at Kaiser Permanente belong to the Permanente Medical Group, an independent physician run and physician led medical group which is separate from Kaiser Foundation Hospitals and Health Plan. Only when the two entities work together does it become Kaiser Permanente.

      • Dr. Liu,
        I have no doubt that Kaiser is providing impeccable care to the patients in their plan. However, the same impeccable care is also available to patients in differently structured systems.
        The problem we face in health care, in my opinion, is twofold. This type of excellence is too expensive and it is not homogeneously available to all. You could argue that expanding the Kaiser model would solve the latter, but there is no indication that it will not solve the former.
        We need a solution that provides the value that Kaiser provides, but for less money. Just like we need a solution that provides the value Apple provides, but for less money.
        In the distant past, when Apple was similarly situated, others came to the table and brought PCs to the masses for an affordable price. I suspect that this time around will be no different. It may take a little while longer, but open architecture, and inclusion of millions of equally creative minds in the process, has a tendency to beat closed and tightly integrated systems, at least in the technology world.
        It remains to be seen how this analogy will play out in the health care realm.

        • Correction:
          Instead of “but there is no indication that it will not solve the former.”
          Should be: “but there is no indication that it will solve the former.”

        • The point of the article was whether the public wants integrated care or fragmented care. The former an organization is accountable for the entire experience, like Apple, or simply to optimize each element, like Android. I simply use Kaiser as an example of a completely vertically intergrated health care organization and of what is possible. Certainly, a virtually integrated is likely to do equally well as a vertically integrated program like Kaiser may not work in many parts of the country.
          The problem that Apple faced in the late 1980s with the Mac versus Windows issue was that the perception of the former was that it no better than the latter. It was only until the iPod, which as a MP3 player, which as a product category was far less expensive than a laptop, did the public have the opportunity to truly realize the importance of the tight integration of design, engineering, and software. Since then, it has been pretty clear that the streamlined and closed system, when focused on the right goals, the total user experience, has been winning over the past decade. Because unlike the past when the PC was not connected to the world via the internet, data was available to be streamed seemlessly 24 /7 via computer, mobile devices, and information was available where and when you want it, having multiple vendors focus on different elements made sense.
          But that was then and this is now. The public doesn’t want the hassle of connecting all of the disparate tasks together, they want someone else to help them do it. As Apple CEO Steve Jobs said recently, “We believe integrated will trump fragmented every time.” He also said if the public doesn’t believe it, then they will not choose Apple.
          I don’t know if the public will ultimately choose integrated care versus fragmented care and that is why I closed the piece with “let’s let them [patients] decide”.

  6. Tim says:

    Anybody who thinks the care at any institution is different because they are “non-profit” needs to buy my bridge.

  7. rbar says:

    I have worked for a private MSG as a physician and read about for profit care – seems to me that both go for the money, but the for profits seem to veer more easily into fraud.

  8. Andrew says:

    It’s really exciting to see the progression of healthcare IT. If anyone is interested, I found a great site called InformationManagementCompare/Healthcare IT. They analyze and compare companies who offer health IT services and software.

  9. J. Stefan Walker, M.D. says:

    Very insightful article that encapsulates a key segment of how HIT will develop at this critical junction in time. Very apt ‘other side of the coin’ from Margalit. Here’s my addition: think about the U.S. commercial airline safety record and standardization. 100% safety record for passengers 4 years in a row; there may be alternative ways to ‘skin the cat’ on airline operations and safety, but who could argue with picking just one, and honing it to that kind of perfection through mandatory standardization? To my analysis, that same reality would be achieved for healthcare through a reputable, evidence-based, physician-led organization developing the ‘walled garden’ of HIT (Apple, in this metaphor), but extending beyond and into process elements and methodology of care delivery. I think we will indeed actually see this develop through projects like the personalized medicine project at the Cleveland Clinic, or through super-ACOs and /or beacon communities: some programs there or elsewhere will be found to work so incredibly well at both cost containment and quality, that they arise as a new standard that will be disseminated. As long as there is no defined standard (or at least a short list of comprehensive standard sets), however, the resulting confusion and lack of accountability will ensure that we continue to spin our wheels in both cost and quality. I excitedly await for the Apple analog in medicine – especially one that embraces the role of non-physician providers to extend the workforce; one that finds a way to integrate the technology ‘luddites’ and not lose their valued wisdom in the transition; and one that properly integrates the patients themselves into the care team. A new standardized, comprehensive, self-updating healthcare delivery protocol like that wouldn’t only save the US economy and healthcare system – it could literally change the world.

  10. Brooke says:

    Hi Dr. Liu, we don’t know each other (a friend directed me to this blog), but I wanted to chime in and say that your thoughts are spot on. I was actually discussing this same thing with another friend last week! As patients, we don’t *want* to make our healthcare decisions based on research of all the options out there. This would be doubly true if we were severely ill (when seriously sick, who wants to focus on researching treatments? You just want to get treated, period). We dont have training in medicine, and there is so much medical misinformation on the Internet – putting the decision in the patient’s hands seems like a horrible idea. I trust my doctors to give me a handful of well-informed options to choose from. When it comes to medical stuff, I would rather have the Apple.

  11. Brooke says:

    PS: you should do a TED talk on this!

  12. "Logan" says:

    I’ve been avoiding mentioning this, because I know so many people on both sides of this equation, and I don’t want anyone to start questioning their situation. That said, I also want to warn people who might end up in the situation I was in. I was also with Kaiser for many years, and appreciated the same things mentioned in the article. Recently, I too was diagnosed with glioblastoma multiforme, grade 4. In my case, the standard treatments didn’t work so well, and I had a recurrence. Here is where the battle began. Kaiser was extremely resistant in allowing me to enter a very promising clinical trial, because the trial required surgery as well, and they wouldn’t pay for it. They wanted to do the surgery themselves, which I understand, but in a clinical trial the surgery needs to be performed by the organization running the trial. I was forced to challenge their decision internally, presenting in less than 10 minutes an argument to convince them that their denial was improper. The argument I presented (written by a family member of mine) was actually incredibly strong and irrefutable. And yet, they once again denied my entry into the clinical trial. I was lucky enough to be able to switch out of Kaiser, but am still angered by their approach and the fact that over the last decade I had been paying them insurance money while I was incredibly healthy. Then when my brain tumor appeared, they essentially forced me to leave them to try to save my own life. A financial coup for them, unless others take heed….

  13. Erin Wheeler says:

    I do have a bias toward Kaiser and my iPhone. I, like the patient quoted, have a brain tumor. Thanks to the digital age, and Kaiser’s cooperative, preventative nature, my Glioblastoma was discovered July 4, 2009 around Noon on the CT scan and removed 76 hours later.

    I had my first MRI on a Sunday. It occurred at the hospital where I was born in 1971.

    With Kaiser’s support, I have been on a UCSF clinical trial since. I received raditaion and Temodar through Kaiser, Tarceva and Avastin through UCSF. The hardworking people at both facilities cannot always transfer documents easily. My phone and Kaiser’s filing system allow me me pull up and print test results while I am at UCSF. Because Kaiser processes and posts my lab results on their secure system, I could easily follow day to day results of platelets, letting me receive Avastin on time. No phone calls, no waiting, no frustration.

    Prior to this era, I was able to watch beta serum tests double as I went through fertility treatments.

    The system lets a practical person be educated. The system allows a person with a “terminal illness,” receive constant reassurance. The system lets the physicians know their paitients better. My last MRI was on a Sunday. Within 48 hours, my radio-oncologist (24 hours), the neuro-oncologist (30 hours) and the wonderful surgeon who removed my tumor (44 hours) had looked at the scan and given me their opinions. The radio-oncologist understood he could give me bad news. Fortunately, there was only good news to give.

    Imagine if a patient had to sit by the phone, waiting.

    People can complain about modern health care and it is a reasonable complaint, but the physicians at Kaiser work together. I am on COBRA, I am still getting a bargain. $15,000.00 a year. In the last 25 months, I had a baby, I had 2 CT scans, a crainiotomy, 13 MRIs, radiation treatment, over fifty physician appointments amongst eight disciplines. Each physician knows my story and knows my attitude. I will beat the odds.

    My only dream would be that my iPhone4 could run the PACS software. That would simply be awesome. In the meantime, Kaiser takes care of immediate needs, and UCSF will watch my tumor for life. From my perspective, I am well-cared for.

    I too, will take the apple.

    Erin Wheeler, http://www.thismomfights.com

  14. Jay says:

    “Do Americans WANT (sp) Apple or Android for health care?”

    Respectfully, Americans want a choice. If I go to my local electronics store, I want to be able to choose from different options of phones. Yes it is true that the iPhone is a popular phone that meets the needs of many people. But does it meet MY needs? Should my needs be the same a everyone elses needs? And what happens when people discover that iPhones DON’T always ‘just work’?

    What should my reaction be if I walked in to my electronics store and they said “Sorry! We no longer have a choice. You can only buy this brand of Phone.” What happens if that brand doesn’t meet my needs? Should I turn arround to leave the store? What happens when I turn to leave and they say “Sorry but you HAVE to buy this phone. It doesn’t matter if you want it or not. It doesn’t matter if you wanted a different make or model. You don’t have a choice. You are required to purchase a phone and it has to be this one. It’s the LAW.”? Like it or not, some people are advocating we do just that with our health care system.

    What happens to a cell phone company, (or a health care provider) when they have no competition? Do they continue to compete? When they know their customers are required to buy their product, are they still motovated to make the best possible product? Will they continue to innovate when there is no reason to try? No of course not. The ONLY reason Apple keeps making new models of the iPhone is because they know if they don’t someone else will eventually come out with a more popular phone. They would loose customers as quickly as a hospital would loose patients if there was a better hospital near by. Monopolies are bad for everyone involved.

    So do Americans want Apple or Android for health care? Yes. They want Apple or Android. Or Blackberry. Or Windows. They want their AT&T’s, their Verizon’s, Sprint’s and T-Moble’s. They want to choose.

    • The point of the article is whether patients would prefer health care organizations which are integrated or not. Note that I close the article with “let’s let them [patients] decide” because I believe in choice.

    • pcp says:

      I think most of the forces are lining up to insure that patients WON’T have a choice (unless they decide to use a concierge-type practice, which isn’t realistic for most).

  15. Pete says:

    I get the analogy between Apple and Kaiser, who has indeed done a better-than-average job optimizing workflows and integrating IT. Unlike Apple this has resulted in lower up-front customer costs, but integrated does not imply holistic, and the technology analogy ends there. (Plus the irony in your discussion is that it’s the smartphone user base’s demands that are driving the overwhelming choice of features).

    For the technology part, Android is fragmented because that’s the byproduct of an open system. On the plus side, it encourages innovative application. On the minus side, everyone tries to make it a ‘one-size-fits-all’ solution, so it goes from handsets to tablets to automotive and industrial uses with the innovators trying to capitalize in different ways in the process. Google is trying to stop fragmentation by (temporarily) closing Honeycomb and requiring strict compliance with its specs. Good luck to them.

    For the healthcare part, my experience with Kaiser has been frustrating. One example was limping into physical therapy after a bad bike crash. The therapist looked at my clavicle plate and said healing was remarkable. He then acknowledged my hip problem and said he knew what to do about it but couldn’t because the appointment was for shoulder only, and to make two more for my hip and for my torn finger ligament. When I tried, my PCP was on two weeks vacation, so I emailed the PT and he talked to his boss but said they wouldn’t make an exception so I’d need to wait for the PCP to return for the referral. I opted for private PT as timing is of the essence in wound care. I’m still sorting out problems with my finger and its care a year later.

    Not here to bash Kaiser (definitely won’t dispute the quality of my specialists there), but its integrated system is designed primarily to reduce its own costs and thus maximize its profits – much like Apple’s. Your point that I agree with: any ‘system’ must be built around user experience and practical use and not let technology dictate its behavior.

  16. As the owner of several Apple computers over the years, I love them for the simple reason that they help do my work easily and intuitively. I am a primary care physician used to making at least a 100 decisions a day about 25-30 patients, and i am not interested in a computer system that gives me hundreds of choice so that i have to have make even more decisons “without adequate data”. Of course, even though I use my apple for vidoe editing as well, I probably use about 50% of its functionality. But that is more than I realle need. I am surprised that Margalit owns up to owning an iPhone, and note that she “is waiting for Android to catch up.” That is it in a nutshell.

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