By JOE FLOWER

The progeny of the iPhone and the iPad will change the shape of your institution — and your balance sheet.

One of the more striking images, to me, out of the online spew in the last few months was from the inauguration. It was a wide view of an inaugural ball. There was the president waltzing with the first lady, and a crowd of several hundred watching them. What was striking about that image was that the several hundred people held several hundred small glowing rectangles in their hands. Practically every member of the crowd was carrying a smartphone and was photographing or videotaping the moment.

The scene was commonplace in its moment, remarkable only in the perspective of history — but such a short history. We could not have imagined so many people carrying smartphones at Obama’s first inaugural only four years ago. Four years before that, we could not have imagined any. The iPhone had not been invented.

There had been attempts at smartphones before the iPhone, and devices like tablets before the iPad. But the rampant success of iOS devices did far more than establish two profitable niche. It changed our relationship with the world.

Continue reading “The Ghost of Steve Jobs and Your Bottom Line”

By JOE FLOWER

Rapid change is engulfing health care across the United States, but the strategic responses of organizations to these changes are sharply divided. In the shift that has been broadly shorthanded “from volume to value,” many organizations across the country are deeply engaged in moving toward “value” by building new partnerships, affiliations, capacities and economic structures, striving to bring better health and health care to more people for less money.

At the same time, some organizations are using the chaos and fluidity of the moment to double down on the old way, aggressively seeking greater volume reimbursed at higher rates. For now, within their regions, some of these organizations appear to be “winning” at the game, building greater market share and margin and increasing their budgets. But is this in fact the wisest strategy to follow in the long run, not only for their institutions but for the good of their missions and the people they serve?

Moving toward Value

Virtually all serious attempts to answer the question, “Why do we pay so much more for health care in the United States?” have pointed to the competition for reimbursements under a commodified, insurance-supported fee-for-service system. If what you pay for is items off of a list, what you will get is lots of items, especially the more profitable ones. That’s how we end up with a system in which waste (stuff we could simply do without) is pegged by repeated studies at one-third or higher.

Continue reading “Divided Health Care Nation”

By Joe Flower

Costs and revenue: This is the oxygen of any business, any organization. What are your revenue streams? How much does it cost you to produce them? Life is not just about breathing, but, if you don’t get that in-out equation right, there is nothing else life can be about.

Right now this enormous sector is turning itself inside out. It has turned the “transmogrification” setting to “warp.” Why? It’s all about the in-out. It’s all about increasingly desperate attempts to get that right — and the clear fact that we cannot know if we are getting it right.

Let’s do some school on the two sides of this equation. Let’s just go over the new weirdness, and the implications for you and your organization. Revenue first.

Hunting for True Revenue

In traditional health care (the way we did business until about five minutes ago) the revenue side was complicated in detail, but simple in concept: You do various procedures and tests and services, and you bill for them. You bill each item according to a code. You bill different payers; each has its own schedule of payments that you negotiate (or just get handed) every year. There are complications, such as people on Medicare with supplemental insurance, dual eligibles on Medicare and Medicaid, and self-pay patients who may or may not pay.

That’s the basic job: aggregating enough services that reimburse more than their real cost so that you can cover the costs of services that don’t reimburse well. This is cost-shifted, fee-for-service management. Cut back on those low-reimbursement services; pump up the high-reimbursement ones. Corral the docs you need to provide the services, provide the infrastructure and allocate costs across the system.

The incentives all point in the same direction. The revenue streams are all additive. The more you do of the moneymaking items on the list, the more money you make.

Continue reading “Why Health Care Is Reshaping Itself”

By Laura Montini

This year at Health 2.0′s Annual Conference, two speakers split stage time during the opening keynote. Joe Flower, a health futurist, and Mark Bertolini, CEO of health insurer Aetna, don’t have a whole lot in common professionally. But in their talks they both made clear that they hold two beliefs in common: the United States health care system needs to react to the country’s cost crisis, and efforts to address health care costs will happen independently from federal reform.

Flower spoke first, laying out the tenets of what he calls the Next Health Care. For such an optimistic speech, it was filled with negatives. Flower went through step by step, talking about what the nation isn’t doing right now, who’s not invested in better care, and why all health care systems can’t just become Kaisers.

Though the talk certainly wasn’t meant to praise health care for all it does right, it was meant to point out the promise that the health care system could be on the brink of.

“Health care is undergoing fundamental economic changes,” Flower said. “These changes are driving us to what may well be better and cheaper health care for everyone.”

The Affordable Care Act isn’t what’s propelling those changes, according to Flower. It’s other factors including an aging population, the sheer cost of care in the U.S., and technological capability that we’ve never seen until now.

Chronic disease accounts for 70 to 75% of all health care costs, Flower said. And as many Americans know, obesity is a huge contributor to those costs. The maps looked at the projection of obesity rates in the U.S. over time, and as the slides passed it looked like the country was being eaten by the disease.

“Now, some of the best hopes for that future, honestly, we see right here at Health 2.0. But we are not there yet,” Flower said.
Continue reading “A Tale of Two Keynotes: Futurist Joe Flower and Aetna’s Mark Bertolini”

By Joe Flower

In Healthcare Beyond Reform: Doing it Right For Half The Cost I lay out the five strategies that healthcare must adopt, and is adopting in various ways and places, to make healthcare better and cheaper at the same time.

Strategy Five is “Rebuild Every Process.” It’s about “lean manufacturing,” smart standardization, measurement, “big data,” evidence-based design, teaching the innovation, all the detailed, rigorous, hard attention to intelligent process re-design that healthcare is so obviously lacking — and that is absolutely necessary if healthcare is to improve its abysmal cost/benefit ratio.

Now in The New Yorker writer/surgeon Atul Gawande has done a brilliant turn on this theme, by diving into, of all things, the processes of a restaurant chain, comparing them to the duplicative, chaotic, mistake-prone processes of traditional healthcare, and finally to some examples of smart, rebuilt healthcare processes that drive down costs while killing fewer people.

Gawande shows how The Cheesecake Factory manages to deliver 308 dinner menu items and 124 beverage choices to exacting standards, on time, from fresh ingredients, with only 2.5% wastage, in a linen-napkin and silverware environment, at lower cost, then compares that with the disconnected, uncoordinated, messy environment that is most of US healthcare. He details several examples of how new drives toward standardization and control of processes in the operating room and the emergency department, for instance, are making a difference, lowering costs and improving not only outcomes but the patient experience, all at the same time.

Continue reading “What Healthcare Must Learn — from a Chain Restaurant”

By Joe Flower

It was some doctor show on cable: Nurse McCarthy bustles into the hospital room, says “Good morning!” brightly, and crosses the brilliantly polished linoleum floor to the window. Humming to herself, she sweeps open the curtains to the view of the brick wall across the airshaft, then goes to the patient on the right and checks his dressing, clucking and offering encouragement. After a few moments she does the same with the patient on the left, makes a note on his chart, and leaves. She’s probably been there less than 10 seconds, and I’m thinking, She just killed two patients.

Consider this: During the remainder of this decade, health care providers will be building thousands of structures — building, re-building, re-purposing, infilling, for new and rapidly shifting purposes. Details matter.

Despite its continued use as a political bludgeon, health care reform will likely be implemented, at least in its broad outlines. The truly deep changes that are transforming us into the Next Health Care are proceeding apace in any case, with different business models and revenue streams, which means new physical settings.

Continue reading “Building the Buildings of the Next Health Care”

By Joe Flower

What a cliffhanger! It is an historic decision, found on the narrowest possible grounds, with a majority agreeing on the result, but not broadly on the reasoning.

Effects: The principal effects of the finding, from the point of view of the system: They have just avoided enormous chaos over the coming years. The system is chaotic enough already, at a tipping point into an unclear future, with the huge shift in underlying economic factors. These factors include especially the various ways of shifting some economic risk from the payers and employers to the providers and the patients/customers.

Stabilizing: The Supreme Court finding stabilizes the future of the system. The affirmation, combined with the fact that a gridlocked polity in Washington is unlikely to come up with any major change or repeal of the law, and that the major parts of the law are self-funding, means that everyone now knows at least the general outline of what the rules are for the foreseeable future.

Permanent: The law is now likely permanent. To overturn it, you would need President Romney with a filibuster-proof majority in the Senate and a majority in the House. The major parts of the law are self-funding and not dependent on Congressional outlays. By 2016, most people will have experienced the results of the law, and found its benefits far outweigh its costs. Business owners will find that it is not as burdensome as some have feared. It will have become obvious that the experience of the actual law is far different and more benign than the fears that have been drummed up about it politically. Once people experience its benefits for themselves, it will be very hard to gin up a campaign to take it away from them.

Continue reading “The Beginning of the Next Healthcare”

By Joe Flower

I’ve been saying it for years now, it’s the theme of Healthcare Beyond Reform: Doing It Right For Half The Cost — and now it’s even hit the editorial pages of the NY Times: A June 2 editorial, “Treating You Better For Less,” trumpets the “good news” about a “grass-roots movement” using “already proven techniques” that “could transform the entire system in ways that will benefit all Americans.”

“It is a measure of how dysfunctional the system has become,” says the editorial, “that these successful experiments — based on medical sense, sound research and efficiencies — seem so revolutionary.” It goes on to describe several of the kinds of new ventures in efficiency and effectiveness that make up the core of Healthcare Beyond Reform, in different healthcare systems and health insurers across the country.

The news here is not that these things are happening, or that they are so widespread that they can be called a “grass-roots movement.” The real news here is that the movement has gained such momentum that big, mainstream media organizations outside of healthcare, well beyond the policy wonk orbit, have begun to surface what may turn out to be the biggest story of our times: The largest sector of our economy turning inside out, like some movie transformer, on the way toward providing all of us with far better care for far less than we could possibly imagine. Better healthcare for half the cost.

Continue reading “Better Healthcare for Less — Even the NY Times Says: “It’s a movement!””

By JOE FLOWER

People have been talking for decades about decentralizing much of healthcare away from massive Big Bricks on the Hill — for lots of good, sound reasons revolving around the efficacy of convenient primary care and home care, and the improvement in communications. It hasn’t happened much because these are all “should” reasons, not “have you by the throat” reasons.

The HYBTT reason is arriving: In the approaching liquefaction of healthcare, provider organizations (today’s institutions or others that will arise to compete with them) increasingly will be identifying particular populations in their service area whose primary care (or chronic conditions) they can manage under risk contracts. They will be doing this so that they can give these people earlier, smarter, resource rich care, and profit from driving the cost of care down and the effectiveness up. To serve these populations, providers will locate wherever is most convenient to that population, because especially in chronic and primary care, convenience is clinical. It makes a big difference if the people you are serving can get care downstairs, down the hall, or down the block, instead of across town, down the freeway, at the end of three bus transfers. So we will see a lot of “forward stationed” clinics in workplaces, union halls, schools, convalescent homes, neighborhoods, wherever the risk-contracted population hangs out.

This drives the second strategic observation: Geographic datamining. Providers are not doing this yet very much, but when they come to be at risk for the health costs of populations they will be all over it like your favorite metaphor. It is now becoming trivially easy to mine your records and discover where your patients come from — not just to the zipcode level, or even the block, but to the level of the individual address (HIPAA compliant, as dots on a map).

Continue reading “Decentralization and Mining Geodata: Thoughts from Health 2.0″

By JOE FLOWER

There is fire in the valley and smoke in the mountains. A plague is on  the land and danger is afoot. That may be — maybe — the good news.

Health care is more unstable than it has been at any time in living  memory. That’s pretty scary, but that instability may turn out to be its most important asset in this moment, as the whole industry becomes open  to profound change.

As long as I can remember, thoughtful analysts have been saying, “We need to do this differently. This is not working.” In this century, the voices became louder and more insistent, and they spread. But health  care has been very slow to evolve in any fundamental way. Even health care reform, when it came through extraordinary political pain and  maneuver, was more a way to bolster business as usual, a way to shore up revenue streams and patch holes in the fee-for-service business model, than it was any fundamental restructuring.

Now the ground under our feet is liquefying.

Continue reading “The Power in What We Most Fear”