Nursing a Health 2.0 Hangover

J.D. Kleinke

So it’s the morning after the big Health 2.0 bash and the hangover is awful. My head is awash with flashing screens of medical alerts, rainbow-colored demos of virtual patients flitting from one personal health app to the next, and a blur of snappy, almost sneering answers to the same old questions about user adoption, ROI, and business models. I just spent two days getting high on health care’s highest high-concept, I can’t log into my own health plan’s portal to look up a simple eligibility thing, and it’s dull, gray cloudy morning in San Francisco.Whither the 2.0 revolution you’ve been reading about all week? Was the blueprint unfurled before the cognoscenti by Matt Holt and the NorCal health care keiretsu? Was there an exhibitor booth handing out the magic bullets, along with the usual pens and mugs? Um – no.Perhaps it’s my own perennial impatience with health care’s miserable status quo; perhaps it’s a sign of the inevitable coming of age for the 2.0 community, or space, or ecosystem, or whatever the corporate concept jockeys are calling a market this year. But at the risk of offending Matt and my other good friends in the keiretsu, this year’s conference felt for the first time oddly normative, almost reminiscent of other conferences like HIMSS and the World Health Congress, where Big New Health Care Ideas run headlong into The Great and Powerful Health Care Inertia Machine.

This year, 2.0 was the usual messy dialectic between e-fantasies deployable in “the cloud” and the deadening reality of who will buy, who will use, and who will pay for all this stuff back here on earth. As in years past, the conference pitted The Entrepreneurs against The Suits, with the indefatigable Adam Bosworth and Keas dancing on the tightrope strung between the two, with a useful-looking product and a credible sounding business model (the more mercenary features of which, I am guessing, are hidden somewhere below the surface of the demo). Not counting the ready-for-primetime Keas, its partner Quest Diagnostics, and the omnipresent and omnipatient folks at Microsoft, this year the establishment players at 2.0 seemed less willing than in years past to play straw man and/or nod enthusiastically at the magic tricks (depending on the choreography of the session) that define the art form. The Suits were there, in greater number than ever; but those on stage seemed far less willing than in years past to jump up and shout that yes, they and their entrenched organizations were indeed on board with all these wonderful ideas designed to make their organizations less relevant, less proprietary, and less in control of everything in health care.In fact, many actually pushed back, some defiantly. And for a few very scary hours in the middle of day one of 2.0, it felt like The Suits were actually winning.Maybe it was the order of things. The conference dedicated to technologies, tools and services emerging to support a health care system that actually engages and empowers patients opened up with a panel on “clinical groupware.” The discussion quickly de-morphed into a barely browser-based show-and-tell about what wired physicians are using in practice today, and the crowd grew oddly restive. And while I think he intended it as a statement about how often we have to pull back to jump forward, Stephen Sigal, a cardiologist on the panel, mentioned having to de-install his practice’s EMR, GE’s Centricity, for security reasons. (It was the first time I’d ever seen an entire conference audience lift their heads from their PDAs in perfect unison.)Things went from oddly nervous to outright ugly in the next session, which empanelled several executives from various health plans to critique, aloud, various user applications, a scary mash-up of corporate sales presentation and American Idol.Faced with the crisp and highly navigable health benefits manager tool from Intuit – one with concise drop-down menus explaining those geeky health benefits terms no one has ever really understood – Chris Ohman of Kaiser retorted that he would love to be able to provide that kind of helpful information to members, but the regulators would never allow it. Pesky regulators: always making it so hard for insurance companies to help people!On the same panel, Mohan Nair – introduced as a “serial entrepreneur in health care information technology” but listed in the actual program as the Executive Vice President of Regence BlueCross BlueShield – let the crowd know that he had been at Regence “studying the problems of health care for the past six years and realized that the system is broken.” Hold the phone! He then threw a cold bucket of water on the panel’s spontaneous and important debate on the true cost impact of health 2.0 tools by stating, categorically, that none of the things designed to help people improve their behavior or lifestyles will reduce health costs. Really. (I guess all those Regence billboards in Portland last year about improving my behavior and lifestyle really were about risk-selection.)With what little air remained in the room, Daniel Kogan of tiny HealthWorldWeb – like Nair, an entrepreneur with a day job – showed what the typical patient looking for a new provider on a health plan web site has to endure, then compared it to the same kind of search informed by actual knowledge of the patient’s wants and needs. The result was a narrowing of results from hundreds of physicians scattered willy-nilly across a market delivered by the health plan, to three physicians, all matched perfectly to the patient’s situation, delivered by the intelligent search.Completely off the point but oddly on cue, Nair responded to Kogan’s throwdown by saying he was “tired of feeling demonized” by comments about health plans not being trusted. I would be tired of it too, if every time I opened up any credible research on the subject (cf. Markle/Connecting for Health, The Commonwealth Fund, Kaiser Family, et al., ad infinitum) I confronted the same perennial fact.Nair’s remark inspired Fred Goldstein of U.S. Preventive Medicine to reveal that his company had seized upon that demonization with a marketing strategy not uncommon in the post-managed care era. “We realized that people don’t want to share with their health plan that they smoke, drink and hang out all night,” he said, “so we’re going direct to their employers.”The conference’s opening morning 2.0 fantasy vs. 1.0 reality free-for-all ground to its inevitable, depressing halt when Ingrid Lindberg, “Customer Experience Officer” of Cigna – having announced earlier Cigna’s recent discovery that members were actually customers – wondered aloud how health 2.0 tools would ever gain market traction, given that “people spend 30 minutes picking their health insurance but four hours [a day] watching flat screen TVs.” Maybe it has something to do with the number of health insurance plans offered by Cigna’s actual predominant customer, i.e., large corporations, i.e., one to three choices of insurers – versus the 600+ choices, five or six of them pretty good, on my TV every day.Luckily, the conference got back on the rails by lunchtime on the first day during some great hands-on creative tool-building exercises (which became fun team-building exercises), and stayed there for the duration. One manic and visionary entrepreneur after another explained how in the future, everything in health care will be digitized, our medical data will flow as freely as tap water (but never spill anywhere), and with all these nifty applications, no one will get sick, go to the hospital or die. More importantly, there were plenty of people with the wherewithal in the audience to fund, acquire, and/or execute on these bold visions. And the whole thing climaxed yesterday afternoon with a carnival-style presentation by several of the companies involved in the Health 2.0 Accelerator project. (“H2X,” as they call it and as far as I can tell, is an odd amalgam of personal health applications providers and infrastructure builders, who are working together to adopt data standards for information movement, e.g., CCR, and create a complex but seamless health information management experience for consumers across products and services in a sort of “co-opetition” (remember that 190s classic?) model.Kudos to Marty Tenenbaum, founder of CommerceNet – an entrepreneur who no longer needs a day job – for conceptualizing, funding and mentoring this ambitious and interesting project. Because “acceleration” is the only thing health 2.0 needs at this point. Ideas, ambitious people, and gee-whizz technologies we got. And naysayers we got, as we saw on day one, many of whom occupy powerful positions within our health care “system.”So maybe that’s the best cure for a health 2.0 hangover: the sobering perspective that this isn’t a party, there is a lot of hard and important work to do, and a real revolution in health care won’t be coming easy or fast. If the American polity defines systemic health reform as a few long overdue tweaks to the regulation of health insurance and a few billion in subsidies to people who consume ten times that in ER costs when their uninsured status boils over into medical catastrophe, then I suppose the whole health 2.0 movement really is moving at breakneck speed.Back to work!

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21 replies »

  1. Tremendous things here. I am very glad to peer your article. Thanks so much and I’m taking a look ahead to touch you. Will you please drop me a e-mail?

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  3. This is exacerbated in health care because the patient does not pay his own bills and therefore has no reason to migrate to the disruptive businesses. 

  4. Dear Mr. Kleinke,
    I appreciate your observations, but would like to clarify several of the statements that you attributed to me during the Payer Panel at Health 2.0. Perhaps I did not communicate effectively, so I welcome the opportunity to provide clarification.
    If I “threw cold water on the panel’s spontaneous and important debate” and stated that “none of the things designed to help improve their behavior or lifestyles will reduce health costs,” shame on me. Given the very polarized format provided to payers and technology entrepreneurs, messages could be misunderstood or exaggerated. I recall thanking fellow technology entrepreneurs but warned them that “pathology can kill technology” and that the culture of the health care system that is opaque and closed should be understood and attacked. I also remember saying that Regence learned that to try to change the system, it should change itself with health programs, consumer engagement tools, etc., which resulted in 20,000 pounds lost since 2008 while health outcomes improved. I provided examples of members all helping each other on the web and shared that our consumer engagement efforts via the web have produced significant value to our members. All of these statements were meant to declare my respect for technology-enabled health and wellness programs.
    What could have been interpreted as “cold water” could be my response when asked “Why have you not created products that adjust premiums with healthy behaviors?” Currently, actuarial measures do not associate healthy lifestyles and health resource utilization with actual premium changes. Independent research on our own company, however, has shown significant advantages to employees’ engagement in healthy habits and the use of technological solutions. Combined, technology and a healthy lifestyle can have a strong – and positive — impact on overall health care costs.
    I do believe the health care community is prone to demonizing each other and now the general public has joined in. Nothing comes out of this approach and I urge us to be one community, trying to find the answers together. I prefer to believe that health insurance is a community asset with trustworthy insurance companies as custodians of premium dollars; thus, a not-for-profit approach is an important factor in the success of our nation’s health care system. I believe entrepreneurs want to change and challenge the system and disrupt the status quo, and the health care system needs them now more than ever.
    If I came across as not listening, thank you for calling me on it. I hope that we can see through the noise of such an event and see the sincere regard I have for all entrepreneurs, and also show that open, transparent, alliance-oriented insurance companies like Regence can break through the stereotype.

  5. This year, 2.0 was the usual messy dialectic between e-fantasies deployable in “the cloud” and the deadening reality of who will buy, who will use, and who will pay for all this stuff back here on earth.”
    And who will actually make it work?
    See this article:
    Pessimism, Computer Failure, and Information Systems Development in the Public Sector. (Public Administration Review 67;5:917-929, Sept/Oct. 2007, Shaun Goldfinch, University of Otago, New Zealand). Cautionary article on IT documenting the widespread nature of IT difficulties and failure, the lack of attention to the issues responsible, and recommending much more critical attitudes towards IT.

  6. JD, your article is a riot!!! Going to order your books now…
    Anyway, here is the rub in my opinion.
    Doctors don’t like to be disrupted and they hold the key to the medical records room.
    Patients are not really consumers and have no power to disrupt anything in this “market”.
    Everybody else, including employers, is in exclusively for the money and whatever disruption they come up with will not align with either doctors or patients interests. Never has.
    So if you want disruption, you want the employers out of this equation and you want a public plan with big fangs and you want technology that will make individual doctors demand to have their records on line.
    Maybe 10 years from now, if all goes as well as expected…..

  7. Well, it’s playing out exactly as Christensen said: the entrenched interests do everything in their power to prevent the disruptive influences from gaining traction. This is exacerbated in health care because the patient does not pay his own bills and therefore has no reason to migrate to the disruptive businesses. Now I read today in the newspaper that insurance companies are warning that the health care bill will raise premiums – a conclusion I came to about 2 months ago. Same old, same old.

  8. Thanks for the concise taxonomy, Alexander.
    Your recognition of a human patient as opposed to inanimate market object is precisely what’s new and different this time around. As for the “disruption” factor and how it actually plays out in the market, I’m a bit less sanguine; the old ironsides in numerous industries (not just health care) have been giving great lip-service to “disruptive” market forces the past few years, and then doing everything in their power – abusing their oligopoly status, squatting on IP, hiding behind regulatory processes they claim to loath, crushing entrepreneurs with lawyers, funding and ripping off technology skunkworks organizations, and of course spending vast sums on politicians – to make certain that the disruption virus doesn’t come near any of their own sacred cash cows.
    Many of health care’s bigger ironsides have begun to bandy about the word “disruption” with increasing frequency these days, thanks to Harvard Business School’s Clayton Christensen, who has turned the term into a consulting franchise, and verticalized it into health care’s well-fertilized fields. When this kind of co-option of a revolutionary idea occurs by the powers that be, you can bet we’re near its market top – and the real power of that idea is nearing its inevitable emasculation as an actual change agent.
    For my full unload on this subject, check out http://content.healthaffairs.org/cgi/content/full/28/4/1223?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=kleinke&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

  9. Dear Mr. Kleinke,
    what you adress is the core problem of two yet very separate and totally differently functioning health networks: the health 1.0 network, which is closed, regulated with a patient faced obey and control paradigm and the health 2.0 network which is in all aspects right the opposite… see page 22+23 at:
    For sure, the “wisdom of patient” driven health 2.0 network with its new phenomenons of the e-patient and patientgenerated content will grow and increase disruptive moments in front of the old health 2.0 system.
    I assume the disruption preassure has to increase dramatically before an implementation into a (digital) participatory helathcare and medicare evolutionizes.
    Best from Berlin
    Alexander Schachinger

  10. J.D. Thanks for that last comment, but as we were focused on the Health Plans during our segment, I did not discuss the Employer side. I agree with you that the mistrust is very high here as well and we make it plain and clear to our members, and that is why we see employee enrollment rates as high as 90%, that we do not share their data with the EMPLOYER or the health plan, UNLESS the member lets us. The data is the members, in fact, the member has to authorize our nurses to look at it as well and when they enroll they can say no. We do share HIPAA compliant aggregate data. Watch this video and see how we discuss that issue. http://www.uspreventivemedicine.com/Resources/Videos/See-What-it-is-All-About.aspx

  11. Thanks for the kind words, Gregg. I agree completely re: the plan/employer churn problem; but the problem is actually worse for Goldstein with the health plan end-run strategy, and that’s the sucker-punch I pulled in this post.
    Vendors trying to get someone, anyone in the purchaser/payer/ASO corner of the ring to do the right thing and actually purchase a care mgmt/wellness/modification type service for a population will run headlong into a stonewall of a fact: EMPLOYERS ARE TRUSTED EVEN LESS THAN HEALTH PLANS.
    Employers are at the very bottom of the “who do you trust with your health data” list, according to research by Connecting for Health. We’re talking low-single-digits bottom, while the health plans are mid-single-digits. Both numbers are of course especially pathetic in juxtaposition with the same research showing that the oft maligned government and drug companies both score into the 20 and 30 percent range on consumer trust.
    This matters. Peoples’ deep-seated mistrust of employers and health plans is one of the more corrosive problems in health care, resulting in gross under-utilization of potentially life-saving tools and interventions, incomplete medical documentation, and widespread under-disclosure of important medical information to providers; stir it all together, and mistrust of employers and helth plans probably kills a great many people every year.
    This is one more reason we should un-do the historic accident that coupled our health coverage with our employment, and one more reason employers should get the hell out of the business of health care, and go back to their day jobs!

  12. As a first time attendee to a Health 2.0 conference I was excited by the opportunity to see how user generated healthcare works and how it is beginning to impact how physicians practice medicine and interact with patients “armed with data and questions”. I was also looking forward to hearing a new generation of healthcare technology companies pitch their wares to doctors, consumers, industry and investors. However, I was sorely disappointed with the content of the conference. Most of the Health 2.0 companies were EMR, wellness and or content portals. I didn’t see much that would excite physicians (such as myself) and couldn’t really see how some of the portals could compete or improve on sites like WebMD. Perhaps the one exception was Patients Like Me.
    The conference was disorganized and poorly run. Audio and video were poor quality and breakout sessions were overcrowded. The one session geared for “practicing physicians” was horrible. There was no meaningful discussion or insights from the panel. The poor presenters didn’t seem to get much out of it either other than a few minutes of a not very memorable presentation.
    The main session panelists were average at best. One panelist insisted on making political statements which didn’t add to the discussion. Fortunately things seem to improve on the second day, but not by much.
    The Health 2.0 movement needs a better home. Where were the VCs/investors? Where was the thoughtful analysis and discussion? Physician participation? One of the moderators called the Health 2.0 conference “one of the top 10 conferences”. As a conference veteran, I can confidently say this was in the bottom 10 of all conferences I have attended.
    I hope that the organizers of the meeting take this feedback and rethink how the conference should work. I sense there is a lot that the participating companies can offer and a lot the audience/panelists could give back to them. It just needs the right format to work.

  13. JD:
    Wow! Great piece and contextual insights. Am regretting missing the payer and Health2.0 segement; this held the most content affinity interest for me; but, it wasn’t meant to be. Hope it was recorded.
    I sat with Fred Goldstein during much of the conference and see US Preventive Medicine’s approach as a default end run around health plans for the reason he mentioned; though in a real world where health plans are actually managing longitudinal risk, vs. skimming administrative only fees (ASO) while their clients churn from one health plan to another, they might pursue a material wellness approach vs. buying ad space or billboard copy to project a politically correct but fundamentally feigned interest.
    Regret our paths did not cross…
    Absolutely love the ‘NorCal health care keiretsu’ vs. suits visual too!

  14. Yep – the missing business model is becoming increasingly evident, with “advertising” just not resonating as the foundation for a healthcare revolution – and the insurance cos clearly not excited by the huge savings 😛 being promised. To me, though, nothing was more telling about focus than the data drives decisions forum … two seemingly successful companies with huge user bases MedHelp.org >9 million uniques PER MONTH and iGuard.org > 2 million registered users (who knew!) and apparently functional business models … contrasted with ‘scarily powerful’ stuff that nobody uses or pays for. Ugh.

  15. You nailed it! Ironically this morning the Kaiser Oakland phone system is experiencing technical glitches preventing callers from even making some appointments. First things first, no?

  16. Your blog is very much good. I am very much impressed by your blog content, i also come across number of sites for the health insurance for the travel insurance and medical insurance, you can also check these are also very much useful for everyone.

  17. At the of the creation of the World Health Organization (WHO), in 1948, Health was defined as being “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity”.[1][2]
    This definition invited nations to expand the conceptual framework of their health systems beyond issues related to the physical condition of individuals and their diseases, and it motivated us to focus our attention on what we now call social determinants of health. Consequently, WHO challenged political, academic, community, and professional organizations devoted to improving or preserving health to make the scope of their work explicit, including their rationale for allocating resources. This opened the door for public accountability [3].
    Only a handful of publications have focused specifically on the definition of health and its evolution in the first 6 decades. Some of them highlight its lack of operational value and the problem created by use of the word “complete.” Others declare the definition, which has not been modified since 1948, “simply a bad one.” [4].
    In 1986, the WHO, in the Ottawa Charter for Health Promotion, said that health is “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.” Classification systems such as the WHO Family of International Classifications (WHO-FIC), which is composed of the International Classification of Functioning, Disability, and Health (ICF) and the International Classification of Diseases (ICD) also define health.
    I also take care of the health my spouse when she was doing home business;

  18. IMHO, in the western medicine world, we have lost touch with the basic concept of true healing. We substitute a band-aid for a cure and wonder why we don’t feel better. People need holistic approach, indeed.

  19. Massive amount of problems would be solved if people would actually start to take the responsibility of their health and focus on prevention instead of treating the illness.

  20. HIMSS, CCHIT, and other trade groups of the HIT vendors have been partying at patients’ expense. The problem is that none have the pateints’ and physicians’ interests in mind…just their wallets.