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Does America Want Apple or Android for Health Care?

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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HMathewson, MD www.hubslist.orgPetepcpJayErin Wheeler Recent comment authors
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Pete
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Pete
HMathewson, MD www.hubslist.org
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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… Read more »

Pete
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Pete

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… Read more »

Jay
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Jay

“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… Read more »

Davis Liu, MD
Guest

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
Guest
pcp

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).

Erin Wheeler
Guest

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… Read more »

"Logan"
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"Logan"

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… Read more »

Brooke
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Brooke

PS: you should do a TED talk on this!

Brooke
Guest
Brooke

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… Read more »

J. Stefan Walker, M.D.
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J. Stefan Walker, M.D.

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… Read more »

Andrew
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Andrew

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.

rbar
Guest
rbar

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.

Tim
Guest
Tim

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

Margalit Gur-Arie
Guest

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… Read more »

Davis Liu, MD
Guest

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… Read more »

Margalit Gur-Arie
Guest

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… Read more »

Margalit Gur-Arie
Guest

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.”

Davis Liu, MD
Guest

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… Read more »

Peleus
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Peleus

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.

kim
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kim

“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… Read more »

Davis Liu, MD
Guest

http://www.ama-assn.org/amednews/2011/03/28/gvsa0328.htm

http://online.wsj.com/article/SB10001424052748703940904575395603432726626.html

[CVS] is seeing a drop-off in new prescriptions for maintenance drugs tied to a decline in physician visits.

Quest Diagnostics Inc., a laboratory-testing company, told investors that its volume fell 2.6% in the first quarter and 1.3% in the second partly because of decreasing physician visits.

kim
Guest
kim

With all due respect, neither study draws the conclusion you cite — reducing utilization is not necessarily a bad thing. Don’t we want consumers to be more prudent?

See, for example, EBRI’s analysis (http://www.ebri.org/publications/notes/index.cfm?fa=notesDisp&content_id=4702) which shows CDHP enrolles do reflect more cot conscious behavior but are more engaged in wellness efforts & not less apt to reduce compliance with chronic care treatment.

Davis Liu, MD
Guest

Issue isn’t decreasing utilization. Issue is it whether it is the right type of decrease in utilization. Consumers simply given more cost sharing doesn’t alone promote the right behavior. Having some financial responsibility and choosing wisely, I agree would be optimal patient behavior.

https://thehealthcareblog.com/blog/2011/03/07/why-consumer-driven-health-care-will-fail/

kim
Guest
kim

I agree 100% with your three sentences above…just not some of your other conclusions (or your cited blog).