Few argue that we have a fully optimized healthcare system. In fact, many argue the opposite. I have good news for you. All of the components of a high achieving health ecosystem have not only been created — they have been proven with solid evidence backing them up.
The future is here. It is just unevenly distributed. — William Gibson
Mr. Gibson could have been speaking about healthcare when he made this oft-cited quote. Unfortunately, while we have the components to fix health and healthcare, they are scattered all over the country and world. Healthcare, in it’s present state, is a design failure given the money, smarts and compassion that we invest. Put simply, it rewards the wrong activities. We pay for illness and treatment, and we get more illness and treatment. Even if we had a perfectly designed health ecosystem, the emerging convergence of new genomic insights, smartphones and mobile Internet, the Internet of Things, sensors, wearables and changed reimbursement models creates an enormous new challenge.
Half of Amazon’s Servers Don’t Add Value
Imagine if that statement were true. Jeff Bezos wouldn’t stand that for a second if every other server Amazon purchased didn’t add value. Yet, we are doing the equivalent of that for the biggest thing the government pays for and typically the second biggest item corporations pay for (after payroll). August organizations such as PwC have stated that 50% of what we spend on healthcare doesn’t add value. Imagine all the ways we could better use that money (examples here). [As a side note, I’ve heard nothing about Amazon’s health benefits that suggests they aren’t making the same mistake as crusty old-line companies in their healthcare purchasing so they should also heed the turn of phrase Tech Industry, Heal Thyself.]
Convergence of Factors Demands Open Sourcing the New Health Benefits Stack
In looking at the root cause of several issues, you work back to the root problem. It comes back to a package of health services that is radically under-performing. Rather than starting with what works best for the key dimensions of health, the bundle of health services that are purchased create what looks like Mr. Potato Head gone awry with a collection of disjointed services. It has resulted in a Gordian Knot designed by Rube Goldberg with tremendous misapplication of resources.
Each of the following major issues can be addressed if we design the health ecosystem in a rational way:
- Consumers rate health insurance lower than every other industry on the Net Promoter Score (see NPS scores here). Contrast CIGNA’s NPS at -1% (the lowest health plan is -24% and highest health plan is +28%) versus next generation players such as Qliance at +79%.
- There are unprecedented levels of dissatisfaction and burnout by doctors. A major reason is we’re layering more and more on top of a design failure.
- As Bill Gates pointed out in a TED Talk, out-of-control healthcare costs are directly devastating education budgets that are critical to the long-term future.
- As US News & World Report found, due to healthcare costs, cities are unable to perform basic services such as filling potholes. More dramatically, there are 100’s of millions of unfunded pension commitments due to healthcare costs.
- Household income has been directly impaired by healthcare costs. Despite significant employee cost increases over the last 20 years for organizations, almost all of it has gone to fund healthcare’s hyperinflation rather into worker’s pockets. Washington Post, NY Times, WSJ, Time and others have reported, healthcare cost increases have been borne by both the employers and employees, not to mention shareholders.
- A corollary to the previous issue is individual households have been unable to save for retirement (read more here and here). Pensions/401-k’s could have been massively funded with healthcare’s waste. Instead most people aren’t financially prepared for retirement, yet have huge costs ahead beyond what Medicare will pay.
- A new wave of exciting, health-improving healthtech is held back due to outmoded health purchasing practices (see Tech Industry, Heal Thyself for more).
- As Atul Gawande pointed out in his book and in the recent PBS Frontline special, we are doing a horrendous job dealing with end-of-life issues leading to a tortuous experience for those at the end of their life and it needlessly squanders money in the process.
A New Health Ecosystem Stack
I believe it is impossible for any one person or organization to make sense of all of the converging new technologies, legislation and medical protocol changes. Rather, it demands an effort that utilizes the ethos of open source. In the technology world, we are well aware of an entirely new technology “stack” that takes advantage of the collective wisdom of millions of individuals around the world. World-changing organizations such as Amazon, Facebook, Google and others have leveraged and contributed to the open source stack. At the same time, they have built highly successful enterprises (read Chris Anderson’s book Free – The Future of a Radical Price for the many examples of how great business models can be built around free components). Even though the tech industry was well-established, the pace of innovation has dramatically escalated by having distinct components that can be rapidly assembled to deliver value that simply wasn’t possible before.
Just as the next generation of technology companies required a new technology stack, the health ecosystem needs a new health plan stack. New incentives and payment structures for providers, along with better access to information with new consumer technologies, and an array of new technologies are enabling the shift. Various pay-for-value incentives are driving us to look for ways to optimize health and prevent illness. A key component of the emerging, more democratic, landscape is a commitment to openness, feedback and learning. To rapidly innovate, we need open source and open innovation to drive our a learning health system.
The idea behind the Health Rosetta is build an open, standards-based platform to decode what works and what doesn’t work in this new environment. It will be initially focused on health benefits design as it provides the broadest umbrella. Over time, the intent is to extend into improving the access and efficacy of new healthcare delivery models and define units of value beyond what underpins legacy payment systems (“Relative Value Units”). For example, a concept such as “Patient Value Units” should develop out of this that captures the elements identified in the Quadruple Aim (Triple Aim items — better outcomes, better patient experience and lowered costs plus a better health professional experience as the 4th, and overlooked, “aim”).
Those health plans that are unnaturally comfortable given the high degree of consumer dissatisfaction would do well to not underestimate players such as Collective Health (addressing the self-insured market) and Oscar (addressing the rest of the private market). Both organizations are massively funded by some of the smartest and most aggressive investors, have whip-smart teams and have no loyalty to the status quo. Those same sorts of dynamics existed when another local/regional oligopoly business (newspapers) discounted an array of at-the-time small players like Google, ESPN.com, Monster, Cars.com, eBay, and many others. More on that here.
On a related note, there has been a creation of 95 Theses for a New Health Ecosystem.The theses are a byproduct of being frequently asked by organizations developing new technologies, health plans, healthcare delivery models, health benefits packages, service offerings and more for a set of guiding principles for how to proceed. Even before the health plan stack has been fully defined, the theses can provide useful information. The can help innovators assess how well positioned their organization’s products and services are for the future.
Thoughts Leaders in Healthcare Using Open Source
There have been open source projects in healthcare for a long time. No doubt, many companies are like Avado when we used open source components in our product. Most people think of open source as limited to software code. However, the ethos of open source is being used more and more. The following are examples of innovative doctors using the ethos of open source to advance health and wellness:
- Dr. Stephen Friend was a successful bioinformatics entrepreneur before running Research for Merck’s Oncology business. He is the founder and CEO of Sage Bionetworks that is creating a commons for pre-competitive research. Learn more by reading Open Source pre-competitive drug discovery: Moving beyond linear investigations – both of the science and of how we work (PDF).
- Dr. Bill Thomas was named by the Wall Street Journal as one of 12 most influential Americans shaping aging in the 21st Century. He is currently on tour to highlight promote the open source project around dramatically improving what he calls “elderhood” — the stage of life after childhood and adulthood.
- Dr. Eric Topol recently called for an international open source resource of health data or “massive, open, online medicine resource (MOOM)” in Nature Genetics.
- UnPatient.org is a new non-profit co-founded by Leonard Kish that aims is building an open-source platform for health data ownership with trusted collection and anonymous sharing.
- Fred Trotter has created DocGraph, originally out of a FOIA request to CMS around physician data, which has grown to include multiple open health data sets.
Volunteer Effort Can Be Accelerated With Resources
To date, this has been a side project for a few of us. Naturally, for this to take off it will need additional resources in the form of additional people willing to contribute their time. However, that will have its limits. We are investigating underwriting sources such as industry associations aligned with this mission as well as crowdfunding. This goes hand-in-hand with the need for assistance with stories (and funding) for the documentary. A prime goal of the documentary is to enrage and then give people optimism about how big a difference they can make. This open source project is one of the calls-to-action. Please leave comments here or reach out to me via LinkedIn if you can provide help.
Naturally, anything this paradigm-shifting will garner a lot of resistance. As mentioned in Healthcare’s Original Sin & Source of Redemption one of the best ways to fight that is openness and transparency. This is the best inoculation against the “FUD” I spoke about in that article. Of course, if components of this aren’t the best at achieving the Quadruple Aim, that’s the beauty of an open source project — it’s always evolving. If critics have something better to offer that is superior on Quadruple Aim objectives, this is really an ongoing “king of the hill” exercise. However, if they criticize without evidence, that’s all the “evidence” one needs as to whose needs are served.
To give you an idea of what needs to get built, I had a tweetstorm awhile back that teased the first items that are part of an optimized health benefits stack.
For each of these items (and more as it gets more granular), there’ll be an outline meant to be actionable for purchasers of health and wellness services. The following is the basic outline:
- What is it?
- What does it cost?
- Improved Experience
- Improved Outcomes
- Lower Cost
- Provider experience
The Diagnostic Toolbox
- Patient surveys
- Quality measures
- Vendor list
- Proposal request
This will be an organic, grassroots project so it will evolve and improve. Naturally, all constructive help is appreciated. Special thanks to benefits consultant, Jim Millaway, who is one of the most innovative minds in the benefits world and is the content expert to make this actionable for purchasers. As you read this, he’s helping many organizations transition from under-performing benefits stacks to high value. Also instrumental are Leonard Kish and Nate DiNiro who are experts in open innovation.
A parting quote from Buckminster Fuller who could be talking about the existing flawed model:
“You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.”