It would have been much easier to reform health care in America if we had the patience to wait a couple more decades until 80% of our children end up living in poverty, but in its infinite wisdom, our progressive government has decided that it is better to be prepared for this inevitable future of ours, and the sooner the better. Unfortunately, the remnants of what was once America the beautiful, are having a hard time understanding the dire need to reform health care for a posterity that looks eerily like Charlie & The Chocolate Factory. Fortunately though, we do live in the disinformation age, hence reeducating the public to see the preemptive benefits of the new ways, is just a matter of devising a solid marketing campaign.
Less is More
Simplicity, as any marketer can tell you, is the key to effectively inducing mass acceptance of new ideas. Less is more. In this case less verbiage is more effective, but we don’t really need to get into subtleties. Plain less is just more of whatever you want more of. Let your imagination complete the message. Less is more, and less is always more, and more is actually less, and why would you settle for less, when you should rightfully have more by having less. Is there anyone out there that doesn’t know for sure by now that in health care less is more? Less superfluous tests, less useless screenings, less harmful drugs, less dangerous treatments, and all the misfortunes resulting from more of the same, in article after article, book after book, interview after interview, spread far and wide, less is more.Note how everything is prepended with an onerous adjective to soften the ground and minimize resistance to the idea that less is not just more, but less is good. The next step is to point to research showing that more bad things are bad for you, and then extrapolate to stating that more of everything is bad for you, while all the time using undesirable adjectives before every noun. Less paternalistic doctors, less irresponsible ER visits, less murderous hospital stays, less confusing choices, less is always more. Always, because poor people need to internalize and accept that less is all they can ever hope for, and less is better than nothing at all.
Too Many Choices
Having no choices at all is usually associated with totalitarian regimes, but even in a free country beggars cannot expect to be choosers, or as insurance executives tell us, we are more "sensitive" to prices than we are to choices when we shop for health insurance. It seems we relish the idea of having less choices (less is more, remember?). Therefore, we have narrow networks, which are being rebranded to high-performing networks as we speak, to improve moral. The talking points say that narrow networks are cheaper because in return for lots of customers, doctors and hospitals, hungry for more patients, are giving the insurer greater discounts. So let’s see: it would be cheaper to only have NYU Langone and maybe Sloan-Kettering and their doctors in your narrow network, than having dozens more area hospitals and thousands of other doctors, right? Well, not quite, because poor people do better with surroundings more concordant with their station in life and we should be more thoughtful in the choices we make for them.We are very fortunate to already have a health care program designed from the ground up for the poor, so there is no need to start from scratch. As millions and millions of American Homo sapiens are descending from trees and gaining health insurance for the first time in their life, two distinct choices are emerging from innovative public/private partnerships. Those who have reached stable poverty are rewarded with free access to tailored networks custom built for their needs, and those who are still struggling to get there, are gradually eased into similar networks, while all obstacles to achieving perfect poverty are slowly removed from their wallets. The hope is that all our citizens will one day benefit from Medicaid, at which point we can truly begin to mold our nation for the future.
Who’s Your Daddy?
Poor people all over the world are acutely aware of being powerless to change their circumstances. Previously free and proud Americans are not likely to march willingly into the confines of poverty, unless of course, we can convince them that health care for the poor is actually an exercise in empowerment for the people. That’s a tall order for the best marketers, but we are executing on it flawlessly and brilliantly, because we had the wisdom to learn from past mistakes. Back in the nineties, America and its doctors rebelled against the yoke of managed care, and the HMOs pretty much failed. Today, we start fresh by breaking the unholy alliance between patients and their doctors, instead of expecting this to be an outcome of reform.First we tell people that doctors are bossing them around too much, and that they keep secret documents about their patients. Empowered patients have a right to not let doctors advise them, and to see those classified files where all sorts of horrible things are written about each patient. Then to support our case, we establish through well researched anecdotal innuendos that doctors are greedy, incompetent, careless, and cannot be trusted. Next we make fun of people who “like” their doctors and want to “keep” them (like pets or old tee shirts), and we make sure that having the same doctor for lengthy periods of time is impossible going forward. Finally, we establish the insurer or the government to be your lord and protector in the perilous journey through the doctor infested waters of a “fragmented” health system. So let’s try that again, and this time we want the right answer: who’s your daddy now?
The New Normal
The transition from being a free and wealthy nation to being just another medium size impoverished country, studded with magnificent sultans, may trigger a bit of anxiety, some anger and certainly lots of sadness in America. It is also well documented that mental disease is rampant among the poor, so we need to prepare. The old premise of an individual right to pursue happiness is now being upgraded to a personal responsibility to be happy. Screening for depression is becoming mandatory for all adults and children over thirteen years of age, and depression is assessed based on answers to nine questions, sometimes over the phone. Back in 2005, studies estimated that almost half of Americans experience some sort of mental disorder during their lifetime. With the recent expansion to the definition of mental disorders, it is clear that by now the vast majority of Americans are pathologically disturbed.But then again, if we are all hopelessly sad, overly angry and addicted to caffeine and such, aren’t we the ones that are “normal”? And perhaps the minority living in gated communities, unaffected by the looming better tomorrow, should be labeled with some sort of new disorder. We’ll leave that to the DSM VI (and the courts), and for an immediate solution to the poverty induced new normal, I would like to suggest a little innovation derived from dental medicine. Instead of wasting time and money on integrating behavioral health into routine primary care, why don’t we just cut through the chase and throw some Lexapro into the water supply? The new abnormal minority is not very likely to drink from a faucet anyway, so they should be safe.
High Tech
Our success at keeping everybody informed, empowered and controlled, hinges on getting high on technology. This was the one missing piece in past attempts to create proper value chains, and just plain chains, for our citizens. Now that we succeeded in gluing most humans to a miniature computer permanently connected to our grid (sticking with calling it a phone was a brilliant marketing achievement), the rest is history in the making. If health care were a product, we could ship its manufacturing to where we ship all manufacturing, and make enough plastic versions of the original to satisfy our poor. But health care is a service, and here is where high tech comes to the rescue. By making enough hardware and enough software, and by strategically repositioning venues, you can productize services into manufactured goods. That’s how we replaced mom’s laborious cooking with packaged foods, for most poor people. And that’s how we will replace health care with health maintenance for the same. It will take time, thoughtful planning, lots of innovation and a carefully cultivated disdain for human life, but I have no doubt that our leaders will guide us safely to the bottom.
Health care innovation comes in three basic flavors, scientific discovery, technology utilization and operational model. What distinguishes enlightened societies from those left behind is the ability to harmonize all three domains of innovation to benefit individuals and as a result society as a whole. Health care in America is in trouble because this paradigm is broken now. Jonas Salk with his scientific discovery financed by the dimes of regular people and placed back into the public domain, could not happen today for two reasons. First, no activities can be undertaken in our time without the potential for massive profit to somebody. Second, few if any individuals are in a position to have and exercise the courage of their convictions, unless of course they happen to be billionaires. The upheaval engulfing health care today is not driven by a desire to alleviate the suffering of small children. Our health care is being transformed in a bipolar process whose diametrically opposed goals are to reduce the costs of care while maximizing the profits extracted from caring for sick people. This is an accounting exercise where the services and passions (and, yes, ambitions) of great scientists and great humanitarians are not welcome anymore.
Technology Innovation
Accounting of dollars and cents, which is what our lives are being boiled down to, is by definition based on what we used to call data, or numbers, and what we now call Big Data, or surveillance. The primary innovation of our times is the stunning realization that for the first time in history, we will be able to collect literally everything – every word, every step, every thought, every breath and every heartbeat, of every person on planet Earth – and we can do it all from afar, without spooking the observed. When the technology juggernaut was unleashed in the health care sector, it came with an audacious philosophy stating that, once we are able to collect every bit of information about every single person at every moment in time and “mash” it all together, the world will be a better place. What was once basically a criminal endeavor, perpetrated by individuals in bits and pieces under the cover of darkness, has been elevated to the #1 aspirational goal of humanity, when administered in bulk by the State and its corporate partners. Bestowing renewed legitimacy on the age old debate about tradeoffs between individual rights to privacy and self-determination, versus tangible material benefits, such as safety, sustenance and medical attention, is the most significant contribution American health care is making to a changing world order.In a recent JAMA opinion piece, physicians from Harvard University are attempting to drive home this innovative idea. First we are reminded of the spectacular benefits to humanity made possible when we go “beyond aggregate data and link information to individual people” as evidenced by the achievements of the NSA, Google and the Obama 2012 cybercampaign. Then in a beautiful graphic, the authors are illustrating how we would combine clinical data diligently collected by doctors, with Facebook, Google, Twitter, tracking devices, police records, grocery store purchases, employment records, genetic information and whatever else we can get our hands on (I would throw in the NSA data too), to “assemble a holistic view of a patient”. To overcome the trifle technical and social barriers to progress, Drs. Weber, Mandl and Kohane are advising that it is time “to convene a public forum whereby the relevant stakeholders, including citizens, the health care community, and commercial data vendors could meet to frame the policy from which legislation and ultimately technical protections for big biomedical data linkage will devolve” [emphasis added]. This in and of itself is a rather innovative idea, seeing how in one fell swoop it dispenses with all the arcane complexities of the democratic process, while elegantly redefining the will of the people to be just another special interest on the same footing with data vendors.
Systems Innovation
In response to the emergence of new technology philosophies, the operational model of health care is now shifting to better position itself to take advantage of these innovations. A stethoscope wielding doctor is as poorly prepared to leverage the potential benefits of big datasets to humanity, as any individual patient focused on his or her own small and, let’s face it, inconsequential existence. The leadership role will fall to others. Three years ago, the President’s Council of Advisors on Science and Technology (PCAST) issued a landmark report advising the government on how to best facilitate the generation of Big Data in health care. Last week, the PCAST issued another report, supported by evidence from manufacturing and commercial aviation, recommending the application of Systems Engineering principles to health care to help big organizations and “communities” (i.e. bunches of poor people living in close proximity to each other) leverage their Big Data. Considering that American manufacturing is dead, and that flying coach on commercial airlines makes you wish you were dead too, one could be tempted to question this second round of massive taxpayer expenditures recommended by the PCAST. In all fairness though, the PCAST does place strong boundaries on government intervention which “should in no way, however, be a substitute for what the market can and should develop, i.e., for-profit organizations that provide training and skills to health-care systems”.You should take a few minutes and read the PCAST report because too many of us are ignoring policy making processes, notices in the Federal Register, and public forums in name only, and even elections, leaving the same handful of very powerful people and their handpicked lackeys to misrepresent the wishes and interests of an entire nation. I will just point to two interesting examples cited by the report where systems engineering principles were applied with great success to health care. One is the VA system, and I find it perplexing that no one at the PCAST saw fit to edit that example out of the final report, after the VA chief was forced to resign in disgrace precisely over a systems engineering fiasco. The other was a truly effective initiative at Virginia Mason, which failed because the hospital saw its revenues tanking when it changed the way it was providing care for back pain. Somehow, the PCAST seems to be of the opinion that cheaper care can be provided without reduction in revenues for those selling care, and the way to achieve this alchemy based innovation is, you guessed it, to switch from fee for service to paying for a yet to be defined concept, called value.
Absent Innovation
The science of medicine is incomplete, yet there are no aspirational goals and no inspirational challenges geared towards pure scientific discovery. There are many initiatives aimed at painstakingly preventing or controlling chronic disease caused by reckless abandon to industrialization and our inability to police the greed of those who are now purporting to solve the health care problems they created, by introducing the same disastrous processes into the last bastion of humanity – caring for our bodies and our minds. And to all the empowered patients (or e-patients) out there, climbing every public barricade, screaming for their “damn data”, and demonizing every old-fashioned physician, while serving as grease for the wheels of our health care revolution, here are the results of your success.According to Dr. Joseph Kvedar, the founder and director of Partners HealthCare’s Center for Connected Health, this is the future of medicine: “So I fully expect in 10 years your healthcare experience to be very personalized based on you allowing us to capture a lot of data from your device ….. the idea that we can capture your mood based on the number of texts you send and outgoing communications …..We’ll know your GPS tracking, all your mobile purchasing data and we can kind of figure out if you’re eating healthy. We’ll know if you’re drinking too much caffeine or too much alcohol. We’ll know a lot of things about you that we can start to serve up really compelling content to you that should be engaging enough — games, rewards, incentives, what have you in the background — that you will want to stay healthy”. As Forrest Gump would have said, that’s good, one less thing to worry about.
In other words, the “paternalistic” doctor, with his anachronistic stethoscope, strange concerns for privacy and ethics, and a ridiculous urge to lay hands on your body and look into your eyes, is being replaced by the unilateral decrees of a royal “we” of an invisible, machine augmented, superior intellect, presumably systems engineered to perfection, delivered by “smart” phone to a nation of feeble minded people who will be kept healthy by playing Veggie Crush all day.
Either we stifle this innovation now, or it will forever stifle every man, woman and child in this entire country, and perhaps the entire world.
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