SOAP: Apply, Rinse, and Repeat

SOAP (sōp) n.

1. A cleansing agent, manufactured in bars, granules, flakes, or liquid form, made from a mixture of the sodium salts of various fatty acids of natural oils and fats.
2. A process of medical evaluation and management which involves subjective, objective, assessment, and plan components.
3. Slang. Money, especially that which is used for bribery.

I have my 10 year Medical School reunion this year. It is hard to imaging that 10 years have flown by since those halcyon days at the University of Utah. Ahhh, the memories: the incredible pervasiveness of the anatomy lab smell, the 12 hour study sessions in the library, the all night test preparation, the 12 hour study sessions, the incredible pathetic instruction (I eventually completely bailed on going to class), getting introduced to the pharmaceutical pimps, the 12 hour study sessions, passing boards, starting on the wards, proud of my white coat, completely embarrassed that I was but a shell of limited knowledge within the white coat, completely arrogant attendings, even more arrogant residents, cool patients, amazing medical science, powerless medical science, trying to figure out what specialty to go into (what respectable student would “settle” for primary care), spending 5 weeks in Palau, passing Step II, match day, and ultimately graduation day. Whew - memory lane.

In reminiscing, many of the most memorable experiences were the many bizarre and absurd situations you find yourself in. One of those, involved SOAP and learning how to do the physical exam from a legendary figure named Bruce (the latter half of the story can only be shared in person).

For the medically inclined, SOAP stands for a simple paradigm of the medical thought process encapsulated in the daily note you make on patients when you “round” in the hospital. SOAP stands for Subjective, Objective, Assessment, and Plan. It is used daily, by millions of providers, as a simple way to think about the care process. First, you take a Subjective history; typically writing down the exact words that the patient uses to describe their “Chief Complaint”. It is subjective because it is what the patient perceives, experiences, or the manner in which they relate or describe their situation. Next, you perform an Objective physical exam. This is the concrete stuff that you can personally observe, elicit, palpate, or document in some hard, reproducible way. Based on the above, you develop an Assessment of the situation. The Assessment is where the diagnosticians can pontificate and conjecture on the theory behind the illness (and where the surgeons write, “Doing well” regardless of the clinical situation). Based on this, a clinical care Plan is created for the patient from which the team continues to manage patient’s care (and the surgeons write “DC with +BS” [discharge with bowel sounds]). SOAP - short, simple, and systemic way providers think about the daily management of their patients.

Turns out that SOAP has broader implications. As you consider many of the new services being promoted or benefit designs being developed, SOAP provides an excellent framework and sturdy foundation from which to create a health, wellness, or prevention plan. In fact, if you review the materials being created by groups like US Preventive Medicine, they are following the SOAP format to a T as part of their “Prevention Plan“.

USPM is helping people to complete a Subjective evaluation in the form of a Health Risk Assessment. Patients fill out a comprehensive evaluation of their health status, including socio-economic, behavioral, and family/social histories. This is patient generated content and therefore it has an appropriate, but not preeminent place in the medical context. Next, they complete a battery of health and wellness laboratory tests (Assessment) to establish a health status baseline. These tests, and the testing process, form a critical part of the overall evaluation. The patients then undergo a full physical exam to obtain the Objective data that USPM providers will need to create a personalized Prevention Plan.

By using the SOAP approach - USPM is creating a simple and systematic way to engage their patients in a iterative process of evaluation / re-evaluation that fits well into a managed prevention plan - a great concept that I have noted before. By having a solid prevention Plan in place, and adjusting as new SOA information becomes avaiable, an individual can modify their behaviors to ensure a “clean” bill of health.

True Insurance: Removing the Moral Hazard

True (trū) adj.

1. Consistent with fact or reality; not false or erroneous
2. Real; genuine, rightful; legitimate, fundamental, or essential
3. Accurately shaped or fitted and conforms to rule, standard or pattern

I recently came across an article so good that I thought it should be republished in its entirety. The article was written by Frank Timmons and was published in the Journal of American Physicians and Surgeons Volume 11 Number 4 Winter 2006 issue. Highlights are mine, commentary to follow, and hints of what I am up to interlaced in between.

“Restoring “True Insurance“

The jury is in and the verdict has been given. For decades, insurance has been grossly misused as a tool to manage medical costs in this country. In fact, it has served to promote and support one of the most damaging elements to the medical market: “first dollar benefits.”

Benefits that disguise the actual cost of medical services do great harm to the naturally occurring and self-limiting economic aspects of a buyer purchasing services from a seller. With minimal office and pharmacy co-payments of $15 or $20, the insured makes a decision on whether to use the services or drugs without having to consider the cost. This creates what insurers call “moral hazard.” It is very inefficient to hire an insurance company to pay expenses that are relatively certain to be incurred over a reasonable period of time: “budgetable expenses.” This seems more obvious with bills for groceries, gasoline, or utilities, but the same economic effects occur with medical bills.

What can we do about this? First, we need to reestablish the true definition of “insurance.” Although there are many dictionary definitions, the most concise one is most helpful here: “risk
mitigation.” One needs insurance if one faces a “risk” of loss, and desires to shift that risk to an entity willing to assume it in exchange for a payment (the premium). What we have come to know as “traditional” health insurance is clearly something else. It would be more accurately described as a very inefficient method of financing medical services.

For medical services, “true insurance” is generally referred to as “catastrophic coverage.” We all know that extended in-patient hospital confinements result in expenses that only the wealthiest
among us would be willing or able to absorb, and would lead to catastrophic economic hardship in the absence of insurance. This is an example of a risk, and its mitigation is the true and proper function of “health insurance.”

This is not mere hair-splitting. In addition to the waste associated with moral hazard, the fact is that insurance companies are terribly inefficient administrators. The logic that demands we not use steam shovels to till our gardens or hand trowels to build roadbeds rings true with the use of insurance as well. Insurance companies are very expensive personal bookkeepers and check writers. In spite of advances in claims–paying software and years of fine tuning, small transactions such as payment of doctor’s office charges and related expenses are most problematic. Decades ago when first-dollar coverage became the norm it wasn’t such a noticeable waste. Now that the medical sector has grown to almost 20 percent of the gross domestic product it is a very serious waste of resources.

How do we specifically define “catastrophic coverage”? Reasonable persons will disagree about this, and the loss that constitutes a catastrophe depends on the ability of the insured to absorb financial risks. Most visualize catastrophic insurance as a comprehensive health insurance plan (similar to the “traditional” model) with a very high calendar-year deductible (very different from the “traditional” model). For the sake of argument, let’s assume the deductible is $50,000.

The immediate objection is that most people cannot afford to fund the first $50,000 of medical expenses in a year. This is no doubt true, but no one is suggesting that the $50,000-deductible
policy is the only protection that anyone may or should have. The goal here is to separate “financial management” from the element of “risk” wherever possible, because insurance companies that are capable of providing risk abatement up to millions of dollars are not the best at managing finances on the individual level. No matter how hard they try, elephants will never be able to play the piano.

Consequently, it is irrational to empower these insurance companies with available medical funding in the form of premiums for “first dollar comprehensive medical insurance programs.” There are many potential solutions for managing that first $50,000 in medical expenses that would be much less costly than the usual policies available today. This “non-catastrophic” expense is best addressed in terms of financing methods, and creative market solutions can be developed. When financing is not appropriate, one would be able to purchase lower cost “limited” insurance programs that are designed to terminate at the point where the catastrophic deductible is reached. The amount and proportion of self-insuring, financing, and/or purchasing of limited insurance by an individual would be tailored to the specific needs of that particular individual and his family.

A combination of financing and insurance would increase the buying power of the individual, because properly structured catastrophic insurance combined with any appropriate mixture of financing methods should be less expensive than traditional insurance policy costs. It would also tend to alleviate some of the problems associated with medical underwriting for those with health problems, because of the separation of catastrophic risks from the expected expenditures for known health problems.

There are other serious barriers to developing solutions to medical financing problems, the most important being the tax code, which strongly favors employer-sponsored benefit programs. However, changing the mindset about what insurance can and should accomplish so as to reflect economic realities is a necessary step.

Frank Timmins has worked in the insurance industry for 34 years, primarily with employer-based benefits. He is founder and former president of Group Administrators, Inc., and a founding partner of Medcon Benefit Systems Group. Contact:

Stochastic Gaps: Insults and Illuminations on Microcapitation

Stochastic (stō-kăs’tĭk) adj.

1. Of, relating to, or characterized by conjecture; conjectural
2. Involving chance or probability

* Disclaimer: The letter is a response to Dave Marcinko of HealthCare Financials who had some pointed commentary regarding my attempt to define a trend I had identified and described as “microcapitation”. This is a lengthy post with written while on a plane ride home from Oakland, CA.

Dave,

I appreciate your note. If insulting me to the point of provoking a response while impugning my intelligence was your intent, you have accomplished both objectives. I will try to write a more coherent and lucid response to your disjointed commentary.

I minored in economics but am not an economic theorist. I am a trained observationalist with a knack for predicting emerging trends. Both as a board certified emergency medicine physician, and later as an entrepreneur, I was charged with identifying clues that would lead to early diagnosis when treatment can be most effective. I have identified the concept behind micro-capitation to be such a trend which I wrote about last fall.

Since you could not “for the life of me” understand what I was trying to say, let me provide some additional context. Capitation is most often defined as a set fee “per head” for a specific service. In the case of health care, providers are willing to take a set fee for a specific number of patients and manage the care required for those patients within the confines of that set fee. The problem with this model, as it was deployed in the mid-late 90’s, was that this form of capitation transfers probability risk from the insurer to the provider. Probability risk is defined as the actuarial risk that someone will get ill during the year and is the primary function of insurance companies to accept payment (premiums) to assume this type of risk. Provider are not insurers, and they were not savvy enough, did not have enough information, and did not have any systems in place to properly manage this form of risk. Furthermore, providers are not risk-bearing entities and assuming or attempting to manage probability risk was naive. Essentially, the took the money, crossed their fingers, and hoped for the best.

While most railed against capitation; it was not the enemy per se. The enemy was assuming probability risk when really the only variable the doctor can exert control over is technical risk. Technical risk is defined as the risk assumed by the provider in actually delivering the services in accordance with their training and expertise as measured against the standard of care in their area of practice. Physicians can exert significant influence over the technical risk, and in fact, the highly competent physicians learn to manage this so well that they delivery not only technically superior care, but can usually do it for significantly less money as well. This creates a virtuous cycle of innovation - good providers getting better with more practice and experience which increases their reputations and volumes which helps them get better and better.

So the previous model of capitation gave the physician a known lump sum of money to provide an unknown level of care and transferred both technical risk and probability risk to the physician. We all know how that game ended.

The few who did well under this regime were those who actually either inherited or evolved their practices to include healthy patients which allowed the physicians to earn more money by doing less. Any patients who crossed the “capitation line“, were kindly shown the door, denied additional services, given alternative treatments, or some combination of the above. These perverse incentive created capitated death spirals as some capitated practices aggregated very sick patients that required alot of care which dissimulated the capitated pools. By not adjusting for disease severity, this risk skimming and/or transfer made the concept of capitation a non-starter.

The budget concept underlying capitation does have merit, however. Budget driven health systems like the Veterans Administration and Kaiser Permanente have been shown to delivery a very high level of care and to achieve outstanding results. However, drilling down into their success one can see that the budgeting process actually was successful but not for obvious reasons. The budgeting process forced providers to seek cheaper methods of care, which pushed them further back along the health and disease continuum. These organizations found that an “ounce of prevention” was truly worth a “pound of cure“; that preventing the diseases or managing them early on in the process could yield profoundly more effective, less costly, and high quality care.

Some of the preventive innovations weren’t in the treatments themselves, but in the way the treatment was delivered. Multi-disciplinary teams began to emerge (Care Teams); with long term care relationships being established beyond just the traditional physician-patient relationship (medical home); multiple problems were treated in simultaneously in a single visit (care coordination); and accumulated expertise of the care teams began to be applied across many patients for further clinical and financial economies of scale (best practices). As these were systematically applied across populations, supported by robust information systems that allowed meansurement, monitoring, and management of outcomes (information technology), the VA and Kaiser began to achieve the outcomes for which they were, are, and will continue to be appropriately lauded.

However, the VA and Kaiser are both staff model, vertically integrated health care and health insurance organizations. Self contained universes wherein salaried providers don’t have the financial incentives to “churn and turn” patients. They are actually incented to provide holistic, patient-centered care within the context of the life long relationship with the patient. Despite my strong preference for independence and freedom, this model of health care delivers the goods (value based health care).

Unfortunately, less than 20% of health care in the United States is delivered in this way. Most of our care is fragmented, discoordinated, and inefficient. The cottage industry framework has been highly profitable to the powers that currently reign, and any change that will disrupt this much cash flow, will surely have to be cataclysmic. However, that is exactly where the US Health Care system is right now - we are heading toward the chasm - not only in terms of quality but more importantly in terms of spiraling cost that threaten the very foundation of the US economic infrastructure (you thought the recent credit meltdown was bad? Just wait until the health care meltdown hits!).

The painting of this dire picture is to establish the point that the first version of capitation got it wrong (transferred probability risk to providers). However, capitation is not inherently negative, as demonstrated by capitation-like (light?) budgeted models from the VA and Kaiser. Therefore, I conjecture that a newer version of capitation might actually get it right and even be desired to achieve the optimal health care outcomes. Hence, the introduction of one form of “new style” capitation which I called “Microcapitation“.

Microcapitation is a less expansive, hence “micro”, form of capitation. Instead of assuming global probability and technical risk to deliver care, physicians accept probability and technical risk around more discrete “bundles” or “packages” of care. These Care Packages can be comprehensive services around a specific disease condition or specific service that you as the technical provider can define. Examples might be comprehensive care around hip replacements or diabetic care for an entire year. For these conditions the providers put together all the various services, evaluations, and followups that need to be done to deliver the care package “product”. These discrete care packages, provided by either vertically or virtually integrated teams, not only help organize the delivery of care but also concentrate expertise within the teams. High volume providers would develop additional experience, which would enable them to introduce innovations and efficiencies in a classic virtuous cycle. With the additional delivery and outcomes experience, providers would be much more willing to list a set price for a set grouping of clinical services, because for the first time, they could have some confidence in their ability to deliver for that price. Thus, microcaptiation is a form of capitation but at a discrete medical condition level (which should be the lowest common unit of care delivery that we should measure).

Clearly these care packages will require intelligence built into them in terms of their specifications, but they are definable, controllable, and limited set of clinical activities in which providers can, with confidence, provide services for a set fee. Microcapitation can be a useful new tool particular in the creation of a health care marketplace. Microcapitation around specific medical conditions also provides a manageable unit of health care delivery, an appropriately sized clinical bite in which measurement, monitoring, and healthcare outcomes to be reported, compared, and ultimately consumed in a healthcare marketplace. No need to make up examples, the experiment is already been live in Minneapolis for 4 months and will soon be opening in Seattle.

Microcapitation is not sub-capitation as you define it. Subcapitation is physicians opting out of providing care for specific conditions and having some other sub-contractor (provider) fill in that gap. Microcapitation is a way for any provider any where to create a discrete unit of care provision (comprehensive care for that specific medical condition) and assume the technical and financial risk for the outcome. By reducing the size of the capitated risk from an patient panel to a discrete condition (wherein the physician controls the conditions and hopefully heavily influences the outcome of the services delivered), microcaptiation provides the appropriate alignment of risk and reward for both the provider and the patient. Furthermore, providers have the opportunity to be creative in the way they deliver the service, how they market it, how they measure success, and ultimately how they deliver better outcomes.

Again, the best example of microcapitation model and philosophy can be seen at Carol.com. Other forms of capitation are also emerging, most notably the work being done by Alan Gorrol with his Comprehensive Payment for Comprehensive Care Initiative (risk adjusted/performance based capitation).

Thank you for the offer to expand these theories in other mediums. While I am always happen to share my ideas, I happen to find this medium credible enough.

Definitely not related,

Scott

–

Scott Shreeve, MD
Crossover Healthcare
(949) 235-9375
scottlshreeve@gmail.com
http://crossoverhealth.wordpress.com/

PS - And by the way, I did not the glaring inconsistency of claiming to be “new wave” while wearing a bow-tie (Does not compute!)

References:

1. Emery D. Value-based formulas for purchasing–PEHP PEHP - Planet Earth Home Page
PEHP - Public Employee Health Plan’s designated service provider program: value-based purchasing through global fees. Managed Care Quart 1997;5(1):64-72.

===

Scott, et. al.,

I re-read with interest your philosophy on “micro-capitation”, and am pleased that there are-foreword thinking folks like you, out there.

Currently, we are crafting a paper on capitation economics for a journal and wondered if you have fleshed out your ideas a bit more? We would be delighted to reference you, and your new term, if you might more pragmatically assist us to understand concept with samples, illustrations, use, potential use, etc.

The bit/byte concept is intriguing, but there are all sorts of stochastic gaps left in your theory, which I can not find on the net; not withstanding the financial.

For example; liability, pricing, continuity of care, leadership, etc.

Most importantly, your small unit condition package concept sounds like a FSS idea, but with more drill-down.

Or, could it just be a “sub-capitation” system, as described in the scenario, below.

Sub-capitated Contract:

The often-contentious dilemma of “carve-outs” from capitated managed care contracts is abating in some parts of the country, just as it is accelerating in others.

Under this scenario, medical services or products such as surgery, trauma, physical therapy, immunizations, certain tests, wound care, or prosthetic devices may be excluded from a managed care contract in favor of another, often “sub-capitated”, provider.

However, if your medical organization is contemplating a sub-capitated contract, consider the following scenarios.

For example, an orthopedic group notes that hand surgery is listed in a new capitation contract that it is considering.

The group is not comfortable with such surgery and they ask that these services be excluded. Since the contract provider will not exclude the surgery, the orthopedist group either has to accept it and perform unfamiliar surgery, or reject it.

SCOTT: Is your idea here a third option in this case? If so, please explain in detail. If not, please explain how it is new?

Thus, the following are conditions considered important for carved or sub-capitated risk contracts:

• equivalent risk for the provider and sub-capitated specialist;
• fixed expenses for the sub-capitated specialist;
• predictable and low cost of care, per specialty episode;
• high episodes of specialty care (not unusual or unpredictable events);
• definable and understood responsibilities of the specialist;
• profit and cost savings potential for both the referring and specialty provider; and
• existence of re-insurance, etc.

IOW: What I am trying to determine here - is if your micro-capitation concept is a real emerging philosophy, or merely the disorganized rantings of another frustrated doc?

For the life of me, I still can’t understand exactly what you are trying to say. Sorry.

Maybe it is me, after all.

My Bad!

Please advise if you wish to promote and expand your theory in a more credible print or e-venue; after more thought.

Fraternally,

Dave Marcinko
Atlanta, GA USA
MarcinkoAdvisors@msn.com
http://www.HealthcareFinancials.wordpress.com
http://www.HealthcareFinancials.com

Millenial Patients: Care Delivery for the Next Generation of Patients

Generation (jĕn‘ə-rā‘shən) n.

1. A group of individuals born and living about the same time.
2. A group of generally contemporaneous individuals regarded as having common cultural or social characteristics and attitudes.
3. A stage or period of sequential technological development and innovation.

* This is a reposting of the article I wrote for the May 2008 issue of MDNG and is related to the recent blog post on Millennial Health Care Delivery.

Modern medicine has adopted technology and pushed the boundaries of science in impressive ways. We see this in the use of high-tech imaging, advanced pharmaceutical agents, innovative medical devices, and recent advances in proteomics and genetics. However, in the actual delivery of care (how physicians interact with patients, manage health information, and pay for care), we still have paper records, we still hand write prescriptions, and we still have as much as 30–40% administrative overhead. This health care delivery “adoption lag” is predictable, and typically averages five to seven years, but may be as long as 10 to 20 years. The automation of financial transactions, the movement toward electronic medical records, or even the adoption of Linux within the health care enterprise have all followed the predictable delayed adoption pattern seen in other industries.

However, this delay can be used to the strategic advantage of astute physicians and health care entrepreneurs. By observing the wider technology adoption patterns in fast-adopting industries like financial services, we can reliably predict what trends will soon be impacting health care. We can also get a sense of how consumers, traditionally called patients within health care, will respond as they adopt—and push their providers to adopt—the technologies that will simplify their health care interactions. This millennial generation of patients will expect to be able to use Internet technology to shop, compare, chat about, purchase, and report their experiences just as they do with nearly all the other services they consume. Welcome to next generation health care and what I like to call the Millennial patient.

The millenial patient

Millennial patients can best be defined by their behavior, rather than their age, sex, or demographic. Millennial patients are the first generation of Americans to grow up with the Internet as a pervasive part of their lives. They use the Internet in their everyday life to research information, purchase tickets, pay bills, and meet their personal, social, and professional needs. They are amazed, bewildered, and ultimately angry with the inability to access their healthcare services in this way. They cannot understand, and they will not tolerate, this disparity in the ability to manage healthcare transactions as simply as they manage their financial transactions. They are knowledgeable, intelligent, are typically prepared for their appointments, and inherently expect and demand a far higher level of service from their healthcare provider.

In contrast to the widely publicized TIME magazine article by Dr. Scott Haig, most Millennial patients are not “Googlers” in the derogative way he uses the term. Most do not use this information as a weapon against their physician, but rather use it to become an informed participant in the delivery of their care. They value the trusted relationship with their healthcare provider and want to work together to optimize their health. Having used professional advisors in other areas of their life, they understand the need to have a relationship with their healthcare provider based on trust, mutual respect, and open communication. In order for physicians to most effectively engage the Millennial patient, it is import to understand the different types of next-generation patients.

Patients as consumers

The days of passive patients cowering under the commanding voice of their all-knowing physician are gone. The outsourcing of medical decision making will continue to wane as the outsourcing of financial responsibility continues to be reduced. As the cost shifting returns back to the patient, the increased financial accountability means that patients will be more involved with decision making, including treatment decisions, because these directly affect costs. The notion of “shared medical decision,” pioneered by Jack Wennberg’s team at Dartmouth, describes the collaboration that occurs in reaching an agreement about a healthcare decision. Part of these conversations will include discussions regarding the pricing of services, which will force providers to reconsider what they are willing to accept for payment for their services. How much does that treatment cost? What are the alternative therapies, and how much do they cost?

It is important for providers to realize that patient consumers are not asking these questions to challenge their clinical judgment. There is no plausible medical tenet or practice bylaw that states the patient “shall not” know the price they are about to pay for a service. They are asking because they need this information to formulate in their own minds the value decision (outcome/ price) that will aff ect what they ultimately decide to do. While providers may believe that the patient will always choose the therapy that potentially leads to the best outcome, patient consumers may not be willing to pay the price to obtain the recommended outcome.

In addition to getting comfortable discussing pricing, providers will need to be able to complete healthcare transactions at the point of service. As more consumers pay a higher percentage of their own healthcare costs (consumer payments are about $50 billion today), healthcare providers will need to adopt new technology and business processes. Failure to do so will result in an everincreasing uncollected payment burden. The McKinsey Quarterly has documented the need to transform the point-of-service transaction capabilities in several papers. Part of this transformation includes eligibility verifi cation, real-time co-pay/ deductible accumulators, card/reader technology, and fi nancial integration with consumer accounts. In addition, providers will need to become much more transparent with regard to pricing for their services. Retail clinics have led the way in posting cash prices, and physicians will need to learn to not penalize consumers with much higher cash prices. Rather, they’ll need to reward them for the real and tangible savings that cash payments make possible by avoiding the Byzantine insurance payment process. Companies like Recondo, TriHealix, and even practice management companies like athenahealth are leading the way.

Physicians will need to realize that pricing information is only the first wave of the oncoming transparency initiatives. Savvy consumers will quickly become interested in outcomes information, wanting to know the specifi c results achieved by a specific physician for specific procedures. Furthermore, they are going to want to talk with the “patients like them” who have actually undergone the procedure from the physician to get a sense of experience, service level, and outcomes. Social networking has already significantly impacted this, and companies like HealthGrades, Xoova, Vitals, and others provide basic rating information right now. This will become much more sophisticated and ultimately include relevant outcomes data in consumer-friendly formats.

Finally, the consumer patient will want to engage their healthcare provider in the convenient ways in which they engage every other service. They will demand the ability to schedule appointments online, check laboratory or radiologic results, and communicate with their physician via “new media” like e-mail, chat, and video. These technologies are all well-established commodities, and they enable providers to meet their patients “where they are” in terms of how, when, and in what manner they would prefer to communicate. New services like American Well, Hello Health! and Organized Wisdom are all representative of enabling technologies that patient consumes will want to utilize to engage their health providers.

Patients as providers?

Enabling new technologies works both ways in allowing patients and physicians to interact in new ways. For physicians, that means the ability to empower patients by helping them become more informed, involved, and in-tune with their own health. Just as the use of mid-level providers served as an eff ective extension of the physician, many of these new technologies can push outsourcing of care all the way down to the patient. In this paradigm, the patient becomes another provider, perhaps a much more accurate and appropriate description of the term primary provider.

David S. Sobel, MD, MPH, Medical Director of Patient Education and Health Promotion for The Permanente Medical Group at Kaiser Permanente, is responsible for 3.3 million members who interact with the Kaiser system and has a simple mantra for success: “Keep the patients healthy, happy, and at home.” Beyond the trite saying is a powerful philosophy about patient empowerment. Namely, Sobel considers his patients as providers and collaborators in the care process. “Patients are most often viewed as consumers of healthcare, and health professionals are seen as the primary healthcare providers” Sobel says. “In fact, 70 to 90% of all symptoms are self-diagnosed and self-treated without the help of health professionals. The true primary care providers are people themselves.” What would happen if providers considered their patients as colleagues in optimizing health? How would patients respond to not only an increased fi nancial stake in their care, but also an increased clinical stake as well?

Patients as Partners!

While we may still be a long way from patients as providers, initiatives like shared medical decision making are helping break the paternalistic perspective and embrace the patient as a member of the care team. Patients can be reliable reporters of treatment regimens, can assist with care coordination, and with appropriate oversight, can serve as outsourced low-level providers. The physician role in this setting is to create an aligned relationship of trust that leads to health optimization; the physician becomes the trusted advisor who guides the partner patient through the labyrinth of healthcare decision making. This is the physician counselor who can facilitate decision making along clinical, fi nancial, and social/cultural lines. Sounds suspiciously like the primary care model, right? What is so novel about the patient as a partner? Get real. Primary care delivered in this way is exceptionally diffi cult to find. You cannot create a trusted, advisory relationship in the 7- to 12- minute patient interval treadmill that most primary care physicians run on every day. However, there is a growing awareness, perhaps even a growing movement, among the proponents of throwback traditional medical practices, with an updated technology twist.

The millenial provider

Having already defi ned Millennial patients, it would be appropriate to also describe Millennial providers. These are the enlightened physicians who realize that technology can help them in delivering an entirely new range of personalized healthcare services that meet specifi c individual needs. While some remain concerned that technology gets in the way of developing meaningful relationships, Millennial providers use technology in such a seamless way as to abstract it nearly completely out of the relationship. Instead of decreasing the intimacy of the relationship, it actually allows healthcare services to be delivered in a much more personalized way.

This style of medical practice is allowing a sense of freedom and fulfi llment that had previously been extinguished in the crushing cycle of managed care. “I couldn’t handle the frustration of traditional managed care practice paradigm,” said Jordan Shlain MD, CEO of San Francisco On Call physicians group in San Francisco. Schlain begin his own on-call, personalized medicine service just two years out of residency. “I was not happy, not in control, and not enjoying my patients or myself. I chose to create the type of practice that I wanted to go to, that I would actually use as a busy, young professional.” Schlain discontinued his practice, stopped taking insurance, and instead created an on-call service whereby he would go to the offi ces of his patients to provide care. He adopted an electronic medical record, wireless technology, and several practice innovations that allowed him to coordinate his practice with that of his patient partners. He worked holistically with the patients, to meet their ongoing health, prevention, and wellness needs. He works reasonable hours, makes more money, and couldn’t be happier practicing medicine on his own terms, using technology-enabled, personalized services that treat the specialized needs of his unique patient population.

Millenial healthcare

Millennial patients are beginning to demand a higher quality of service and a more meaningful relationship with their provider consistent with their experiences in other sectors of the market. Millennial providers will create service off erings that will address patients’ specialized needs and help deliver appropriate health services within a personalized context. This partnership of care relationship will need to be supported by the very best technology, products, and services associated with the pricing, quality, and effectiveness information required of a value-driven system. When these elements become transparent and aligned with appropriate fiscal incentives, the US healthcare system will approach the efficient, next generation healthcare system that can continue to serve our countries healthcare needs well into the new millennium.

Scott Shreeve, MD, is interested in the convergence of medicine, technology, and business. He works to design, develop, and distribute healthcare technologies that enhance patient safety, increase clinical efficiency, and improve overall quality of care. His blog, Crossover Health is dedicated to ensuring that these technologies are eff ectively applied to healthcare delivery in order to create a true consumer market for optimal health.

Personalized Medicine: Back to the Future

Personalized Medicine (pûr’sə-nə-līz d mĕd’ĭ-sĭn)

1. The type of sing molecular analysis to achieve optimum medical outcomes in the
   management of a patient’s disease or disease predisposition,
2. Right treatment for the right patient at the right time.

As I have mentioned in several of my posts, I have been working on a couple of health care finance reform initiatives over the last six months. After banging away now for awhile, I am starting to see some emerging ideas that are starting to bring out that old revolutionary feeling of doing something that can have an industry changing impact. The opportunity lies in the ongoing pace of innovation, with new forms of health care delivery, with new models of health care financing, and that fact that eh American public and politicians are slowly waking up to the fact that our health care system is headed toward radical surgery (not the cosmetic kind).

So lets start this out by talking about the personalization of medicine. This is typically thought of in a genetic sense, wherein people are customizing medications and therapies based on your individual genetic profile. Said in other words, the “Right treatment for the right patient at the right time”. However, most consumers already assume Right/Right/Right is happening, and more likely consider personalized medicine as a type of practice delivery style. This is where the physician knows the patient intimately, their social and demographic context, and the correct diagnostic or therapeutic approach given the patient’s preferences that have been learned throughout the relationship. The only physician I have ever had whom I had this type of relationship with was Dr. Richard Jones who took care of me from age 6-21 (when the front office lady finally told me that I “really should find another doctor“).

Dr. J, as he was affectionately called, had a personal interest in our family. Not only did I play football with his son throughout my school years, but he was always available to to see us at a moments notice. He was larger than life in our home - he expertly took care of coughs, earaches, nosebleeds, annual physicals, immunizations, concussions, and nearly every other ailment we could bring to him`. He was an excellent diagnostician, compassionate clinician, and very efficient with his time and practice. As our team physician, I got to know him as a second coach, a counselor, and someone who could console in times of defeat and share the joy of championships. In fact, more than any single factor, Dr. J influenced me to go into medicine because of the significant impact that he had in my life. I looked up to him as a role model, as an advisor, and as a friend. The relationship was time-tested, absolutely trusted, and he represented someone and something that I aspired to be.

However, that was not the world that I would find years later when going to medical school. The late nineties represented the first major backlashes against both nationalization of health (aka “HIllaryCare v1.0″) as well as the oppressive managed care regimes. The physicians that trained me and my classmates were angry, bitter, decrying the loss of the “golden era”, and just plain burned out. The Dr. J’s of the world were being forced onto a 7-10 minute treadmill, procedure focused, and RUC enhanced schema that perverted the primary care practice style that has been shown to increase health care value. The entire E&M coding concept, the fee for service, “do more get paid more” delivery model supported by RUC reimbursement methods (and its 24 out of 29 specialist committee members) has led to a dramatic DECREASE in VALUE (outcomes/price) by dramatically driving up the “price” part of the equation. In addition to driving up price, (which was initially combatted and later retracted through the managed care “spasm”) the problem has been that even with all the increasing costs there has been very little change the overall health outcomes. Research by Wennberg, and books like Overtreated and Crisis of Abundance effectively make the case against the specialist and procedure intensive “Premium Medicine” currently practiced in America.

But all that is beginning to change. Just as data drives discovery, medical evidence can and should drive medical practice. The evidence is showing that our current cultural expectations, third party payment misincentive system, and malpractice litigation environment are creating the perfect storm for healthcare reform. The winds of revolution are being buoyed up by the pioneers of health care delivery reform, and a return to when becoming a primary care provider delivering true health care (preventive care and wellness) versus “disease care” (what is currently practiced) is actually cool. Its the “going green”, renewable wave as applied to health care. I have documented the first wave of hip new doctors, now better equiped through technology to deliver highly personalized care (personal health records, predictive practice analytics, and evidence based treatment sensitive to individual cultural, demographic, and contextual preferences) who are reinvigorating the entire field of primary care which has unfortunately languished for decades (not for a shortage of solid physicians!). When added alongside payment reform (initially beginning as cash payment for services), and ultimately the realignment of incentives (through market forces supported by an appropriate regulatory environment) and reassignment of work tasks (appropriate utilization of physicians and other trained healthcare providers (RN’s, NP’s, etc), primary care has an opportunity to survive in a modified form.

So we are back to where we started 50 years ago. Trusted primary care physicians using technology to delivery highly personalized and effective medicine that their patients value and are willing to pay for - now that’s a future Dr. J could be proud of.

Millennial Health Care Delivery

Millennial (mə-lĕn’-əl) adj.

1. Of or pertaining to the millennium, or to a thousand years
2. Generation of Americans younger than 29 in 2007 with unique social, cultural, and market identity

* This is a companion piece to an article called Millenial Patients that will appear in MDNG shortly *

The highlight of last months Health 2.0 conference was the segment in which three enterprises physicians discussed their next generation practice models. We heard from Enoch Choi, MD at Palo Alto Clinic who has a traditional, but technology enabled practice; Jordan Shlain, MD of San Francisco On Call which provides a cash only mobile practice; and from Jay Parkinson, MD who has attained the most notoriety through his unique approach, clinical skill set, and artistic flair. These services are representative of a growing number of similar practices that serve as an example of another important concept to consider in preparing for next generation health care. Millenial patients will demand a new range of services, many of which currently do not exist within the current medico-industrial insurance construct. In fact, the provision of niche services which have traditionally fallen outside the concept of traditional health care may prove to be the biggest opportunity to impact care delivery.

This conceptual framework can be understood within the technology description of The Long Tail. First described in the popular press by Wired Magazine Editor Chris Anderson in 2004, it is basically descriptive of unique markets wherein distribution and storage costs approach zero and therefore the provision of small numbers of less popular items actually is more profitable than the provisions of large number of popular items. The math works out as such that the area under the “long tail” part of the curve is as big or bigger than the area under the curve to the left. This long tail represents all the niche, specialty offerings that can be purchased so that when aggregated, the niche market opportunity is bigger than the mainstream.

The anatomy of the long tail shows that most patients consume a relatively small number of core health care related services. These have been provided in a prescribed way for decades and have address most basic health care needs. However, as science and technology advance, there have been, and will continue to be new, more efficient, and hopefully effective treatment options. Over time these new therapeutic options themselves become more personalized and specialized in order to address the needs of niche target populations. The number of personalized services will ultimately outstrip the traditional health care service offerings.

Remixed with the expectation of obtaining permission from Wired Magazine Issue 12.10, October 2004

But niche products are not for everyone. Most people have gotten and can continue to get traditional health care services. However, newer technologies that create new value propositions might fill an entire set of health care needs just as well, or perhaps even better. The personalization of medical services allows them to be consumed “wherever the consumer is” along the health care delivery continuum based on their unique value equation. So while not everyone will want to speak live with a physician for $1.99/minute, there are certainly some who will, and they can be recruiting into the next generation health care system via health care delivery offers that occurs within the long tail of healthcare.

* Remixed with the expectation of obtaining permission from Wired Magazine Issue 12.10, October 2004

Millenial Health Care System

We are entering an unprecedented period of accelerated discovery and change within health care. Millenial patients are beginning to demand a higher quality of service and a more meaningful relationship with their provider consistent with their experiences in other sectors of the market. Millenial providers will create service offerings that will address these specialized needs and help deliver appropriate health services within a personalized context. This “partnership of care” will need to be supported by the very best technology, products, and services associated with the pricing, quality, and effectiveness information required of a value-driven system. When these elements become transparent and aligned with appropriate fiscal incentives, the US Health Care system will approach the efficient, next generation health care system that can continue to serve our countries health care needs well into the new millennium.

Gatekeepers vs. Quarterbacks: Primary Care Gets Back in the Game

Quarterback (kwôr‘tər-băk‘) n.

1. The backfield player whose position is behind the line of scrimmage and who usually calls the signals for the plays.
2. To lead or direct the operations of an enterprise.

I have been reading with interest all the recent articles (here, here, here, and here) regarding the decline of primary care as a specialty and the rise of practice reform models, such as conceirge, retail clinics, and related variations. The common theme is that through the debauchery of managed care and RUC reimbursement schemes supported by the AMA (24 of 29 representatives represent specialties), we have created a completely skewed, unaccountable, and unsustainable financial model incenting the delivery system to provide a specific type of care. In essence, we are getting exactly what we paid for - dyscoordinated care, excessive procedures, and too many specialists (an excellent treatise on this is provided by Shannon Brownlee’s excellent book, Overtreated).

In reading non-physician commentary about this situation, I am intrigued with some of the insights but have to smile about most of the conclusions. Let me be candid with my experience regarding career choice options while I was in medical school. I attended the University of Utah, well known for its genetics and informatics programs, with a moderate slant toward rural care given the remote expanses which fed into the tertiary care centers of the University and Intermountain Health Care. There was a strong bias to recruit primary care physicians beginning with the free brown bag lunches that started during my first year. Incentive programs, like loan forgiveness or related financial incentives were tossed out as carrots, to attract potential primary care physicians. The problem for me, and most students, was that both the message and the messengers were unconvincing.

We all busted our tails to get into medical school, and despite whatever your higher motivation of choice you relayed during the interview process (I want to help people, I want to do well by doing good, etc), the rigors and demands of 7-12 years of post college training completely beat the altruism out of you. It came down to what specialty can provide the most value to me (outcome/price). This formula is important for non-physicians to understand. Some physicians in training are motivated purely by their love for some aspect of medicine - pediatrics, public health, AIDS, surgery, etc - but most settle on the practice type which helps them attain the outcomes they desire (quality of life, financial security, and career stability) at a price they are willing to pay (years of training, lifestyle, financial considerations, etc). When you sit down with a highly intelligent, highly motivated (remember these folks are gluttons for delayed gratification) person and present Hamburger A or Hamburger B, their decision making process becomes clear:

This data is taken from my personal thumbnail sketch and do not represent actual practice information.

So, please, tell me why as an aspiring medical student, feeling a little entitled by the prospect of the extra two initials looming, would ever go into Primary Care? You can drop the altruism right now because altruism does not put food on the table, children through school, or the finer things in life within reach. This is exacerbated when you have a plateful of specialty choices in front of you that offer everything you are dreaming about and in some cases much more. Remember, I am not disparaging my primary care brethren/sisters in anyway, they are fighting the “good fight” in the trenches and the evidence is clear that primary care is an integral part of improving health care and population health. I am merely acknowledging that the current financial system we have in place creates overwhelming incentives to go into a specialty, or even if you choose primary care (ie, internal medicine) you still choose to specialize (cardiology, pulmonology, infectious disease, etc).

As a result, I have become very interested in redefining health care financing to align incentives in order to obtain better health care outcomes. I believe that primary care needs to be paid in a way that recognizes the value that it creates for improving population health (just as I believe that teachers should be paid for the value they create for society). Notice that I did not say physicians – as I am of the persuasion that primary care physicians are being undone by their own lack of demonstrating value and moving appropriately up the health care delivery value chain. Primary care physicians ARE GOING TO GET REPLACED (appropriately so!) for all the simple stuff that is covered by retail clinics. Anything that can be reduced to a guideline, a template, or treatment algorithm should absolutely be given to someone else in the health care delivery chain. PCP’s should not fight this, they should embrace this, in order to move toward delivery of higher value oversight, complexity, and clinical conundrums where they can uniquely put those years of training and experience to work.

Paying primary care providers more has to be more than just a cost shifting scheme where more payment is given for the same method of delivery. I personally believe payors are willing to pay more for something new, better, and less costly. In order to facilitate this transition, primary care physicians need to move from the failed “Gate Keeper” concept (impotent guardians of health care expenditure) where they were perversely incented to do more and do less simultaneously to the much more enlightened “Quarterback” of a primary care delivery TEAM. Having been a quarterback myself both on the field and in the ER, I know what it is like to deliver great outcomes in a highly effective team environment. Primary Care Physicians should provide the clinical leadership, practice population oversight, care coordination, and overall direction for care teams (nurse practitioner, registered nurses, medical assistants, dietician, etc) that gets paid based on delivering outstanding results. This type of “Quarterback” model has some promise.

Its still pregame, in fact, the players are just wrapping up the final instructions prior to taking the field for final run throughs and warm-ups. However, the money boys are starting to place their bets. Everyone is looking for quarterbacks who can take lead the team.

The Lawrie Dowry: Misys Acquires Allscripts in Shotgun Wedding

Dowry (dou’rē) n.

1. Money or property brought by a bride to her husband at marriage.
2. A sum of money required of a postulant at a convent.
3. A natural endowment or gift; a talent.

Misys PLC has offered to acquire struggling Allscripts “the leading provider of clinical software, connectivity, and information solutions that physicians use to improve health care“. The rumor mill regarding the fate of Allscripts has been rampant since HIMSS. Despite achieving record revenues and several recent customer wins, the stock has been absolutely trashed by market perceptions of stagnation (prior to November 2007, the stock had a 52 week moving average of $22.21 to $31.38). The beleaguered software company was forced to jump in bed with the Brits in what feels like a rushed deal to create a new company called Allscripts-Misys Health Care Solutions (what kind of name is that? Perhaps Amalga Too would have been a better name).

Watching the press release with Mike Lawrie and Glen Tullman was painful (and who on earth was that interviewer?). Sidelong glances, forced smiles, and sitting uncomfortably close to one another was just disconcerting to watch. I couldn’t even listen to what they were saying as the Bz:Rw (Buzz Word to Real Words) ratio was off the charts. In the end, in looking at the numbers, Misys is paying $330M for 54.5% of the company. This translates into a $600M valuation, or 2.13X the record 2007 revenues. This figure is stunning, particularly for a company that as recently as November 2007 was trading north of $25/share and worth $1.5B. A BILLION dollar loss in valuation in a 4 month window while the company is reporting RECORD revenues. As Mr. HIStalk said, “Momma’s, don’t let your companies grow up to go public!” (At least it was better than the fate of Bear Stearns).

What to make of this deal?

Look, I realize it is easy to sit back here in anonymous blogger land and take pot shots at the big boys while they are trying to create shareholder value and deliver for their customers. So in one sense, I applaud Glenn Tullman for sucking it up and doing what needed to be done with a company that was paradoxically getting crushed in the market when by most every other measure the company was delivering. However, from another perspective, I think Allscripts stock price is so depressed because their current business model has run its course. They cannot compete with the like of eClinicalworks and the athenahealth who are cleaning their clock on most deals. But more than the deal by deal analysis, the stock price reflects the perceived future value of the company, and in these numbers, a simple comparison is instructive:

Metric	Allscripts (MDRX)	Athenahealth (ATHN)
Market Perception	Old School	New School
Business Model	Software Licensing	Percentage of revenues
Software Paradigm	Hosted solutions	Network solutions
Software Model	Feature upgrades	Software Enabled Service
Market Cap	$554.9M	$831.7M
2007 Revenues	$281.9M	$100.4M
Physician Users	~30,000	~20,000

Bottom line is that Athena has a better business model than Allscripts. Period. Now with the merger to Misys, the new Allscripts-Mysis-I-am-NOT-giving-up-my-name Health Care Systems company, is going to have an even harder time in the market due to the inherent market confusion and channel conflict created with the new combined product offering. The products have been in a competitive death match for years, and they won’t make nice overnight. Think of the dedicated sales teams, the marketing collateral, the ingrained compensation plans, and the corporate inertia that is going to have to be overcome while these guys try to sort this thing out. While the ambulatory care space is ripe for continued adoption, I don’t think it is looking for more confusion.

The concern is that while they are focused on the transition, the product integration, and the solution story, they are going to continue to get killed in the market. Glen Tullman is going to have to be constantly on the road trying to soothe over skiddish customers worried about the lack of focus, the ongoing commitment to current products, the inevitable distractions of the merger, and the longevity of the new entity (Misys track record in this regard is less than impressive). This won’t leave much time back at the ranch to ensure things are getting settled. Plus, a 10 person board? Man, Glen, all I can say is good luck dude.

The one bright spot, in my opinion, is the potential for Misys to really do something interesting with their newly created open source health care unit. Think about it: Misys is going to have to dump some of their product lines as Allscripts has a very solid ambulatory EMR. Therefore, some of the Misys products will need to be sunsetted or eliminated (although Misys Myway seems to be getting some traction) to avoid channel conflict and market confusion. Instead of just chucking these products, they could be placed out in the open source community for reuse, recycle, and remixing. Having made the big open source commitment and actually delivery on the promise (to a large degree), Misys could break open the flood gates of innovation by releasing something truly meaningful, and then working with community partners to grow it into something even more meaningful. This could potentially lead to some new lines of revenues, new developments, or related opportunities for software that would otherwise would be in the junk folder.

I have been impressed both personally and professionally by Tim Elwell, the units general manager, and his trusty sidekick Ryan Bloom, of Apache fame. Both were specifically brought in to help create an open source plan at Misys and coalesce a community around real source code and real projects. I was actually proud to see them at HIMSS waving the the open source banner and Tim even participated at the recent Health 2.0 Conference. I get the sense that these guys are really trying, and their efforts could be a HUGE boon to the open source community and to greater software development transparency within the health IT industry. They are off to a fast start, and their efforts could prove useful to the valuation and forward movement of the new company.

I hope the honeymoon continues.

Health 2.0: The Long Tail of Health Care

Long Tail (lông tāl)

1. New business phenomenon in which low distribution and storage cost enable significant profits to be realized by selling small volumes of niche items instead of large numbers of popular items.
2. The potential for online retailers to make more money than their bricks and mortar counterparts because there is virtually unlimited “shelf space” to offer products.

Chris Anderson of Wired magazine editorial fame, coined the term and described the phenomenon in a 2004 article called The Long Tail. For the unfamiliar, the Long Tail is best described as the ongoing niche interest in something once the large pulse of public interest has died off. Essentially, so the theory goes, when distribution and storage costs of a business are very low, they can realize significant profit by selling small volumes of hard to find items to many customers instead of selling large volumes of a few popular items. Given the length, or the area of the curve under the “tail”, it turns out there is actually a greater opportunity for profits pursuing this niche strategy if the right distribution and cost elements exists.

The Long Tail Explained. As demonstrated by the above example, while Walmart sells the bulk of popular music at their stores, the distribution and storage costs elements of online retailers like Rhapsody are such that they can actually mine a very large, underserved niche market that proves to be just as, if not more, profitable.

In my closing remarks yesterday on the final reactor panel at the Health 2.0 conference (totally off the cuff by the way as I was unaware I was going to have an opportunity to make a statement), I had mentioned this concept. However, given my uncharacteristic lack of preparation and desire to offer a coherent closing statement. I have including the following:

First, I wanted to thank everyone for participating in the conference. Health 2.0 remains a very unique type of conference, where the energy, the mojo, and the level of attendees is extraordinary. While the novelty has somewhat worn off for those in the space for the last 18 months, the organizing influence of the Health 2.0 banner continues to grow in strength, magnetism, and centripetal force. I likened this growing movement to the appearance of an oncoming swell, and those paying attention can position themselves appropriately to catch the choicest part of the wave and subsequently ride the fastest, furthest, and with the most style (some will even get in the “green room“). Others, with their backs facing the wave (whether in denial, dismay, or disarray), will get rolled under the force of change wrought by Health 2.0.

Second, I wanted to highlighted the concept of “Aggregate, Analyze, Advise” (halfway down page) and briefly outlined how most Health 2.0 companies are openly demonstrating the value of this paradigm. Others, have extolled versions of this vision as well. I believe this creates a nice framework to think about how the various companies, in their various niches can help solve unique consumer problems by addressing unique needs. In fact, the very reason these companies exists is that there is some real or perceived need that is not being met and they are attempting to use the enabling web 2.0 tools to engage people who have not been engaged in the past.

This allowed me to make my third point in rebutting the notion of technology as a disintermediary force - the cold steel of the computer inserting itself between the warm and engaging relationships enjoyed by humans. I shared how I was initially very critical of the new Dr. IM model, going so far as to call out Jay Parkinson when he announced his new practice model. I had failed to realize, based on how the initial press portrayed (downside of virtual medicine) things, that Jay was using enabling technology to engage an entirely new generation of patients on their terms, in ways in which they were familiar, in language they understood, and consistent with how they lived their life. In fact, the enabling technology was allowing him to practice in a more intimate, personal way. Jay is not trying to serve the mass institutionalized health care system, he is trying to service a niche group of young, urban professionals who for whatever (or for obvious) reasons have opted out of the medico-industrial complex. And, his 7 million hits the first three months his website was live should help people understand that this new style of health care delivery was meeting some previously unrecognized need.

Which led me to my final point: I am struck by how this explosion of personalized technology, and how much opportunity there appears to be to service the “Long Tail of Health Care” - the vast majority of underaggregated, underanalyzed, and underadvised niche patients who are looking for niche services. These niche services, as demonstrated at both Health 2.0 conferences, are the first attempts to use technology to personalize the health care consumer experience, to meet them where they are, in the way they want to be reached, in a language they understand, and with means that meet their unique values. This perhaps, becomes an even better definition of Health 2.0.

So whether you believe using American Well or Live Wisdom fundamentally changes the delivery system or not, it is going to address some need for someone who is interested to pay $50 for 10 minutes or $1.99/min for glorified telemedicine services. Whether you personally would ever go to a doctor like Jordan Schlain or Jay Parkinson, they are on the cutting edge of a new era of personalized services - including those delivered by caring, effective, and high quality professionals. In addition, folks like Phreesia with their electronic clipboards, Eliza and Silverlink with their Voice Recognition Software, or patient centric applications like Emmi Solutions, ReliefInSite, or even PharmaSurveyor are attempting to deliver to products to service niche needs that have traditionally fallen outside the mainstream medicine but squarely within the context of the Long Tail of healthcare.

A word of caution about this Long Tail notion, however. As pointed out by David Sobel (“The Elder” as became known during the conference) in his exit speech during my panel, for all the enabling technologies we are developing to addresses the Long Tail of health care, we need to also be concerned about addressing the fundamental and structural flaws within our current system:

The assembled talent, brain power and passion in the room was truly remarkable. Thanks for giving me the opportunity to participate. I do hope that my brief, hastily constructed remarks before my departure were not offensive to people, but hopefully provocative and constructive. I was truly impressed with the efforts I saw of people trying to empower patients and professionals as partners, but at the same time somewhat distressed by the reality. Namely, for the most part our healthcare system is broken and handicapped with perverse incentives. Many of the fee-for-service models and concierge practices are not going to be able to provide care for many who most need it and can’t afford it. And many of the tools have the potential to further fragment care if not used wisely. While Kaiser Permanente itself is limited in reach with only 8 million members nationwide and unfortunately unaffordable to many, this aligned system offers so much promise for integration of these Health 2.0 tools as well as primary care and specialty care. Again, my intent was to urge people to work towards a more rational health care system, while respecting that they have business plans and models to execute. - David Sobel, MD MPH (used with permission)

I have long argued for a broader and more inclusive definition of Health 2.0 for this reason (although Dr. Sobel appropriately cautioned me to not even attempt to constrain my thinking by defineing something so fluid and dynamic). I have always maintained that the enabling technologies were only part of the story - and the thing they should be enabling is the transition to next generation healthcare (which is going to involve some very painful reform - ie, “this is going to sting a little”). For this reason, I have focused on the concepts of value driven health care (outcomes/price), transparency, openness within healthcare (and open source!), and collective intelligence via networked collaboration (social or otherwise). These reform concepts are critical if we are to begin to correct the fundamental and foundational problems that plague our health care “system”.

But these conceptual platitudes are empty if there are not real dollars attached. We have to have finance reform to fundamentally change the twisted and perverse incentives that currently exist. This will include financing mechanisms that align interests, incent appropriate behavior, that reward for results (see what MedEncentive and even consumer oriented Virgin HealthMiles are doing), and that bring market principles to bear on price, quality, and choice. As we pay for care in this way, the hope is that it will be delivered in the most efficiently and effectively way possible. So while “vertically integrated” health care systems appear to deliver the best results to date, perhaps the next generation of Health 2.0 companies will be able to use technology to pay for care from technology enabled virtually integrated delivery systems (more later) that achieve comparable results. I believe this software enabled coordination of care, and the financing mechanisms that enable its creation, can be likened to some of the new delivery models we are seeing as we slide down the Long Tail of Health Care:

Sliding down the Long Tail of Healthcare: So, you like the comprehensive care model of Kaiser? May I introduce you to a Carol.com care package, or perhaps you would like to schedule an online visit with Dr. Enoch Choi, or could I interest you in a $50 online visit with an American Well physician, or perhaps you have a quick question that can be addressed in a $1.99 LiveWisdom e-visit? You get the drill.

I have great hope for the future of Health Care in the United States. Perhaps the call to create a more rational health care system will begin in the grass roots of the Long Tail, “shifting left” up the curve as Health 2.0 companies can demonstrate objective increases in value, and push on further still as catalyst for the foundational reform efforts that will enable us to create next generation, high performance healthcare.

In the vernacular of the day, the 7 word challenge to describe this next generation health system:

Effective, Efficient, Equitable. Technology Enabled Reform. Thrive.

Incoming! Microsoft Aims for the Clouds

Cloud (kloud) n.

1. Computer term describing rich Internet applications, traditionally installed on personal computers, reconfigured to run over the Internet (or “cloud”).
   
2. Cloud applications utilize massive data centers and powerful servers that host web applications and web services accessible to anyone on the world wide computer grid (or “network”).
   
3. The architecture behind cloud computing is a massive network of “cloud servers” interconnected as if in a grid running in parallel, sometimes using the technique of virtualization to maximize computing power per server.

The whole Microsoft thing is about to go non-linear.

Late to the ‘net, late to the cloud . . . but deeper pockets than anyone in our galaxy.

Monkey boy about to go whole hog open source . . . is it freezing somewhere?

MF$T WMD?