Our Future Selves & Current Healthcare System

A concierge physician recently told me the greatest recurring challenge they face is delivering what the patient needs, versus what the patient simply wants.  This veteran doctor embraces much of what is being called the consumerization of healthcare; but the doctor is also fearful that on-demand appointments, patients and doctors having access to blood tests at the same time, and yelp-like ratings of a doctor may only serve to reinforce the need versus want struggle.

This need versus want struggle is pervasive throughout our lives. We live in a modern world.  We also possess a primal brain that acts as if agriculture, cities, cars, microwaves, and pizza delivery do not exist.  This creates a disconnect between immediate reward centers of our brain that encourages us to eat donuts and drink sugar filled coffee drinks, and the more developed part of the brain that regulates long term decision making.  As a society we have and continue to ask much of our healthcare professionals.  What we have implicitly tasked physicians and nurses with, but not set up the system adequately for, is to play a governing role in managing the results of this short term versus long term disconnect.

If we have a meaningful chance of moving from a treatment to prevention based medical system, then we must allow for and encourage doctors to play a greater role in helping us manage our healthcare decisions to the long term. 

To get to my doctor’s office I walk a little over a mile and pass no less than four coffee and pastry shops. That is four chances to easily grab a donut for a dollar and syrup laced latte for around four bucks.  Assume for a second that I posses a nasty habit racking up $25 a week on bear claws and lattes.  My annual spend on these items would clock in around $1,300 and my immediate reward center would be well satiated.

In contrast, if I wanted to do something a little healthier and sign up for a concierge medical practice to support future 50 year old me, it might cost $2,500 a year or $48.08 a week.  Oh, and there would not be one on every block.  Nearly double the expense, less convenience, and long term need driven.

The contrast here is the simplified sales challenge concierge doctor’s face as a profession.  Even when they acquire a new patient, this dynamic never really goes away as concierge practices have to constantly sell against Dunkin Donuts and Starbucks to keep patient churn down.

Dunkin Donuts and Starbucks are in great businesses when it comes to brick and mortar retail. For the reasons found in the table above.  Healthcare is a lousy brick and mortar business as you can see.

Healthcare 2.0 has promised a bright future.  Many pundits paint a future where an individual's health information flows freely across providers.  A common complaint among doctors has been the proliferation of information rather than easy access to the most relevant and up to date[1].  For those with practices based on patient volume, this becomes a significant operating challenge and a roadblock to quality patient care. As many of us run around with smartphones, wired workout apparel, and biosensor bracelets collecting all sorts of daily health data, the volume of individual health data grows rather rapidly.  This is to say that the utopic picture painted by the founders and investors in health 2.0 tech ignore the foundational principal that it is not about having access to all the data.  Rather it is about having access to the relevant data for the question you are trying to answer. 

Technology alone will not be the solution for managing the rapid appreciation of healthcare costs. Many technologies, especially those designed for clinical environments, currently look to marginalize high skilled labor, rather than solve longer term patientcare issues.  We are now back to the donut today versus healthy me tomorrow dilemma that is playing out on an institutional basis rather an on an individual basis.  Solving and managing this would have longer term savings distributed across society requiring front loaded investment, a higher human touch, and a view of the patient that is similar to that of marketers who look at the total lifetime value of the customer[2].

Concierge physicians are currently just one market mechanism being leveraged to try to moderate the donuts today versus healthy me tomorrow issue.  Corporate wellness programs leverage wearables data and incorporate behavioral hacks,[3] reduced barriers to health foods and fitness facilities, and offer reward based incentives to get people to make longer term healthy decisions.  They look to corporations to be the organizing entity for change, as well as the financial backer of said change[4].  Yet they admittedly fall short and are regularly questioned regarding efficacy and return on investment.

Part of the reason for this is that employees do not live their lives 100% at work.

An employee working 40 hours a week has approximately 72 waking hours a week[5] outside the office to undo the health benefits of a corporate wellness program.  Or put differently, that is 72 weekly waking hours where the employer is not imposing principals of maternal libertarianism[6][7] that help employees short circuit the donut today versus healthy me tomorrow dilemma.  Without the employee wanting it for themselves and accessing the knowledge and resources needed to sustain this, most corporate wellness programs at best offer bounded results that are often under quantified.

Am I being critical of the healthcare system and the current proposed solutions—yes.  Defeatist- no.  Improvements to a system takes time and are most often iterative and incremental. Corporate wellness programs and technology applications seeking to make access to care more on-demand, help change the cultural norm of what healthcare is, how healthcare is delivered, and who delivers said care.  In my opinion this is for the better.

What will help move the ball forward is integrating various practice areas more closely so that the individual has more preventative nudges from outside of the confines of an office.  

Concierge practices need membership fees to fund the greater face to face patient time and offset the lower patient volumes.  Growth comes traditionally through either acquiring additional physicians to work for the practice, or through more traditional patient acquisition methods.  For many concierge physicians the latter translates into one off personalized sales. 

Corporate wellness firms offer up a unique patient acquisition platform for concierge practices, especially those that have integrative medical offerings.  If the goal of a company is to increase productivity and decrease employee churn, then medical providers offering more preventive based care extends the health effects beyond the forty or more hours spent at the office.  Corporate wellness programs are increasingly challenged to quantify efficacy and returns for the employers making them data centric, not just data hogs focused on data collection for collection sake.

Corporate wellness firms should look to invite or hire concierge doctors to provide lectures and town hall sessions, or on-site consults as part of the firms’ wellness offerings.  Allowing the physician to leverage native marketing and the corporate wellness team to improve the health of company they serve. Put differently, integration of corporate wellness efforts and that of a concierge physician accelerated sales for one constituency, increases customer satisfaction for another, and better manages  the patient’s donut today versus healthy me tomorrow dilemma.  

Admittedly the successes here are not systemic.  Lower patient rolls without increasing the number of nurse practitioners and physicians does nothing to ease access issues for the general population.  In fact, this will only get worse in the coming years as aging boomers consume greater amounts of the healthcare resources.  Here is where the application of technology comes into play.

A future exists where the vibrant success of American healthcare is reliant on the tiering of medical care.  In Canada, they have taken steps to empower pharmacist to write prescriptions for minor ailments, as well as issue refills of existing doctor prescriptions.  The aim is to ease the burden and wait times of primary care providers.  Tele-medicine has the same potential to ease supply constraints in relation to primary care. 

Last year, I was suffering from summer allergies for the first time as an adult. The symptoms appeared to be similar to a sinus infection.  Upon going to my doctor, he told me they were allergy based and in order to avoid a bacterial sinus infection I should pick up an OTC nasal spray.  The visit cost me my $30 co-pay, plus an unnecessary strep test, not yet covered by my insurer due to the deductible.  A simple Skype session with a doctor would had saved me time and money. 

Tele-medicine has the potential to treat minimally invasive aliments and affordable at home testing will only expand the systemic impact that remote medicine can and should have.  On-demand consults can be the first tier of medical care.  Followed by visits to minute clinics, physician offices, and possibly one day even American pharmacists.  Changes to government regulation and state to state licensing restrictions must change in order for the full potential of such technology enabled services to be realized. 

I believe it is important to note that this does not meaningfully shift the system from treatment to prevention.  The utilization of tele-medicine for the screening and treatment of common aliments is still primarily treatment based.  An eco-system of remote coaching and in-person, on-demand care is still being developed. Standards, certifying bodies, and individual responsibility in the form of diligence is needed to make this a viable, efficacious, and long term solution that moves the system to greater emphasis on prevention.   I for one hope for the future being promised where my lab tests, Fit Bit data, and medical records can easily be accessed, processed, and actionalized by nutrition counselors, sports medical professionals, and physicians.

As much as I am critical of where EHR systems and the general state of HCIT resides, I do believe the technology being built and sold ultimately is a primary tool that can have a broad based systematic impact on delivering prevention based healthcare to the masses.  Even one where it helps manage individuals to get what they need as well as what they want, so that we eat less donuts today and collectively enjoy a healthier tomorrow.

 

 

 

 

[1] There are many reasons to this.  One of them being the use of cut and paste templates and another being that most EHR systems are designed with billing guiding the design.

[2] Recent consolidation of hospital systems supports a shift to this life time value approach to patient care as the number of providers shrink. 

[3] Sometime the simplest of acts are the most elegant.  Google shifted candy jars from clear to opaque and consumption dropped.  Similarly, putting sugary drinks on the bottom shelves and bottled water at eye level increases consumption of water.

[4] This has made me wonder about what principal agent problems prevail or will emerge from this relationship.

[5] Assumes eight hours a sleep a night.

[6] For more on this read the behavioral economics book, Nudge by Richard Thaler and Cass Sunstein.

[7] The Cleveland Clinic realized this in 2007 and went a step further beyond being a smoke free campus to refusing to hire those that use nicotine.

 

Jacob Grosshandler