Neupert On Health : consumers and healthcare

The Six Billion Pound Challenge -- How a Focus on Driving Outcomes can Improve Health Faster and Better than Legislation

pnblog — Wed, 11 Nov 2009 02:30:00 GMT

I commend the administration for shining the light on the need to improve health in America! While I want to be optimistic about change, I’m skeptical about how much real improvement we will really see under the guise of healthcare reform. Like I’ve noted before, the national conversation we are having -- which bill will pass, a public option or not, an abortion amendment or not, which party is winning -- is just the wrong conversation. Imagine if we were to take all the TV time, print space, blogs, and so on, consumed by the political debate and use it to advance an audacious goal like improving the state of our health! Imagine what we could accomplish with a big sustainable campaign across schools, employers, state governments and the media -- just imagine!

Today’s reality is that more than 75 percent of America’s healthcare costs stem from six chronic diseases. About 133 million Americans -- nearly one in two adults -- live with at least one chronic illness -- and the numbers are forecasted to grow unless we do something differently. Realistically, the only way to maintain some fiscal responsibility under any reform scheme is to address the controllable elements of chronic diseases.

What if we were to focus on a couple of conditions like obesity and diabetes? Two-thirds of American adults are obese or overweight, leading to chronic diseases like diabetes, heart disease and other conditions. Currently, obesity alone costs the health system $147 billion a year! What’s more, obesity is one of the biggest risk factors for developing the six chronic diseases that drive the majority of direct and indirect costs to our system, including diabetes ($218 billion), cardiovascular disease and stroke ($437.5 billion). Not to mention childhood obesity with equally alarming statistics (one in six children are obese), the most alarming of which is that children who are obese have a 70% chance of being obese as adults. Yet, obesity is completely within our control to manage/prevent.

According to CDC, the average American adult (age 20 and 74) is 5’6 ¾”, weighs 177.65 pounds and has a BMI of 28 (Note: an adult who has a BMI between 25 and 29.9 is considered overweight and an adult who has a BMI of 30 or higher is considered obese). To achieve a BMI of 24, America needs to lose 29 pounds per person. With the U.S. adult population at 205,639,360, that means 5,963,541,440 pounds…almost six billion pounds.

If we were to collectively lose this weight, we would have a direct impact on obesity and as a result, diabetes and other conditions. Healthier diet and exercise are things we can immediately start doing -- without legislation. Not to sound trite, but losing weight can be the “quick fix” for our health problems and rising costs. Obese individuals incur an 42% more in medical expenditures -- about $4,800 for per person per year -- compared with normal weight individuals, who incur an average of about $3,400 in such expenses. And little things matter -- for example, walking half an hour a day, five days a week cuts the incidence of diabetes by 40%. Think of the impact we could have on costs and the economy!

I know losing weight is hard work, but letting the growing waistlines of America continue unchecked will only doom us to continue the cycle of out-of-control healthcare spending. While I’m not sure I agree with Japan’s approach to legalizing waistlines, it does seem to have an impact. If we can send a man to the moon, create 200 different versions of yellow sticky notes and other wonders of the modern world, we can figure out how to lose a few billion pounds!

And it should all start with a public education campaign. Even though this is fundamentally marketing, it does belong in the domain of government action. It doesn’t take much to create a great ad campaign, viral marketing and so on. Look at the popularity of shows like the Biggest Loser -- now there’s a whole line of products and services. There have been a lot of one-off “celebrities” championing the cause of weight loss -- Mike Huckabee, Valerie Bertinelli, and others. But these have been isolated. Imagine if the government organized a group of great marketing companies -- Nike, Apple, Proctor and Gamble -- and got them together to create a campaign about obesity and health -- and involve popular sports heros or celebrities -- in a sustained way over a period of time. I’d bet there’d be some impact. Another great example of something that could easily and inexpensively be rolled out to schools nationally is the preventative childhood obesity program driven by the Columbus Research Foundation. These folks thought deeply about how to influence middle school students, and developed a program focused on education around diet/nutrition and exercise -- including a virtual cross-country competitive walk (students used pedometers connected to the Internet via HealthVault to track their progress). Ten middle schools were involved with nearly 1000 participants.

Real reform in healthcare isn’t solely the responsibility of government. It’s about individual responsibility and how we, as consumers, embrace our part of the current situation. I hope that reform will include changes to the payment system to enable and reinforce changes in behavior and stimulate innovation, but we don’t need to rely only on legislation to make things better. We can all individually start making better choices.

I understand that neither 'health reform' nor legislation are easy. As many have noted, whatever legislation passes will not include a 'silver bullet solution' to either goal 'bending the cost curve' or improving the value we get for our healthcare spend. Simple things can make a difference. By taking more responsibility for our own actions, we can impact the healthcare costs of our nation.

Reflecting on the healthcare system while waiting at the hospital for a loved one

pnblog — Wed, 30 Sep 2009 03:12:00 GMT

Often when we talk about healthcare reform, it can be a rather abstract discussion -- you watch some tv show with ‘experts’ reflecting on some 20 page bill or hashing through the merits of a public insurance option. Last week, however, all the intellectual and abstract ideas were brought into something very personal for me and my family.

My wife had a Hysterectomy, and I spent three days at Swedish hospital in Seattle caring for her. With all the waiting time, it was hard not to reflect on the experience and think about it in the context of health reform. I’m happy to say that my wife is now recovering on schedule, and she’s given me permission to share the story and my insights.

Once she had decided surgery was her best option, we became even more avid information seekers; we shopped for the procedure with the best outcomes and then the surgeon with the most experience and best quality results for this procedure. The best available counsel we found was for a Robot-Assisted Hysterectomy because there was less risk, less pain and faster recovery times vs. the alternatives. We didn’t have to shop for ‘price’ (thanks to Microsoft’s benefit plan, but that is a different future post)…but even if that were the case, we probably would have chosen a more ‘expensive’ option if it meant less risk and more productive days -- getting back to normal life as quickly as possible.

We all know that surgery can be pretty scary. Throughout the experience, everyone from the doctor’s office to the staff at Swedish helped to make the experience a positive one, allaying any fears and making us feel comfortable and confident. We often forget that healthcare is truly a people business. In just three days – the number of different people we dealt with was amazing -- five docs, seven nurses plus the ancillary folks (lab techs, transport and other helpers). They all took time to connect with our emotions while doing their jobs.

Swedish is leveraging technology to improve their systems. You see it throughout the organization, starting in the lobby, with signs advertising the hospital’s new EMR system. During the course of our stay, when there was time I asked various staff members about their experience with the new EMR, and they were positive about the system because they had all the information in one place. While a common complaint was that the data entry took them more time, they felt overall it made them more productive and effective.

This highlights that we need to remember that technology is a means to an end. It is NOT the introduction of technology that will make a difference, but rather how leadership leverages the right technology to make a difference…in both quality results and economic outcomes.

I also saw a real focus on patient safety, starting with the pre-op processes. Each member of the care team carefully checked her arm band, her chart and asked several specific questions to be sure she was getting the right action. For us, the repetition became frustrating, but if this process were to improve patient safety, then it would be worth it. Despite the technology investments, the core safety process was in the human factors.

After the surgery was completed, she spent two days recovering in the hospital. This was a day longer than originally planned due to very low blood pressure and a declining hematocrit. While I used the guest Wi-Fi for work and email, it was even more critical for answering key questions about her condition, the trade-offs, the next steps – which helped me to get some context and understanding to a) engage more thoughtfully with the care team about questions/choices and b) assure my wife about what was going on during the long time periods when neither doctor or nurse was around. I think hospitals should consider leveraging their video and wireless infrastructure more effectively for patient specific education and connecting with their care teams. This is potentially a big opportunity for improved patient compliance and care team coordination.

Because the low blood pressure persisted, I called her primary care physician to get her baseline BP. If we had stored this information in HealthVault, I wouldn’t have had to make the call – I would have just been able to look it up. Furthermore, I would have preferred to have gotten her discharge information automatically transferred to HealthVault. We were given paper copies. This should be easier.

So, what’s the moral of this story?

· We can’t lose sight of innovation and there’s a risk that could happen if the government were to become the primary funder of health.

· Technology is a means to an end, but we have a long way to go to figure out how to use it smartly.

· We can’t lose sight of how important the personal aspect of healthcare is. The emotional support and human caring delivered by the care team was the critical component of our overall satisfaction.

This experience reinforced for me that a ‘healthy’ health ecosystem requires consumer choice -- it is a critical component to the effective functioning of markets and innovation. We made the decision to ‘save time/hassle’ vs. saving dollars as we do in other aspects of our lives. This really drove home for me that the debate about ‘rising health care costs’ doesn’t really account for improved patient outcomes in terms of fewer lost days of work/productive living. I am all for comparative effectiveness of various options and knowing what things cost, but it needs to include patient values -- like less pain and getting back to normal faster -- or it may lead to bad unintended consequences. I am more concerned than ever that increased government financing of health will ultimately lead to fewer consumer choices and will stifle future innovation with tangible economic benefits.

I haven’t received the multiple confusing bills and outrageous line items of detail from the hospital stay yet. Nonetheless, when it comes to getting a quality outcome from an advanced surgical procedure, I prefer the current U.S. health system with all its flaws to the alternative future of less consumer choice and innovation.

In the Health Reform Recipe, the Missing Ingredient Is the Consumer

pnblog — Wed, 16 Sep 2009 01:28:00 GMT

So this week’s question from the Washington Post RX Blog was:

What's Your Take On Obama's Speech? What did you think of President Barack Obama's Sept. 9 speech to a joint session of Congress? Was it effective? Did it "move the needle?"

My response is below.

I applaud the administration for shining a bright light on health reform. The government -- as buyer, regulator and leader -- must be a part of any solution. The political calculus has created a real sense of urgency to do something about this complex system which touches everyone and accounts for one sixth of our economy. The consequence however, through a lack of transparency and understanding, has reduced the public dialogue to be between "public insurance options" vs. "death panels." Framing the debate this way and consuming available public attention on "wedge" issues won't lead to a sustainable future system.

My attendance at an Institute of Medicine workshop this week in the midst of the buzz about the speech served as a stark reminder about the depth and breadth of the hard problems:

• Access (too many uninsured)
• Costs (growing faster than inflation)
• Demographics (aging populations driving up systemic costs)
• Quality (not enough -- as measured by comparative outcomes, disparity in care geographically)
• Worsening health (people dying because of a lack of focus on improving the care delivery process).

I was struck by the number of smart, passionate people representing the major stakeholders working together to drive change. Veterans of the process recognize that change is imperative but hard -- because the details matter. We are in this predicament because incentives, tax policies, government reimbursement schemes and increasing specialization and capability of medicine have led us here.

The president delivered an inspirational speech, laying out basic principles: everyone should have access, nobody with insurance will have to change it and cost growth must be slowed. Voters know there is no free lunch, and health is no different.

We can't achieve reform without educating the public. A sustainable system is not as simple as providing more access. Consumers are ultimately responsible for their health and their daily choices cost the system. We need to help them engage in their health differently, be wiser purchasers, and understand trade-offs. As long as they believe the price of care is their co-pay and continue to engage as they have, there won't be sustainable reform.

There are best practices at organizations like Geisinger that have re-invented care delivery and consumer engagement models. These leaders will tell you that success is about aligning incentives, understanding the details and making trade-offs.

The difficult work of figuring out the details and making hard choices is still ahead.

Three Simple Truths

pnblog — Wed, 26 Aug 2009 22:20:00 GMT

So this week’s question from the Washington Post RX Blog was:

Recent polls show declining support for President Obama's handling of the health-care issue. What should he do to get the effort back on track?

My response is below.

Today's debate is mired in details about the wrong topics, chiefly public insurance options and the best government bureaucracy to determine what gets reimbursed. To drive the unprecedented reform vital to our country's future, we must up-level the conversation and focus on real reform: analyzing the system holistically and figuring out how health care can be delivered in better ways to improve outcomes and value. The challenge is how to leverage market-based solutions while dealing with the unique properties of health, such as the moral imperative to provide for the under-privileged.

Much of the justification driving reform has been economic, yet the debate has been politically focused, obfuscating the economic issues rather than illuminating them. The result? A missed opportunity to educate citizens on the fundamental issues and frame a public conversation about the choices that will bring change.

To refocus, we should acknowledge three simple truths:

Healthcare isn't free. A recent Los Angeles Times editorial highlights a clinic offering free health care that turned people away because too many showed up. The editorial suggests mandating charity care by doctors as part of the solution. Unlimited health care will be paid for by all tax payers either directly or indirectly. Free goods are always over-used as evidenced by the classic example of The Tragedy of the Commons.
Reform and innovation are inseparable. The history of industry transformation has shown us that change and ultimately better value aren't possible without innovation. We need Congress to change today's rules to enable health service delivery innovation, allowing new entrants, solutions, business models and types of care delivery.
Change is a function of our willingness to change. As consumers, we have to be more accountable for and sensitive to the care we're using. Providers and insurers have to engage with consumers differently and offer new products/services that focus on outcomes and offer real value. The system that governs has to provide the right incentives to drive the right behaviors.

There are pointers in the right direction -- the Healthy Americans Act provides solid thinking about improving outcomes by focusing on prevention, wellness and disease management, and tying accountability and incentives appropriately. In the words of Sen. Ron Wyden (D-Ore.) -- "passing a reform bill that doesn't really reform the health care system is just about as wrong as not passing any bill at all."

Individuals and Personal Responsibility May Be the Tipping Point in Health Reform

pnblog — Thu, 13 Aug 2009 05:16:00 GMT

The latest turn in the healthcare debate is the increasingly sensational coverage of town halls happening across the country. While they’re described as rancorous and sometimes violent, I’m pleased to see my fellow Americans so passionate and involved in one of our country’s biggest long-term challenges. For most of us, we think of health care personally -- it’s about my relationship with my doctor or my insurance company -- versus considering the system as a whole.

But this dynamic seems to be changing. There are a number of forces -- the media and current political agenda, technology trends, the economy -- converging on Main Street that are pushing people to get educated and more engaged in Congress’ proposed changes than they ever have before. Our sensational media machine is in full swing highlighting healthcare across every communications vehicle available 24/7. Technology’s influence over other industries has created consumer expectations for more convenience and value from healthcare. And the downturn in the economy has forced many to face the stark realities of healthcare tied to employment. So perhaps out of all this turmoil will come something good -- people coming together around the cause of improving the healthcare for today and tomorrow.

What many fail to understand is that the personal connection people have with their own healthcare is the very core we need address in order to make some of the greatest changes to the system. People make choices every day that impact their health – and the system as a whole. The diabetic who decides to not follow the course of action prescribed by his doctor costs the system. This is evidenced by two studies I read this week. The first is from the CDC, which states something we all know – that by losing weight, not smoking, getting exercise and sticking to a good diet, we will dramatically lower the risk of chronic diseases, such as diabetes and heart disease. Imagine the impact we could have on the system given that 70% of current costs stem from six chronic disease states.

The second from PricewaterhouseCoopers highlights some stark realities:

About half of surveyed individuals indicate their current lifestyle was less than healthy
90 percent said they would become active in improving their health if they were diagnosed with a chronic illness, which is obviously too late
Disease management programs are rarely used -- employers report than less than 15 percent of eligible patients participate in the programs
25 percent of surveyed individuals are not more involved in their healthcare because they don't know where to go for good information
15 percent aren't more involved because they aren't interested
25 percent of people in poor health are not involved in their healthcare and treatment choices

The juxtaposition of these two studies really brings to light for me how much our reform efforts need to focus on our citizens -- educating them and involving them in the health system in very different ways than they have been in the past. For the health system to work for all, economic incentives and costs need to be aligned with consumer behaviors and choices. We can’t continue to support the diabetic’s decision to make poor choices and drain the system for all of us. There have to be some consequences for actions. If something’s free, I think we all know that there is a strong possibility that people will not appreciate its value. We can look to many examples of this over time.

While we can argue that patients absolutely need to step up and do more for themselves (and their children), we also have to acknowledge that our system hasn’t been designed to support them. We have a provider-centric system, not a patient-centric one. Today, the average time a physician spends with a patient is 18.7 minutes. There isn’t a lot of room in 18.7 minutes for much “education.” In Maggie Mahar’s new documentary, one physician describes how he’d love to spend time with the diabetic educating him on how he needs to get involved, but he gets paid more to do procedures.

“We are paid to do things to patients,” said one doctor. “We are not paid to talk to them.”

In addition to patients needing to take more responsibility for their own health, our government needs to set up (or get out of the way) a new framework that will enable "healthy" markets to develop new value chains to deliver services like education, motivation, etc. at lower costs than high-cost professionals. We need highly educated physicians focused on the right things -- like diagnoses, solving major health crises, etc. If we look at chronic care today, much of it is about helping patients stick to a particular course of action prescribed their physician. But today’s chronic care "business model" is based on physician and hospital care -- acute care. A totally different type of "business model" or offering is required to keep people well. We’ve already seen innovation like this in other health related-areas like veterinary medicine, dentistry, and cosmetic surgery where consumers have taken more control of their on-going care.

The decisions we make today will impact generations to come -- financially, socially, and medically. We have an opportunity to come together, influence our elected officials and shift the debate in Washington to drive real change.

Health Care Needs New Rules to Enable Innovation and Reward Experimentation

pnblog — Wed, 29 Jul 2009 03:00:00 GMT

(cross-posted on Microsoft on the Issues)

Technology is playing a major role in helping bring healthcare into the 21^st century. Many of us have seen it first hand in treatment from our doctors, from MRI scans to laser surgery.

But these clinical advancements represent only a small piece of what technology can do to transform health care. The power of technology lies in the potential to transform the rest of the health care system, enabling new ways of working and communicating, new economics and new business models. As consumers, we’ve experienced how technology impacts nearly every other area of our lives -- how we manage our financials, travel, communicate, shop and so on -- with more self-service, more control, more convenience and ultimately better value for what we spend.

Similar business innovation and consumer engagement has been slow to reach health care, where many physicians still opt for a pen-and-paper over a computer to maintain patient histories and chronicle treatments. Patients continue to navigate frustrating and hard-to-understand medical and insurance organizations, physicians don’t always talk to one another about care and medical errors, waste and duplication drain the system of resources.

Today, we are finally seeing the first signs of systemic change in health care. This change was clearly highlighted with the President’s recent visit to the Cleveland Clinic, which has leveraged technology to improve efficiency and health outcomes and give patients an active role in their health decisions. But the Cleveland Clinic is just one example. There are other health care institutions -- the Marshfield Clinic, Kaiser Permanente, the Mayo Clinic -- whose leaders have embraced technology to improve efficiency and quality while reducing costs. And newer players are showcasing the possibilities brought by innovation, including virtual care from American Well and new delivery channels like Minute Clinic.

But we haven’t yet seen widespread change. The rules governing health care simply haven't allowed this to happen. Congress created rules that have in fact stifled innovation (e.g. Medicare) by reinforcing volume over value -- reimbursing on a per-procedure basis rather than on the number of patients who remain healthy year over year. Now Congress needs to look to the organizations that have used technology to create a new health care reality -- such as the Cleveland Clinic -- and develop a new framework that drives value, rewards experimentation and enables innovation. Only then will we realize the policy goals of increasing access to health care while maintaining fiscal responsibility.

Reform efforts should focus on enabling the kind of transformation that Clay Christenson describes in his book "The Innovator's Prescription". He describes how almost every other industry has been transformed -- complex, expensive products and services once only affordable to the wealthy have become accessible to the "masses" and provided by those with far less training.

As I described in my post this week on the Washington Post’s Health Care Rx blog, real change requires:

Figuring out what works (and what doesn't)
Enabling supply-side innovation
Letting consumers do some of the work that expensive health-care professionals shouldn't be doing anymore

With our ailing economy and worsening health, it’s imperative Congress act quickly and tear down the barriers that exist to enabling innovation.

Another milestone on the journey forward…

pnblog — Tue, 23 Jun 2009 03:43:00 GMT

Over three years ago, we started on a journey -- to empower consumers with tools to help make better health decisions and drive better health outcomes. We believed that the simplest, easiest way to start was to give consumers their data in a secure and private way, and allow them to share it from provider to provider, keep it in one place over time, and learn about it in order to make better daily health decisions. That simple idea was the beginning of HealthVault.

Back then, there were a lot of objections. Consumers don’t want their data. Consumers can’t understand their data. Their data might actually do them harm…blah…blah…blah…

But fortunately, things have shifted. Consumers have made it pretty clear that they want to be involved in their health – as evidenced by looking at social networking sites like PatientsLikeMe, the raw numbers of health Internet Searches, or research reports like The American Public on Health Care: The Missing Perspective, released by the CEG, Accenture and IOM:

· 78% of American favor giving doctors the ability to share access to their medical records if done with their permission.

· 66% said that they see the value in including their own information anonymously in a large database to help researchers.

And I’m happy to say for a number of reasons that consumer products like HealthVault and GoogleHealth continue to gain market traction.

Today marks another milestone – the first Industry-wide initiative to establish a “Declaration of Health Data rights” to support patients’ rights to access and share their own health information – https://healthdatarights.org will go live tonight, along with blog posts and endorsements from thought leaders and organizations across the country.

While we’re making change, and it's great to see so many organizations and thought leaders coming together, it’s important that we not stop here…that we continue to move forward—specifically by ensuring that consumer access to their data is included in the definition of “meaningful use.” While I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system -- we will not be successful without further refinements. Consumers cannot just be given access to data in static form, but must be provided with an electronic copy of their data so they can easily share it, use it, add to it -- creating a lifelong health data asset. In the end, consumers are the ones accountable for their own health.

The willingness to succeed is only exceeded by the willingness to prepare

pnblog — Fri, 19 Jun 2009 06:24:00 GMT

After many long months of discussion and debate, the first draft of Meaningful Use has come out. I’m optimistic about what I see -- what’s been laid out seems to focus on driving real outcomes improvement in the health care system.

It’s important that we keep this in mind -- that we’re not just trying to implement technology. We’re trying to improve the performance of the health system. And our willingness to succeed should only be exceeded by our willingness to prepare, and as part of that preparation, we must ensure that flexibility, scalability, and interoperability are inherent traits in the system. Why? Because, health is fundamentally data-driven. Nobody -- physicians, consumers, hospitals, insurance companies, governments -- can make good decisions without good data.

So driving data liquidity -- that is the ability for data to flow throughout the system -- has to be the critical focus. For years, we’ve been building systems in a “top-down” way to reach information, but what we need to do is build from the information up. One thing Carol Diamond said at a Health Affairs event that I attended with her really struck me -- the idea of bringing the question to the data -- leaving the data where it is and bringing the question/problem/issue to it. For a long time, what we did as an industry was use expensive research grants and complex tools to cull and compile data that was intended to answer one specific question, and by the time we’d sorted through the data enough to answer that question, it was either out of date or ten other, more pressing questions had popped up in the meantime. What we need is a system that unlocks all of the data that exists already in the health care sphere, and allows it to flow between silos so that when questions arise, we can bring those questions to the data for quick, evidence based answers -- rather than the other way around.

Given this, as discussions/refinements continue around meaningful use, I believe it’s critical for the following to be a part of the final definition:

· We can’t just capture data, it must be available in “real-time” in order make the right decisions and improve outcomes -- whether we’re talking about patients or populations.

· We have to enable data to become liquid -- specifically, doing this by separating data from applications. This is one of the recommendations from a study by the National Research Council of the National Academies that takes a look at what types of computational technology and investments are best for improving health outcomes. Let the excuse not be that the data is trapped in systems that we built, that we have to wait for standards.

· We’ve got to give consumers access to their data -- not just in static form -- but empower them with an electronic copy so they can easily share it, use it, add to it–creating a lifelong health data asset.

· We should accelerate the objective of having PHR access to EHR data to the 2011 Objectives and Measures. There is no need to wait until 2015. These technologies are available today and will bring real, sustainable benefits, not just for consumers, but for the overall health care system.

· We must ensure that we do not have an overly-prescriptive certification regime that focuses on certifying features and functions every-other-year. This will produce the unintended consequence of stifling innovation. Software vendors will be forced to develop towards a certified feature list rather than look for new and better ways to improve clinical processes and health outcomes,

The foundation of success is based upon data liquidity, and so it must be central to our thinking as we prepare for the future.

And the debate rages on…about access…

pnblog — Wed, 10 Jun 2009 05:01:00 GMT

I think we’d all agree that the healthcare debate continues to intensify. Many say it has entered a new stage as conversations move to proposals -- with Senate Democrats recommending a bill that will amplify the debate even more -- to decide if the US will adopt universal coverage.

Access seems to have replaced change as the word of the day. Everyone seems to be focused on it -- including Peter Orszag and Virginia Postrel. There’s no doubt that access is important -- but addressing access prior to reengineering the system is like adding passengers to a sinking ship. And in this case, the ship is going down in a sea of red -- the growing debt that will be incurred.

What we really need to do is what I highlighted in my contribution to the Washington Post’s new Daily Dose Panel Blog, Diagnosing and Treating the Health Non-System.

It’s not just about access. There are multiple symptoms and ailments that interact with one another. The three principal "diseases" are:

· Access (too many uninsured people)

· Value (too much spending for the health results delivered)

· Ignorance (at every level - who really pays for health, misaligned incentives, true costs, quality measures, transparency and more)

The most important to fix is value -- how do we improve health outcomes for the same or lower economic cost? Why is this most important? Everyone acknowledges that health spending is already in an economic crisis -- both in the near term and certainly in the long term (Medicare's unfunded liability exceeds $36 trillion!). Even if everyone in the country woke up tomorrow morning with health insurance coverage, it still would not address the hard economic truth -- we must get more value, as measured by better health outcomes, for every dollar we spend on health. The recent article in the New Yorker illustrates this particularly well.

The whole operating framework surrounding the health delivery system requires re-engineering to realize value. We need a system that supports and rewards innovation in health around new drugs, new devices or new procedures. Today, this innovation happens on a small scale, at times producing great results. But what we need is broad-scale innovation around health delivery for chronic disease management (which accounts for 70% or more of total spending) as well as prevention and wellness.

The reason this innovation and re-engineering isn't happening right now in the delivery of health services is because of the inflexibility in the payment system and misaligned incentives -- largely the result of Medicare rules and regulations driven by Congress today.

Each of us pays for health care (taxes, lower incomes, cash) whether we realize it or not, but as consumers, we’re rarely informed and engaged with our own health. We can’t get the basic data we need to make the right daily decisions.

I believe that Congress must focus on building an operating framework of rules and regulations that aligns physician and hospital payment with health outcomes and encourages innovation on how best to deliver it. This is evidenced by an amazing statistic I read this week. In June 2008, the Congressional Budget Office estimated that up to one-third of 2006 spending – roughly $700 billon or nearly 5% of our GDP – did not improve health outcomes. And we want to add more people into this system?

Navigating through the noise to find the signal

pnblog — Wed, 13 May 2009 06:04:00 GMT

I don't know about you -- but trying to keep track of and make sense of the company announcements, the many awareness events designed by politicians and the folks hoping to influence the policy makers, the work being done by folks at HHS and the Hill to create new rules and policies and the press and punditry all commenting on all these activities -- makes my head feel like it is going to explode!

Just look at the past two weeks. IBM said they were going to finance $2B of HIT spend to enable health systems to bridge the 'donut hole' in the stimulus package, complementing their earlier announcements this year of health ‘innovations’ through their partnership with Google and Continua. GE followed with an announcement of $6B of investment, financing and 'innovations' that will lead to even more billions of savings in the U.S. health sector...and they will help underserved health markets globally at the same time! At a White House event this past Monday, a group of health industry stakeholders promised trillions in future savings by restraining price increases and 'doing better’. And Tuesday, there was another White House event on health -- featuring the role of employers. Cecily Hall, a colleague of mine at Microsoft, attended and explained some of Microsoft's innovative health benefits around clinically driven weight loss and mobile medicine. I don't know how many billions of savings this event will lead to -- since I'm still on yet another plane, but given I have a 'healthy imagination' -- I am confident the projected savings will be significant.

The choices we make about the future of our health system matter a lot for the future welfare of our country -- so I hope we have an informed and fact based debate that goes beyond the sound bite outline that seems to be shaping up in both the media and the political arena. Health touches everyone. We have all been to the doctor and had our own or extended family based experiences, and so we all have our opinions about what works and what is broken in our healthcare system. Consequently there is a lot of 'noise' about both the challenges and the ways to fix the healthcare system -- some that ignore basic laws of economics.

For whatever reason -- a generation of employer sponsored health insurance, government programs, no checkout lines in the doctor’s office – has caused people to make a fundamental mistake, to think of health care as something 'unique' and to suspend the principles of economics when they conceptualize and think about the problem. The price of healthcare is not your co-pay...no matter what the public perception is. Providing universal insurance and covering everyone will not fix the health system by itself...and in fact may exacerbate critical flaws that exist. No matter HOW it is funded (cash at checkout, employer payroll costs or taxes); individuals are paying for their health care...just like they are paying for their retirement income or car insurance. There is no economic free lunch here -- that a government run, single payer system or other construct makes it either free or creates 'more healthcare' for folks to consume. It doesn't. Yes, the societal question of income re-distribution remains (namely am I paying for my health care AND your health care or just mine). But we should not confuse how to organize a sixth of our economy around income re-distribution goals...think of how clear, fair and effective our income tax system is.

Educating the public around the principles that health is an economic good and that individuals are indeed paying for their own health care, albeit in hidden ways, would go a long way to improving the probabilities for a more efficient, intelligent health system coming out of the reform debate.

If we acknowledge that health, that is the delivery of health care services and the prevention of illness, are economic activities -- then we can ask the question about what is the best way to organize that economic activity to create value -- value for producers (doctors, hospitals), value for consumers (patients, employers, payers), and value for society (more quality life years). It is not a zero sum game. In most of our economy, we expect market mechanisms -- things like prices, product or service innovations, or profits -- to allocate resources, improve productivity, lower costs and improve quality over time. In health, many of these important factors are constrained or hidden given the structure of the payment system and the role of the government in setting the rules of the game.

In applying the principles of economics to the health reform debate, it is important to be consistent and not selective. There are many stakeholders in the dialog who believe that the problems are the result of for-profit companies (insurance, pharma) and that non-profits and government are a priori better (better use of resources and results). This perspective is simply wrong and not supportable with an analysis of the facts. Participants are optimizing given the rules/framework they understand -- and here the government is setting the rules (taxes, reimbursement, CMS) and must take accountability for the consequences -- intended and unintended just like in the housing boom and financial crisis. One of the really hard challenges in health is measuring the right outcomes/results. Does pay for performance mean the physician ‘checked all the boxes’ for documentation or that we got more health for a given set of inputs? In the end, not-for-profits are economic actors too -- no margin, no mission -- they have to pay market prices for inputs and charge market/regulated prices for outputs. They raise money in the capital markets (debt) and mostly try to optimize like for-profit enterprises.

Today's health system in the U.S. is a regulated system....and it many ways it doesn't work so well...but perhaps better than our 'facts' acknowledge. Everyone acknowledges that we need to get more 'value' out of the resources we have put into providing health care. Everyone acknowledges that there is no 'silver bullet' or no easy fix to the multiple challenges that exist in delivering and paying for health. Nearly everyone acknowledges that 'cash based' segments of the health system (cosmetic surgery, corrective eye surgery, dentistry, veterinary) have done a better job innovating and delivering better quality and lower costs than the more heavily regulated segments of the system. Unlike other industries -- a lot of the challenge in health is we don't know enough -- about disease, about what treatments really work, about what to do when -- and so on. Consequently, we need a system and framework that allows and incents systematic learning and improvement, discovery of new diagnostics and therapeutics and the best systems to deliver them.

So let's have a real conversation about how to build a framework for a health system that works.

Signposts

pnblog — Tue, 21 Apr 2009 20:57:00 GMT

I don't normally blog about our products per se, but today marks an important milestone for Microsoft shipping solutions that are important signposts toward the future -- the transformation of healthcare.

The first is the launch of the Mayo Clinic Health Manager powered by HealthVault -- the focus of this solution is to enable the 'family health manager' to organize her information in one place and receive customized recommendations. The second is New York Presbyterian’s realization of a ‘connected health environment’ that brings together information on the clinic or hospital side using Amalga and extends it to patients through the introduction of mynyp.org via HealthVault. Each of these solutions concretely demonstrates how collaboratively we can move health systems forward today -- connecting users with their clinical information and providing interactive, personalized tools to empower them further.

The HiTech stimulus and health reform policy debates acknowledge the importance of information technology in transforming the health system...however questions remain about the how and shape of that transformation. Last week, I finished the Innovator's Prescription by Clay Christensen et al., which I strongly recommend to folks trying to understand the types of disruptive innovation that can and should occur in the health ecosystem to improve outcomes and change the cost dynamic. The books brings a new vocabulary that can help advance the discussion -- and highlights the importance of new business models in creating innovation. We need a different business model to deal with chronic care and prevention. I am confident that technology in general and the type of technology we are building and deploying with these innovative leaders in particular is critical to enabling these new business models.

It is exciting to go from ideas -- to plans -- to prototypes -- to actually shipping solutions that tear down the walls of data silos and begin the journey of using liberated data to deliver new solutions for consumers/patients. We are still early in this journey, and I look forward to getting feedback from users -- consumers, clinical users and IT professionals -- on how to improve the capability and usefulness of our solutions.

Connect Consumers with “Meaningful Use”

pnblog — Sat, 28 Mar 2009 01:41:00 GMT

The current hot, behind-the-scenes, debate in HIT is around how “meaningful use” of HIT will be defined for purposes of the incentive payments provided in the HiTech portion of ARRA. Since there is a lot of money at stake and a lot of interested stakeholders, I am sure it will be an energetic debate.

Hopefully the definition of “meaningful use” will include some concept of improved health outcomes (Message to Washington - Its all about the Outcomes ). I know this presents many challenges, and I don’t pretend to have the complete answer on how to best define “meaningful use”.

As Zeke Emanuel remarked at our IOM meeting this week, specific suggestions are much more effective than general principles in rule-making – so I’m taking to heart his recommendation.

My simple, concrete, critically important and specific suggestion for incorporation into the definition of “meaningful use”? Make sharing data and actionable information with consumers a required condition of “meaningful use.” Specific and simple. I can add lots of characteristics to it – near real time, two-way sharing, portable, and so on – but the essential point is that consumer access to their own data has to be DEFINED as part of “meaningful use.” Consumers are the ones ultimately accountable for their health. If we don’t include them, we will miss this historic opportunity to create a new ‘platform’ for transforming care in innovative ways.

We need to think bigger. Folks in Washington talk about HiTech portion of ARRA as being a down payment on the future of health delivery. I am not sure what that means myself. But if it means we are building a platform for transforming care or creating a learning health care system – I know it must include connecting the last mile, which means incorporating the consumer and the home into the platform – by design.

The formal definition of meaningful is: full of meaning, significance, purpose, or value.

The key word for me in this definition is value. Unless the definition of meaningful use is extended to include the consumer, real value in way of improved health outcomes or return on this huge investment will never be realized.

International Travelogue Part Two...

pnblog — Thu, 12 Feb 2009 22:09:00 GMT

Last week, I continued my round the world itinerary visiting customers, partners, and governmental agencies. I took an overnight flight from London to Bangkok on a Saturday—the plane was full, primarily of tourists taking advantage of what Thailand has to offer, despite the political turmoil. My day started with a random act of kindness—receiving a text message from someone who picked up documents I left on the train to London and offering to send them to me—remarkable! What many folks don’t recognize when looking at maps is how large, spread out and diverse Asia Pacific is. After arriving early Sunday morning, I caught up with my team on the ground, many of whom just came from Arab Health—a huge HIT conference. I then spent Monday in Bangkok with customers, Tuesday in Kuala Lumpur departing on an overnight flight to Sydney, and Wednesday to Friday in Sydney departing on an overnight/day flight to U.S. for a brief, but important meeting in Scottsdale, AZ on Friday afternoon before the last leg getting home to Seattle that evening. Amazingly throughout the 13 days, there were no big logistical problems (no lost bags, no delays over an hour, no lines over 30 minutes)—made it much easier to survive!

Here are a few of my observations from Asia Pacific—with more specifics this week to provide context:

Monday morning started with a visit to a large public hospital in Bangkok. They are at the same time very sophisticated from a diagnostic/therapeutic perspective (research lab, surgery center) and very antiquated from a work process perspective. They see a huge number of patients—both with appointments and not. Their “system” is primarily paper-based—the amount of forms and paper they have is overwhelming. Their whole system is based on queues—throughout the hospital, there are people waiting and standing in line. To get a pharmacy or lab item, a patient might go through three separate queues or tellers with an indeterminate wait time at each—identify/submit order, make payment, and draw or receive lab or Rx. I was struck by the incredible opportunity for the use of technology to improve the entire system—in terms of throughput and satisfaction, and ultimately patient care. Hospital management also sees the need and the opportunity— to invest in the information infrastructure as they have invested in the medical equipment infrastructure—but the implementation task seems daunting to all.

I spent the afternoon at Bumrungrad Hospital in Thailand where I have a development organization and key strategic partner. Bumrungrad is an amazing example of excellence—using technology to support clear outcomes—quality, efficiency, and customer satisfaction. Each time I’m there, they show me advances in infrastructure, workflow processes and facilities. It is great to have strategic partners who push the agenda for our products forward. Now they’re moving on to Bumrungrad Version 3.0—a whole new level of service and are again looking to IT to help. While they serve the local population, they serve an even greater number of foreigners—thousands and thousands of “medical tourists” from the US, Middle East, Europe, and Asia. Interestingly one of the key topics was how to leverage HealthVault in supporting the medical tourist and expatriate part of their business…something we have talked about internally but now have prioritized.

In Kuala Lumpur, I visited two private hospital groups, each of which is part of a larger conglomerate. They view healthcare as a growth portion of their portfolio and they have money. I enjoyed learning from them about their goals and approach, and explaining our strategy to them. The perceptions of what Microsoft is as a brand are so prevalent and ingrained—consequently, I have learned my most important objective is to communicate with folks that HSG is a serious and thoughtful player in health information technology. These private hospitals want technology partners to help them do a lot; —streamline their clinical and business processes, use clinical workflow tools to put guardrails on clinical processes, provide sophisticated BI tools and to stay on the leading edge. While they are focused on their enterprise needs first—our Health connected strategy—of connecting consumers to physicians to facilities—really resonated with them for their future business needs.

In Sydney, I met a very diverse group of folks—shadow ministers, MDs, CEOs of hospitals, members of the Clinical Excellence Commission, and members of the NSW health service. Australia has been pursuing leveraging HIT for several years. Some states are pursuing standardized Cerner implementations for hospitals and there is an institution named NEHTA that has been exploring the policy issues/standards around community or personal ehealth records. As I’ve noted before, the challenges in Australia are similar to the U.S. and Europe—leveraging information across the continuum of care, getting more out of their existing departmental systems, improving performance at the enterprise and system level and engaging consumers. The health of the healthcare system is a hot media and political topic—everyone is talking about the Garling report and what it means, physician concerns about the Cerner implementation in emergency departments and other specific bad ED incidents the media have publicized. While I get the scale benefits of standard software and standard rollouts by centralized and skilled service organizations—they frequently run into challenges in the healthcare domain.

I concluded my trip in Scottsdale, AZ, where I had the opportunity to address a small group of CEOs at the Health Management Academy. It was a great interaction about how technology has changed many industries. I had the opportunity to use my personal history to tell the story of how connecting vision, technology folks and domain experts has powered positive and sustainable change—which I have had the good fortune of doing at Microsoft, at MSNBC and at drugstore.com. It was fitting to conclude the trip back in the U.S with leaders dealing with the challenges in their organizations and the economic climate. Increasingly I see the local market separating into two segments—while all are focused on cost containment—some are primarily hunkering down and others are seeing the current climate as an opportunity to invest in transformation. Obviously I believe the right technology is critical to both groups.

Let me wrap with a side comment. I’m over 50 years old and have been traveling internationally for nearly 40 years. Even though there have been many articles and books written about how the world is flat, it is remarkable to me how much the world has changed in this relatively short period of time...and yet, in some respects I believe the change is just starting. From the ease of staying in touch (my kids could call/text me anytime—didn’t need to know where I was at all)—to the ability to stay connected to important events in the U.S. (Superbowl started at 6am local time in Bangkok with Thai announcers and a pre-game show)—to physically getting from place to place—it is all steadily improving and becoming part of the norm. In the same 13 day time frame, I worked out on four separate continents—ran in the cold in London’s Hyde Park and in the heat around the Sydney Opera House—and collected all the workout information on my HealthVault compatible Polar heart rate monitor and watch.

International Travelogue

pnblog — Mon, 02 Feb 2009 00:50:00 GMT

After my visit to Washington D.C. and the U.S. Senate, I thought it might be instructive to visit other parts of the world to gain additional perspective on the challenges the global economic crisis is posing to health systems. For the last five days, I have been in Western Europe visiting four different countries and interacting with health system CEOs and CIOs, ministers of health, leading social service bureaucrats and members of the Microsoft health ecosystem.

Here are some observations worth sharing:

Everywhere there is a deep interest in personally controlled health records - more than I anticipated, and despite the fact that some early projects in the category have performed poorly and have low adoption. Stakeholders recognize that citizens/consumers need to be actively engaged in their health in order to improve the results and economics of the health system. They view personally controlled health records as an important tool to motivate and engage them. They don't see other options that can accomplish this goal.
Privacy is a major issue surrounding the sharing of health data -- either in the professional arena (insurance, provider to provider, provider to pharma) or in the case of professional to consumer. Many have concluded (as we have in the design of HealthVault) that personally controlled health records are the best solution (but not the only one).
Health systems and their funders are looking for ways to connect the health delivery system across institutional boundaries -- from GP systems to hospitals and specialists. No one is doing it well yet. They see it as critical to delivering better outcomes and containing costs, and they acknowledge that seamless data sharing is critical to enable new work flows. Unfortunately there remain many barriers to this seamless data sharing -- some technical, but mostly economic fear of existing stakeholders around loss of revenue or the implications of transparency on business practice/quality of delivery.
The payment systems inhibit innovation in many cases or drive it in others. In some markets, governments are pinning their hopes on private insurance as a vehicle for innovation and focus on wellness/prevention while in other markets the government is directly trying to tinker with the payment schemes to encourage new behaviors by the provider organizations. From an economics perspective -- what strikes me as the real problem and challenge with these approaches is that the feedback loops are long and indirect, and consequently the cycle time of improvement will be incredibly slow. This is why price mechanisms in the capitalist system are so important - real time feedback mechanisms with the ability to self adjust.
The people with whom I met had an informed interest in what was going on in the U.S., particularly around the stimulus bill for health IT and about the prospects for health reform. They are watching to see the impact. What surprised me was the low esteem in which most regarded the U.S. health system...based on the statistics around health spend as a % of total GDP spend and reported health outcomes. I acknowledge that the U.S. system has many flaws, is broken in many ways, and has lots of waste that should be eliminated. But I have always been a bit of a skeptic that the statistics on outcomes really tell the full and complete story around quality of care delivered across different societies. I am not sure that the perception of others really matters in this case in terms of the U.S. needing to fix the problems regardless -- but it bothered me enough to flag it and put in my "think about it later" list.

Some I visited are surprised to learn that Microsoft is investing in health specific software and services solutions. Others are challenging us to do even more to bring ease of use, effective application integration and user interface innovation to the health worker desktop today! Most are hopeful that the next round of technology and software investments really help improve the working environment on the front lines of health delivery and health outcomes.

Next stop -- Asia Pacific. Given our ambitious goals, I often tell my team that time is our enemy when it comes to success. Ironically, I have turned the motivational saying into a concrete reality as my itinerary has three of the next six nights aboard planes. whoops

Message to Washington -- It's all about Outcomes

pnblog — Sat, 17 Jan 2009 00:35:00 GMT

Yesterday, I testified before the Senate Health, Education, Labor, and Pensions Committee, otherwise known as HELP. You can see a video of my testimony here. Before getting to the substance, I need to highlight how I continue to be awe-inspired about how our government works -- in a positive way. Any body can walk into the halls of Congress and sit in and listen to a hearing. Folks from all walks of life have input via a variety of means -- and while I get it's not perfect and can be better -- I remain proud of our democratic system and feel honored to be able to contribute/participate in it.

My main message to the Senate was: We should really focus on the health outcomes we want to achieve, not just on the technology itself. What the health system needs is to adopt technology in ways to deliver better outcomes, better chronic care management, better hospital effectiveness. We really want to make sure that we have the leadership focused on encouraging the usage of technology to achieve certain goals, like better chronic care management.

We were the only technology company testifying, and I think people were surprised to hear us saying that technology isn’t the silver bullet. It's not that Microsoft doesn't want to see spending on health care technology. Far from it. We just want to see smart spending, on technology that will really have impact. When we decided to go to the moon, we didn't say let's build a great rocket...we said let's go to the moon...I feel a little bit of the conversation has been about let’s build a great rocket and hope we get to the moon.

The other witnesses included Health Leadership Council President Mary Grealy, National Quality Forum President Janet Corrigan, Permanente Federation Executive Director Jack Cochran and Valerie Melvin, Director of information technology for the Government Accounting Office. Their comments were unexpectedly aligned with mine -- namely take a holistic view; incenting the adoption of technology is not a silver bullet; and, we must have reform of the payment system too. So at a high level -- folks understand the challenges of creating the right kind of change in the complex health ecosystem. Where the differences lie -- is how to get started. Unfortunately as is often the case -- the stimulus bill (big incremental spend investing in health IT) is separate from the activities around health reform. Getting the spend without the right payment system reform -- could lead to the unintended consequences the panel was cautioning against.

The legislation is being drafted now -- that is why the hearing was held on a day when there was a lot of other activity going on in the Senate. There is a clear sense that something big will pass in 2-3 weeks - which is like moving at the speed of light. I am sympathetic to the challenges of the staffers trying to find the right language -- it is not easy to figure out how to guide the spend of $20billion over two years! The scale of spend is still hard to put into perspective for me -- in my last post I tried a per physician number, so this time let's try per day -- it is $27M/day! I am very confident there is lots of low hanging fruit to generate a return on investment in the health system (waste, overuse, misuse, error reduction) that technology can enable -- but still $27M/day!

Since I spend the bulk of my time building software -- decisions about features, hiring great people, how and where to sell -- the hardest question from the staffers to answer is - how do you recommend we spend the money?

My answer is in my closing remarks with the five key things that I think the government needs to focus on:

1. Encourage innovation in health IT by setting out objective goals and criteria, not by mandating specific technologies or development models.

2. Reward innovative doctors who make the Internet the foundation of the patient-physician connection.

3. Provide incentives for sharing data.

4. Focus on making data interoperable today, not waiting for standards tomorrow, and insist that vendors separate data from applications.

5. Enable the private sector to develop an information infrastructure that connects data, systems, and people.

These are really critical, so we don’t end up in the wrong place. They’re based on our learnings as we’ve delved into this complex world of health.

One final thought -- surely it is an exciting time to be in the health information technology business! I personally got passionate about trying to really contribute and make a difference in HIT from my time on the President's Information Technology Advisory Council (PITAC) in 2003-2005. As co-chair of the Health Subcommittee -- we published a report titled Revolutionizing Health Care Through Information Technology with key recommendations for the government to consider. While my depth of understanding has gone up dramatically, what I find is both fascinating and perhaps cautionary -- is the discussion is largely on the same key issues/recommendations. This time there is a lot of money at stake -- but it goes to show that change is hard and probably slow.

I had a great exchange with Fox News --- video embedded below.

You can also read more about Microsoft's general views on a number of topics here.