This audacious Holy Grail was the topic for a panel II moderated today at the Connected Health Symposium, sponsored by Partners Heathcare, the Boston health system that includes Harvard’s hospitals and other blue chip health providers around the region.
My panelists were 3 health ecosystem players who were not your typical discussants at this sort of meeting: none wore bow ties, and all were very entrepreneurial: Jeremy Delinsky of athenahealth, the health IT company; Scott Howell, of Cardinal Health, the granddaddy of health supply chain companies (#19 on the Fortune 100, with the tagline “the business behind the health business”), and Joshua Seidman of EvolentHelath, the emerging partner funded through $100 mm of investment fromThe ADvisory Board and UPMC, to drive population health in concert with health delivery systems.
Earlier in the day, Dr. Donald Berwick spoke about The Triple Aim that desirable if elusive three-legged stool of improving health quality, driving good health outcomes, and reducing the per capita (person) cost for health care. Dr. B pointed out that “there’s only one payer in the U.S. health system, and that is the wage earner,” who funds health through tax payments, wage reductions for health benefits,and out of pocket spending.
I introduced the panel with the basic math that we spend 1 in 5 dollars in the U.S. on health, which means we’re not spending that money on other things, or better yet, saving as much as we might.
So when we look soberly at the unsustainable business model that is the U.S. health system, we have to get real about how to drive greater value for money.
In this conference devoted to “connected care,” our panel brainstormed the “connections” that often get overlooked in connecting health – with stakeholders in the larger health ecosystem that can help drive great value – if we can break through industry silos.
On day preceding this panel, Mad*Pow’s Founder Amy Cueva graphically portrayed the health ecosystem as a galaxy of ‘stars,’ like hospitals, pharma, schools, supermarkets, banks, churches and retailers. My panel was a microcosm of that universe
We began with the question of defining innovation; there are many definitions of the concept in and outside of health care. Some adherents of Clay Christensen’s theory of disruptive Innovation look for new-new breakthroughs especially imported from outside the health milieu. For other people, new riffs on old processes suffice as innovation. To kick off this conversation, I quoted an executive from a Fortune 10 firm speaking at the Cleveland Clinic innovation summit who said that, “we are innovating faster than we can get things through the system.” I suggested to the panel that this isn’t what we mean when we say “innovation.” These are probably really cool white board ideas that can’t get traction outside of the lab.
For Scott Howell of Cardinal, innovation is much about scale. “We wouldn’t rule out smaller cool ideas that might be more interesting in some locales than others, but we get excited about solutions that can launch at scale,” Scott said. Increasingly we are asked, he said, to go beyond a creative solution for one segment of health care and span it across different lines of business internally, to deploy across health sectors outside of Cardinal. “These are collaborative solutions where the cooperation needed goes beyond the walls of the enterprise, lining up the players within the hospital along with pharmacies in the community and nursing homes to work in new creative ways,” Scott explained.
Josh coined a practical equation: innovation = a combination of creativity and execution. It starts first with a good idea, and second, it can be executed. Eventually, that good idea can then achieve scale over time.
From the health IT perspective, Jeremy said that “innovation is not features. Most HIT solutions have feature parity but what accounts for one successful or failed install? People look too much for software and not enough for service,” he elaborated. He said that people are looking for the kind of true innovations we have come to love in our personal lives: say, evolving from U.S. mail to UPS, to email through 3G in our hands. We have to innovate a lot faster, Jeremy noted, which is why in health, it’s useful to be a learning system..
We moved from the innovation discussion to the health economics discussion about “whack-a-mole” health care in the U.S. I talked about the game, where you hit a “mole” sitting on one part of the game board and then another pops up across the way. In American health financing, you press down on one segment – say, inpatient surgery – and then costs rise in outpatient surgery, whichi s what we learned in the 1980s when Ambulatory Surgery Centers popped up in every hospital system, shifting patients from inpatient units to the ASCs. These outpatient sites became significant revenue centers for hospitals, representing that second mole popping up and making up more than the difference in lost inpatient revenue. On the positive side of the ledger, patient experience was favorable as people began to appreciate getting care in a more convenient setting closer to home with accessible parking and no waiting time. Thus was convenient care born.
But costs still grew. Scott of Cardinal proposed greater collaboration beyond the enterprise, calling out the company’s Ondology pathways program. Here, the company works with payerrs and physician networks, rewarding doctors for delivering quality care built on evidence-based protocols. Cardinal has published data calculating that the prograam saves as much as 15%% while patients are getting better care and oncologists are paid in a way they like. This involved hard work and collaboration across siloes, but was achieved in the real world.
Josh made 4 observations about how to conquer whack-a-mole health economics: first, implement a model of population health focused on a set of clinically integrated initiatives that support the model; keep a long-term horizon (say, three years); measure, measure, measure to guide care coordination and understand what works for patient and family engagement; and finally, watch out for the transitions that Dr. Berwick talks about.” This will take time, Josh said: the providers with whom Evolent is working have begun to take on population health risk – at the level of 5-10% of the total business. It’s one step at a time, moving toward the innovation of population health management. One gets the feeling these health systems with whom evolent is working are growing new muscles — and committed to doing so.
Jeremy noted that the health system has elements of a zero sum game which are hard to avoid. He called out the fact that the U.S. may have as much as 50% overcapacity of inpatient beds. That structural imbalance of capital resources makes it hard to lower the rate of inflation in health care costs, he argueed. “A lot of that [sunk] capital could fund innovation,” Jeremy continued. The objective: streamline the care system the way other sectors have, from retailers to banks and the travel industry.
We evolved our conversation to the Triple Aim. Here, the critical piece is for stakeholders in the ecosystem to collaborate and have ownership in the re-designed health care processes – including people, patients, caregivers along with industry.
Ultimately, Scott reiterated one of Dr. Berwick’s central messages: that “We, The People” are the funders of health care in America.
So at the end of the day, how do we realize The Triple Aim with the person at the center?
That’s the ultimate question for innovation in health: how to leverage people in their own care which could add tremendous value, in collaboration, with the health ecosystem players.
Health Populi’s Hot Points: The 2013 Aon Hewitt Employer Survey found most employers “migrating risk” to employees they were insuring in health plans. That risk perspective can be the fire underneath health industries’ strategies toward accomplishing The Triple Aim by:
1. Enabling consumers/people to understand this new world of personal health risks
2. Understanding the [multiple] ways people want to receive information and tools – via mobile platforms, print media, phone calls, emails, texts, videos, in-person meetings, group health visits with head educators, and the longer list of creative consumer-informed media and channels. This gets to user-centered design, which Mad*Pow, IDEO, Luminary Labs, Frog Design, and others in the field are proving can work to gain peoples’ engagement and sustained use over time
3. Evolving and devolving these solutions to help people feel self-efficacy (confidence) in taking on self-health care
4. Developing measurement tools and metrics that are meaningful in tracking success and failure and points in-between. This bolsters learning and our ability to tweak and tailor programs incorporating valuable lessons learned.
Ultimately, this also means collaboration which Frank Moss of the MIT Media Lab spoke about on Day 1. The goal: enable a new “design point” which enables collaboration between people and health providers. “Given great tools and social support,” Frank said, “ordinary people will exceed our expectations of their ability to play an active role in their own health.”