“Hacking” Healthcare

[Photo: Mayberry Health and Home]

I wish I had thought of this title before anyone else, but there is a book, scores of domains registered already, a lot of hand-wringing about evil hackers and I’m sure, a lot of events like this where people will try to hack healthcare to win contests. But this article isn’t really going to be about any of those things. This will be the first of a series of articles about how communities, thinkers and smart startups are taking back control of their healthcare.

Why does healthcare have to be hacked? In case it wasn’t painfully obvious, the state of healthcare in the US in 2017 is in basically the same shape that it has been for some time: too expensive, mediocre in terms of outcomes and nowhere near as safe as it should be. Compound that with epic gridlock in Washington and it becomes clear that these problems won’t be easily solved via policy. And yet, these constraints are forcing creativity. Think of it as the DIY movement in healthcare. In art, engineering and just about every endeavor, DIY is a concept that is near and dear to my heart and I want to celebrate it when it happens in healthcare.

So, let’s start with AI. So much hype.

Despite this hype, there is plenty to work with. While yes, AI is getting better at looking at x-rays or suggesting treatment options to physicians, the real value today comes from augmenting rather than replacing the caregiver. While teaching myself API.AI for a non-healthcare related project, I could see first hand the value of well designed tools to extend the caregiver relationship, leveraging the principles of CRM as well as the challenges inherent in training them. I like the chatbot, even though they still have a ways to go. Chatbots are hard to build well. If you’ve interacted with one, you likely figured it out pretty early on and hated it. But the technology is getting better and you will likely be engaging with many more bots  at your work or when you are applying for a job.

Some excellent use cases for bots include: improving adherence with provider recommendations (medication, diet, exercise) by gently nudging the patient via text messages to their phone or Facebook Messenger. Yes, HIPAA is hard. But it’s not insurmountable with a well crafted strategy. Also, most patients aren’t worried about the occasional reminder to eat better or work out via their phone after they leave the doctor’s office. And they work.

Another use case I love is augmenting a therapist for treating minor depression and other low-acuity behavioral health issues. Why aren’t we creating pathways for patients to get screened for depression in their doctor’s office and handed to an appropriate resource that doesn’t have to be the PCP? We know that depression is often associated with other chronic illness and that depression can prevent patients from adhering to medication and treatment plans, or just not showing at their doctor appointments. We also know that one-third of the adults that have major depressive episodes never see a professional. In addition to the costs of untreated illness, millions are needlessly suffering.

Here’s a hack worth doing: evidence-based chatbot tools overseen by a team of clinicians and technologists, regularly monitoring that the AI is providing quality support to patients and that it is aligned to their care plans and appropriately linked to technology.

If you read this far and you’re of a certain age and time, then maybe you’ll get this reference. At least it’s not  stock photography of people in lab coats in front of computers.

Housecalls, baby!

Direct Primary Care is the future of medicine.  With insurance premiums spiraling out of control, more and more people are looking for the least expensive alternative to traditional insurance.  It’s the classic problem of insurance.  How much insurance do you need if you are in reasonably good health?  Actuaries will tell you, for example, that a traditional health insurance plan with high premiums, low co-pays for doctor visits and prescriptions doesn’t really make financial sense for say, a 25 year old male in good health (it makes more sense for a woman of the same age, who should be getting annual exams and has the possibility of getting pregnant).  He’s unlikely to see a doctor unless he’s seriously ill, doesn’t want to spend a lot of time in a heavy consult with his doctor and certainly doesn’t want to hassle with the average wait time to see his doctor. His doctor, similarly, is not likely to be stumped by the average ailment for this person and if she suspects its a common illness going around (like the flu), she’s likely to prescribe bed rest and plenty of fluids, and probably only do a diagnostic test out of obligation instead of necessity.  Hardly a case of House, M.D.  Compare this with the same guy with a bad case of the sniffles stopping off at the Minuteclinic (or, the Wal-Mart), waiting 15 minutes to see a nurse practitioner with automated tools at his disposal.  In about 15 minutes, the nurse has checked our guy’s blood pressure (it’s fine, he’ll want to check it more often after his 30th birthday), determined our 25 year old has a sinus infection and prescribed an antibiotic our patient can pick up in 15 minutes by walking across the store (and maybe picking up a bottle of Gatorade and a Snickers as an anodyne to his misery).  The whole affair is addressed in less than an hour.

Oh, and he paid $35 for the visit by swiping his card at the nurse’s terminal.  And $25 for the prescription.  And the whole visit including diagnosis and prescription can be captured electronically and saved in our patients’ personal health record like MS HealthVault or similar, so should this be part of a chronic problem, it can be shared with all the medical providers he may visit in the future.

The time involved with a traditional doctor’s office visit almost certainly took longer, then the patient has to travel to another location to pick up the prescription that maybe the doctor sent ahead, or maybe it’s on a little piece of paper that the pharmacist has to put in the queue. Then, there’s the small army of staff in a doctor’s office.  Their main purpose: to wrangle the myriad of paperwork for a whole variety of health insurance plans, engaging in the back and forth with the payer to get reimbursed and pass bills on to those patients who either don’t have insurance or have enough insurance. It’s all about the administrative overhead.  Is this for everyone?  Definitely not, but not only will this approach make sense for those in reasonable health (paired with some form of catastrophic insurance), but also those with chronic diseases that require close management.

Or, maybe the doc comes to you.  Why isn’t this happening, then?  It will and it’s probably closer than you think.  As more and more people are becoming active consumers of healthcare services, we will see more uninsured (and insured) people trying out MinuteClinics, (maybe) Wal-Mart, MedLion or a handful of similar concepts.  I’m waiting for a single entrepreneurial medical professional to figure out how to safely care for people from a roving van, armed with a few key medical instruments, a cell phone and a laptop.

Dispatches from the Field, 2/25/08

For better or worse, these are the kinds of hard discussions we have to have as we look at our options for the ailing healthcare system:

Prevention is Good Medicine, but it’s Not a Fiscal Panacea
Prevention saves lives; it is the right thing to do. But prevention does not save money

http://blogs.usatoday.com/oped/2008/02/prevention-is-g.html

One of my favorite economists is Dean Baker. His “Beat the Press” Column tackles the ignorance and hidden agendas in economics. As you can imagine, there’s a lot of material when the issue is the economics of healthcare!

When it Comes to Health Care the NYT Is Protectionist

Just yesterday the NYT editorial board was complaining about the threat of protectionism in discussing Senator Obama and Clinton’s trade policies. Today, the editorial board discusses Medicare’s financial problems and never once mentions the extent to which this is caused by protectionism.

The basic point is very simple. Every other wealthy country provides high quality health care at a far lower price than in the United States. If we want to lower cost then an obvious way would be to try to take advantage of these lower cost systems. It is easy to develop mechanisms that would allow for Medicare beneficiaries to take advantage of lower cost systems.

The argument for the gains from trade in medical services is exactly the same as the argument for gains from trade in cars and clothes (we can even use the same graph, we just have to relabel the axis), except the benefits are likely to be much larger in the case of medical care. It is inconsistent for the NYT to be so committed to eliminating trade barriers in manufactured goods but willing to tolerate much costly barriers to trade in medical services.

http://www.prospect.org/csnc/blogs/beat_the_press_archive?month=02&year=2008&base_name=when_it_comes_to_health_care_t

In the interest of full disclosure, it should be noted that I am working on the Austin health insurance program mentioned in this article.

Texas Urban Areas Work to Bring Three-Share Programs to the Working Uninsured

HealthLeaders-InterStudy, a leading provider of managed care market intelligence, reports that five Texas urban areas — Austin, Dallas, El Paso, Galveston and Houston — have made various levels of progress toward forming health benefit pools
authorized last year by the Texas legislature. According to the latest Texas Health Plan Analysis, these three-share health benefits programs are designed to provide coverage access to small businesses who feel they have been priced out of the healthcare market.

http://www.prnewswire.com/cgi-bin/stories.pl?ACCT=104&STORY=/www/story/02-26-2008/0004762435&EDATE=

This is shaping up to be a disappointment. The new office created by the FDA “will not get the ultimate power to sign off on label changes or recommendations to remove a drug from the market.”

FDA Unveils Plan to Boost Oversight of Drugs Once They Are on Market

The Food and Drug Administration unveiled a new effort to bolster its oversight of drugs after they’re on the market, in the agency’s latest response to years of criticism about its handling of medication safety issues.

http://online.wsj.com/article/SB120405750657094407.html?mod=wsjagent