Hi, I’m Rob. I’m a Recovering Doctor

By ROB LAMBERTS, MD

Yeah, I know I used that line once before, but it’s a special day for me today.  Humor me.  Five years ago today I earned my last money from an insurance company.  Yep, today is my five year sobriety date.

Five years.

That was before the Affordable Care Act, before the Cubs won the World Series.  Before anyone knelt for the national anthem, and if they had, people would’ve probably not minded.  It was before the election of a reality TV star to our highest office, before “fake news” became a thing (there was plenty of it, but nobody called it that).  It was before half of the rock legends died, before Anthony Wiener went to jail, back when Hamilton was a guy nobody knew much about who was on the 10 dollar bill, when the world wasn’t quite this warm, when Oprah hated me.  Actually she still does.  I’m not sure why.

I left my old practice because of “irreconcilable differences” with my ex-partners.  Instead of going to the VA, joining another practice, or moving to New Zealand, I started a different kind of practice.  My Yoda, Dave Chase (who wrote a book that you MUST read) told me about “Direct Primary Care,” where doctors don’t charge a lot, but are able to see a lot of people and give good care because they are paid by their patients.  It made sense to me.  There were a few folks doing it, and I talked to a couple (I’m looking at you, Ryan) who made it sound possible.

So I did it.  I dumped all insurance and started charging people a flat monthly fee.  People were skeptical and only my most loyal patients followed me (about 200).  It took a while, but we figured out how to make it work, and my patients figured out that this was the best experience they ever had in healthcare.

And we grew.

I added a second nurse, went through several medical record systems (even built my own) before finding one that actually focused on patients over billing.  Had some squirrels in my attic (some of them dead), went through an ice storm, a couple of earthquakes, and a hurricane.  I also got socks with llamas on them.

And here we are.  I have over 700 patients and still have room to grow.  My busiest day was when I saw (gasp) 15 patients in the office.  I still average between 9 and 10 (although much of the care we give is done via messaging or over the phone, so that number’s a bit deceiving).  I still take Monday mornings off, still get home around 5:30 most days, and still seldom get bothered on weekends.  My life is still much better than it ever was.

And there is still room to grow.

So what of my critics?  What of the people who said I was shirking my duty to Medicare, abandoning my patients, and putting myself over what was best for others?  They are idiots.  Was it truly better when I was unable to give good care to any of my 3000 (give or take) patients, or is it better when I can give excellent care to 700?  Am I truly abandoning my duty to the system by keeping people healthy, taking people off of medications, and keeping them away from ER’s and hospitals?  Have I truly put myself above others by taking a huge cut in pay and spending my retirement money?  Yeah, that last bit is finally changing, but I’ve got 700+ people who say I made the right choice (and I am still seeing old patients who finally come back to me from my old practice).

What about the criticism that says that this model can’t work in the big picture?  What about the argument that if all docs convert to practices like mine, they would not be able to meet the care needs in our country?  Again, I am actually giving excellent care to 700 patients.  That’s 700 more than I was giving good care to before switching, and 700 more than most doctors give.  And there is room to grow that number beyond 700 through increased system efficiency, use of midlevel providers, and improved technology enabling better care, automation, and better communication.

This model works.  It is able to give truly good care to people, decreasing their use of the system and dropping the overall cost of care.  Do I have proof of these claims?  No, but direct primary care has dramatically grown in popularity with both patients and doctors over the past 5 years, to nearly 1000 practices around the country.  Patients and doctors chose it because it’s better.  It makes sense.  I don’t have to waste people’s time, force them to wait in my office (my wait time still averages about 30 seconds), or spend most of my time staring at a computer screen.

So I will pick up my medal for 5 years’ sobriety.  There is no temptation to go back to my old life.  I hit rock bottom and have been actually enjoying the job of doctor.  My future is bright.  My income is growing.  My schedule still has plenty of room.  My patients are happy.  How many doctors can say that?

And we are growing.

And I am happy.

Rob Lamberts is a doctor. And he’s happy. 

 

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Big Names, Big Ideas at Health 2.0 Fall Conference

The Annual Health 2.0 Fall Conference has harnessed the creativity and passion of health care’s brightest professionals to tackle the industry’s most intractable problems and leverage technology-enabled solutions to drive more compassionate, more accessible patient-centered care.

Check out the full agenda of our eleventh show, Oct. 1-4, in the heart of Silicon Valley.

Our killer line up of speakers covers the full spectrum of healthcare, and includes:

Innovative leaders, including Jason Pyle, CEO of Base Health; Simon Kos, CMO of Microsoft; Aashima Gupta, Global Head, Healthcare Solutions, Google; Brian Otis, CTO of Verily Life Sciences; Daniel Kraft, Founder and Chair of Exponential Medicine; and Jeff Margolis, CEO of Welltok.

Policymakers, such as HHS CTO Bruce Greenstein; ONC National Coordinator Don Rucker; former ONC Director David Brailer; and former U.S. CTO Aneesh Chopra.

Patient advocates, including Dave DeBronkart (e-Patient Dave) and Patient Power President Andrew Schorr.

Representatives from more than two dozen major health systems, including UPMC, Mount Sinai, Dignity Health, UCSF, and more!

Major healthcare investors, including Providence Ventures, Merck Ventures, GE Ventures, and more!

Check out our full line up of speakers.

Limited amount of tickets are available. Register Today to secure your place at the Fall Conference-event starts this Sunday.

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Lessons From Massachusetts’ Failed Healthcare Cost Experiment

By SOUMERAI, KOPPELL & BOLOTNIKOVA

Massachusetts passed a massive medical cost control bill in 2012, a “Hail Mary” effort to make health-care more affordable in the nation’s most expensive medical market. The problems of the Massachusetts’ law offer invaluable lessons for the nation’s health-care struggles.

Driven in part by a Boston Globe investigation that exposed the likely collusion of the Partners Healthcare hospital system (including several Harvard Medical School teaching hospitals) with Blue Cross/Blue Shield, the largest healthcare insurer in the state, the law marked the biggest health reform since Romneycare in 2006. While most agree Massachusetts needed cost controls, there’s no evidence that the 2012 law has accomplished its goal—and these same failed policies have been folded into the national Affordable Care Act.

Romneycare, Massachusetts’ universal health-care law, already lacked effective rules to control the rapid growth of state medical costs. That, paired with the Boston Globe’s exposure of the likely collusion between Partners Healthcare, the largest hospital system in New England, and Blue Cross Blue Shield to raise health care payments to hospitals and doctors by as much as 75 percent, led to passage of a hefty, 349-page cost-control law in 2012. The legislation included a dizzying number of committees, an uncoordinated “cost containment” process, and dubious quality-of-care policies, like “pay-for-performance,” a program that pays doctors bonuses for meeting certain quality standards, like measuring blood pressure. These incentives might make sense in economic theory, but have failed repeatedly in well controlled studies. They’ve even created perverse enticements, such as some doctors avoiding sicker patients. The cost control law also encouraged widespread use of expensive electronic health records, even though there’s no evidence that they save any money.

Additional policies in the law are “accountable care organizations” (ACOs) and “alternative quality contracts,” programs that pay doctors for staying under an arbitrary budget and penalize them for going over it. But the best studies show, again, that these policies actually increase costs if you count the expense of implementing them. In fact, most of the hospitals in the federal government’s “Pioneer ACO” program have dropped out, including Dartmouth Hitchcock, the famous medical center, associated with Dartmouth College, that initially coined the term “ACO.”

Given the MA cost control law’s outcomes so far, we should be very skeptical about its projected savings. Suffice to say, the law is too complex, unwieldy, contrary to evidence and, worse, doesn’t have the teeth (e.g., regulating price) to enforce cost reductions among the most powerful medical providers. Nancy Turnbull, one of the architects of Massachusetts’ health reform and a member of the board of its insurance exchange, told the New York Times in 2012 that the law “was not nearly what we need to deal with the market power and the unjust price differences that result.”

So how has the law’s repeated disappointments been described to the public? Recently, a front-page, above the fold story in the Globe suggested the law resulted in a “slower rise in health spending” in 2015—which amounted to a decrease of 0.3 percent from the previous year. Researchers often doubt such tiny effect sizes and for good reason. They usually aren’t real. But even worse, the Globe’s “analysis” relies on just two data points, both from years after the 2012 law passed. Had the Globe’s story begun with data from before the law’s enactment, (see graph below) it would have shown that per-capita health-care spending growth actually increased by more than two percentage points since the policy began. This month, the Globe again wrongly reported that new data in 2016 shows the state has helped reduce health-care spending. The data from the last few years contrasts with the previous decade, when health-care cost growth had been declining steadily. Thus it’s unlikely that the tiny changes in costs from 2014-2016 had anything to do with the new cost control effort. And the average annual cost growth over the last three years is still about twice the level at the time the law passed.

This figure, with more complete data, shows that between 2002 and 2011, the year before the law, there was a much greater decline in Massachusetts healthcare cost growth—from 9 percent annual per capita growth to under 4 percent. The tiny changes in the growth rate from 2014 to 2016 (years after the law) is not evidence that the 2012 state law reduced costs, because cost growth in those years was still twice as high as it had been in 2012 and 2013.  In addition, the reporting did not even mention the start of Obamacare regulations less than two years before the MA cost control law, so it is impossible to know whether these policies caused the increase in health care costs observed in the graph. This untrustworthy analysis could fool Massachusetts policymakers and citizens into thinking that its policies were working, or convince other states to follow Massachusetts’ model.

The Massachusetts cost control law has not fulfilled its promise to “bend the cost curve.” If anything costs have gotten higher. The commission set up by the law “may encourage, cajole, and, if needed, shame [providers] into doing their part to control costs. “But this is insufficient to fundamentally change the behavior of the systems with the most market power. Charges for a single aspirin pill in a hospital can be higher than $25, but only pennies at the local drug store. It is already clear that the health care cost crisis is threatening the viability of essential government services from education to defense. To make matters worse, the state’s largest newspaper acts as the law’s cheerleader without even considering the history of health care costs that clearly shows the law’s shortcomings.

So what should be done now? In the near term, the legislature should consider much stronger cost controls that do not rely on the voluntary cooperation of hospitals or on market-based incentives and penalties. The state (and nation) must abandon ineffective, wasteful “alternative payment arrangements” that save miniscule dollars while costing delivery systems billions. Massachusetts and the nation need effective, negotiated price controls that fairly compensate hospitals but do not allow a few elite institutions to receive excessive reimbursement. But the current Republican health plan would retain all the failed aspects of Obamacare, while dropping the parts of the law that gave millions of poor Americans access to health-care.

There are better solutions: Our political system thus far has rejected government-run, single-payer systems, like the British National Health Service and Canada, but there are plenty of private, market-based models in Europe that provide better care to their citizens at half the cost. They rely on straightforward price controls, negotiated between the private and public sectors—not more failed market incentives. Germany’s system, for example, relies on hundreds of competing health insurers. The key difference is the use of medical fee schedules (price controls) that are negotiated between provider associations and insurance programs that prevent the kind of price fixing uncovered by the Globe. Switzerland has similar arrangements. The companies compete on quality of service and efficiency. Germany and Switzerland have managed to avoid most of the costly deductibles and copayments that keep health-care out of reach for ordinary Americans: no prohibitively expensive $10,000 deductibles (which is more than most Americans have in savings), as allowed under the ACA. The US could choose the best aspects of these successful plans that fit our culture and our health care environment.

Ten years ago, Massachusetts built the model for the nation’s health reform law, which then expanded health care to more than 22 million Americans and offered needed protections to America’s population, e.g., removal of pre-existing condition restrictions, free mammograms, and the ability to insure adult children. But we remain the only developed country in the world that fails to provide care to all its citizens. And we allow costs to grow at unsustainable rates. Rather than wait for the implosion of our medical system, Massachusetts must again lead by example in the nation’s polarized health reform debate—this time, by establishing affordable health-care as a right for all its residents.

Stephen Soumerai is Professor of Population Medicine and teaches research methods at Harvard Medical School.

Professor Ross Koppel teaches research methods and statistics in the Sociology department at the University of Pennsylvania and is a Senior Fellow at the Leonard Davis Institute (Wharton) of Healthcare Economics.

Marina Bolotnikova is an associate editor at Harvard Magazine.

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Graham-Cassidy is Dead. It’s Back to the Drawing Board. Why Not a Two-Tier System?

BY BRIAN JOONDEPH, MD

Remember back in 2012 when then Vice-President Joe Biden told us, “Bin Laden is dead, General Motors is alive”? The good old days. Also around the time Senators John McCain and Lisa Murkowski promised to repeal Obamacare. Along with a bunch of other Republicans seeking reelection to Congress.

Fast forward to 2017. The new catchphrase is “GOP is dead, Obamacare is alive.” At least their credibility is dead. Buried in the rubble of broken campaign promises. Not only Obamacare repeal, but also tax cuts, immigration enforcement, balanced budgets, reduced spending, and so on.

Repeal and replace, as a promise was simple enough on the campaign trail.  We heard this promise in 2010, when voters gave the House to Republicans.  We heard it again in 2012, when voters gave them the Senate.  Despite controlling Congress, Obamacare remained alive and well.  Candidate Donald Trump, along with most Republican members of Congress, promised repeal and replace last year.

Eight months into the Trump administration, Obamacare is still kicking. Congress had three bites of the apple this year and each time came up with a worm instead. This week was their third attempt to fix Obamacare. Not the promised repeal, instead only financial window dressing to keep Obamacare alive in some shape or form.

Graham-Cassidy didn’t even earn a Senate vote this week after three promised GOP defections. Too bad they didn’t vote. Senator Richard Shelby thought a vote was fruitless saying, “Why have a vote if you know what the outcome is and it’s not what you want.” Why? How about getting the Senators on record with a yea or nay vote? Votes that they could be reminded of during their next campaign.

Once again, the do-nothing Congress has squandered a once in a generation, or lifetime, opportunity to advance a conservative agenda. Instead after 8 months, they have little to show for their control of the executive and legislative branches of government. Obamacare remains the law of the land.

Republican lassitude is not lost on voters, as Luther Strange learned this week. Senator Bob Corker noticed too, choosing to do nothing as a private citizen rather than as a U.S. Senator. Congress may not want to repeal Obamacare, but the voters do.

Many want a simple repeal, similar to what Congress passed multiple times, certain that their virtue signaling repeal bills would be slapped down by an Obama veto. Now that the veto threat is gone, so are the votes for repeal. It won’t happen. Neither will the IRS ever be abolished, or the Departments of Education and Energy be closed. All conservative pipe dreams but far from the reality of current Washington, D.C.

Obamacare remains in a death spiral. Another year of double-digit premium increases, some families paying more for their Obamacare insurance premiums than they are for their mortgages. Not to mention rising copays and deductibles, and narrowing physician and hospital networks. All making medical care unaffordable for many Americans, even though they have insurance.

What’s next? Waiting in the wings is Bernie Sanders’ “Medicare For All” bill which has the support of 17 Democratic senators, more than a third of their caucus. On the House side, John Conyers has his own version of single-payer with 119 cosponsors, more than half of the Democrats’ House caucus.

America is already drifting toward single-payer. Medicaid, Medicare and the VA System are all single-payer health insurance plans. Or more accurately, government-run healthcare systems. Obamacare is following this path. A third of counties have only one Obamacare insurer. It’s not far from what we have now to a true single-payer plan. And the Democrats are ready and waiting to take advantage of Republican chaos and an imploding Obamacare.

Perhaps this was the plan all along. It was then Senator Obama who once said single-payer is the goal, but “we can’t get there immediately.”

If President Trump cannot get anything done with his own party in Congress, maybe he calls his new buddies Chuck and Nancy. Just as John McCain always extolls, “reaching across the aisle.”

Suppose Donald, Chuck and Nancy cook up a two-tiered system, something for everyone? A public option and a parallel private option. Just as most developed countries have. The public option covers everyone. Think of Medicaid for all. A bare bones catastrophic coverage plan available to all Americans. With minimal or no out-of-pocket costs to patients but with the tradeoff of long wait times for care and limited treatment options.

The private option allows individuals to purchase medical insurance or actual care directly, what they want and need, nothing more. Insurance without mandates and regulations. No subsidies, tax breaks or government assistance. Pure free market.

Think of K-12 schools. Public schools available without cost to all students. For most a good education. And a private school option for those who desire and have the means. Pay the private cost or default to the public option and pay nothing.

Pros and cons to each system, but both are separate and distinct, each doing what it’s designed to do. Rather than an amalgam of both systems, which is what we have with Obamacare, Graham-Cassidy, skinny repeal or whatever the witches and warlocks of Congress conjure up.

Something for both the right and for the left. Free market for the right. Universal coverage for the left. Perhaps the only way to get past the current logjam in Congress. If Republicans continue to twiddle their thumbs and do nothing, they may soon find themselves in the minority. Leaving Bernie in charge.

If the Democrats control Congress, make no mistake, they will pass single-payer. No defections. They will change procedural rules such as the filibuster if necessary. And they will accomplish what the Republicans are unable to.

In the meantime, Obamacare is alive and it’s the GOP on life support.

Brian Joondeph is an optometrist based in Colorado.

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How health IT organizations are using security as a competitive advantage

BY ANDREW HICKS          SPONSORED CONTENT

When speaking with our health IT clients, I’m hearing a distinct shift when it comes to cybersecurity. They no longer view it as an IT cost; they understand how it can facilitate growth, create competitive advantage and build trust in their products and brand.

Their executive management is on board with this thinking, too. They don’t want to hear about fear, uncertainty and doubt when it comes to data breaches, hacks and cyber threats, but rather how cybersecurity can help ‘protect the house and the product’ while at the same time enabling the business, customers and partners.

As more products and services in the healthcare continuum are connected, the need to proactively address cybersecurity increases. And as more consumer and business information is generated and shared, data privacy becomes a critical business requirement. This explains why we’re seeing forward-thinking health IT organizations moving to a new model of cybersecurity – one that’s adaptive to evolving risks and threats plus aligns with overall business objectives, such as increased revenue.

The one unifying thing we see with most health IT clients is the cloud. They need to design, build, assess, test and validate architectures and products on the cloud to confidently go to market with secure solutions. They’re finding that as they address cybersecurity in the design and development of products and services, they experience new ways to innovate and move faster. These cloud-integrated solutions can also enhance data privacy and boost customer trust and brand reputation. These are crucial safeguards as consumers are more concerned than ever about how their data is collected and shared.

Organizations aren’t waiting to hear that security program elements to demonstrate customer data protection are a requirement to closing a deal, they’re getting proactive by using cybersecurity as a sales strategy.

They know that threat actors will always be ahead with new tactics and techniques, so they’re being forced to step up their game.  It’s not just about compliance programs like PCI, HIPAA/HITRUST, FedRAMP or SOC reports that prove they’re serious about data protection. Many organizations are implementing additional security measures to ‘protect the house’, such as technical testing conducted on a regular basis to identify vulnerabilities, cyber engineering to fix identified issues, and incident response plans that are tested every six months.

So, what’s the payoff? After continuing to deliver products and services in a secure manner, customers come to trust interaction with certain companies. Security becomes part of the fabric of what these companies offer, which sets them up nicely to build trust into everything they do. And in the end, it’s a huge competitive advantage.

To learn how leading organizations are integrating cybersecurity from the outset, and in recognition of National Health IT Week, Coalfire is hosting a webinar with a panel of health IT executives who will discuss how their security programs have enabled them to better engage with existing customers, attract new ones, and optimize operations, business processes and IT investments.  For more information, or to register, visit http://ift.tt/2xEKsd1.

Andrew Hicks is the Managing Principal at Coalfire

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How Wellness Become the Wrong Word

JIM PURCELL

What do employers want more than anything? Healthy, engaged, productive, energized, and thriving employees who provide great customer service and high quality products. What they have is all too often the antithesis of that.

This article is about why and how to move away from “wellness” to “wellbeing.” Wellness is one dimensional—the absence of illness. But for employees to thrive, they need so much more. The essence? They need to be happy with what they are doing and where they are doing it. Without that, good physical health, engagement, and productivity are almost impossible. It’s as simple as that, and with happiness comes success on multiple levels for the employee and the employer. And yet the all too many of today’s American employees are dreadfully unhappy with their jobs and bosses. It’s time for that to change.

The companies that successfully address the deteriorating health (both physical and mental/emotional) of their employees have a huge competitive advantage, and not just from reduced healthcare coverage, but in cultivating more enthusiastic, productive, and engaged employees which drive competitive and financial success through better products and better service.

Dee Edington confirmed this in his book Zero Trends when he wrote: “Our mission is to create shareholder value. We create shareholder value because we have innovative, creative, and quality products and services. We have innovative, creative, and quality products and services because we have healthy and productive people.”

This is, as we say in Massachusetts, “wicked important.” Yet most American CEOs do not yet see it as even rising to their level of attention. That is nothing short of astonishing given how much they pay for healthcare coverage and the truly poor value they receive in return. Starbucks pays more for employee coverage than for coffee. GM pays more for coverage than for steel. Businesses don’t realize it, but they are truly in the healthcare coverage business whether they like it or not. And that doesn’t even begin to total up the costs of disengagement, absenteeism, and turnover.

So, what about today’s garden variety workplace “wellness” programs? In fact, they haven’t worked on virtually any level. The “wellness” industry has deservedly opened itself to criticism that “wellness” investments are a waste of resources. Critics have eviscerated the industry all too often.

Typically, workplace “wellness” initiatives have been developed by HR and floated to senior management for approval with the usual justifications of reducing coverage costs and a healthier workforce. Someone in C-Suite, often NOT the CEO, might approve such proposal and its budget. In rare cases, there might even be some business plan. But little else. There are so many other things to focus on like quarterly dividends, customer relations, and the current crisis, whatever that might be.

And then the matter goes back to HR and becomes largely indistinguishable from any other employee benefit plan. Nice to have, but not strategic in any sense. HR might retain a vendor or hire wellness coaches, and may acquire programs that focus on exercise, smoking cessation, and nutrition. All good things, but not nearly enough. Employers also may do the dance of incentives and penalties, but neither result in long term lifestyle change or improved morale.

After a few years of lukewarm enthusiasm and modest employee participation, someone in C-Suite might ask about the return on the program’s investment. Unfortunately, few companies even try to measure returns, and if they did, the numbers would be indeed disappointing. Even so, shouldn’t something be done about healthcare costs? And wellness programs, whatever their returns, just seem like the right thing to do. That is indeed sloppy thinking.

The reasons why today’s workplace wellness programs have not worked are many, but the most important are: lack of strategic focus with a comprehensive approach; focus almost exclusively on the physical health side ignoring mental and emotional health; lack of CEO leadership; absence of a culture of wellbeing; and a one size fits all approach that appeals primarily to the already healthy and fit.

The stark truth is that the wellness industry has accomplished remarkably little in the areas of return on investment (ROI, which I define as reducing employee claims expense by more than the cost of the wellness programs) and long term lifestyle behavior change. To have any chance at positive ROI, the focus must be on chronic illness with a supportive culture of “wellbeing” and caring to maximize employee and family enthusiastic participation. Yet so often, it is not. Swim, gym, and weights alone won’t do the trick. Programs for smoking cessation, weight loss, exercise, and nutrition (traditional “wellness” programs), while helpful on almost any level, do not truly move the needle on coverage costs or employee engagement. They are one size fits all and quite randomly implemented.

Accordingly, it is submitted that we must move away from “wellness” to “wellbeing.” There is a world of difference between those two similar nouns. When our society and our medical profession refer to “wellness” (as in being well), what they really mean is the absence of illness, almost always the physical kind. “Wellbeing” is far broader, meaning a positive physical, mental, and emotional state. The difference is profound.

Shawn Achor in his book The Happiness Advantage underscores the importance of this point when he writes:

“You can eliminate depression without making someone happy.  You can cure anxiety without teaching someone optimism.  You can return someone to work without improving their job performance.  If all you strive for is diminishing the bad, you’ll only attain the average and you’ll miss out entirely on the opportunity to exceed the average.”

Despite abundant data from Gallup and others showing the central role of employee wellbeing (as opposed to mere wellness) in driving workplace engagement, American employers haven’t taken the cue. And Gallup has been doing this for decades!!

Gallup’s 2016 Q12 Meta-Analysis of The Relationship Between Engagement at Work and Organizational Outcomes makes it abundantly clear how engagement drives measurable and substantial improvement for “customer loyalty metrics, productivity, employee turnover, safety, absenteeism, patient safety and quality.”  According to Gallup, higher engagement means higher profitability.

And when you combine high levels of wellbeing and engagement, magical things happen. Consider that Gallup’s Well-Being Enhances Benefits of Employee Engagement tells us that the benefits of adding high wellbeing to high engagement are enormous with employees reporting:

• 42% more likely to evaluate their overall lives highly
• 27% more likely to report “excellent” performance in their own job at work
• 27% more likely to report “excellent” performance by their organization
• 45% more likely to report high levels of adaptability in the presence of change
• 37% more likely to report always recovering “fully” after illness, injury or hardship
• 59% less likely to look for a job with a different organization in the next 12 months
• 18% less likely to change employers in a 12-month period
• 19% more likely to volunteer their time in the past month

So why is a move away from workplace “wellness” to workplace “wellbeing” so wicked haahd (how we say “very difficult” in Massachusetts) to do well? There is a forest for the trees aspect here. It is so obviously the right thing to do on any business level that it is simply missed. It doesn’t sound critically important or strategic. CEOs and boards are distracted by other things and do not connect the dots between employee wellbeing/engagement and operational success. And if they do consider it, many believe that it is like curing world hunger and sitting around the campfire singing songs. After all, they can’t be responsible for what happens away from work. Yet…they can be responsible for what happens at the workplace, which is where many Americans spend more time than anywhere else and is a primary cause of stress.

Once organizational leaders and boards really, really focus on the importance of the difference between employee wellness and wellbeing, they should have an “aha” moment. Workplace wellbeing should be the​ top strategic objective of any company. Done right, workplace wellbeing must be strategically planned, staffed, and financed like any other mission-critical strategic objective. The outcomes that matter must be measured. Leadership, from top, to mid-level, to front line, must be engaged, enthusiastic, and held accountable. When is the last time a CEO was held accountable by his/her board for employee wellbeing? When is the last time organizations based a significant part of executive incentive compensation on employee wellbeing?

Whole person “wellbeing” must become a defining characteristic of the company’s culture and environment. It must become part of how organizations “do business.” And it most definitely is not too much to take on, particularly considering the potential upside benefits as outlined by Gallup.

Employees and their families must come to understand that the company invests in their wellbeing because it truly does value employees. It also happens to be both the right thing to do and very good business that will reap untold dividends.

More to come on this subject. But please, tell me if I’m wrong. And of course, why. And if you disagree with the move to the word “wellbeing,” what word would you use to be the label for what has been described above?

Jim Purcell is the former CEO of Blue Cross & Blue Shield of RI, and prior to that, was a healthcare and trial lawyer in Providence RI. Today, he mediates and arbitrates healthcare disputes, and is writing a book to start a national movement for employee wellbeing. See ReturnsOnWellbeing.com.

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Postgaming Sunday’s Graham-Cassidy Action

By PAUL KONNOTH

Another day, another draft of Graham-Cassidy. And yet another slew of special deals for Alaska, which I have criticized as unconstitutional elsewhere. Congresional Republicans must pass their recent version of Obamacare repeal by September 30 to avoid the filibuster rules that are usually applicable, and which would require a 60 vote threshold. Until then, they need only 50 of the Senate’s 52 GOP Senators to eke out a victory. John McCain has said he won’t vote for the bill; Susan Collins has said she is leaning against it. Rand Paul, after signalling early disapproval of the bill because it did not go far enough, is now negotiating with the bill’s authors to roll back even more patient protective regulations.

 

If Paul shifts, eyes once more will turn to Lisa Murkowski. In anticipation of this, news outlets are once more reporting sweeteners to Alaska that characterized earlier versions of the bill. The reporting is somewhat vague and sometimes inaccurate, so I thought a deper dive would be helpful.

 

I must caveat all of this by noting that this analysis is based on a quick read of a bill that was released just today—I welcome any corrections or additions.

* Five percent of the funds appropriated for a particular “short term assistance plan” will be distributed to low density states (with less than 30 people a square mile). (Bill, p. 7). This by itself isn’t horribly disproportionate at the moment—in 2015, these states had 3.8% of the population. But over time, as the population in some of these states keeps dipping, it will grown more disproportionate. NBC misreports, however, that 5% of all federal funds will be going to these states, which does not appear to be the case. But Alaska is one of the 9 states that benefits from this slight bump.

 

* It reintroduces (p. 22) a provision that was floated earlier, that would give a bump in funding to low density states whose healthcare costs are more than 20% of the population. This benefits only North Dakota and Alaska. The bump is proportional to how much their costs exceed the national average, so Alaska at 38%, benefits more than North Dakota, at 22%. As I mentioned in my earlier post, the argument that Alaska needs this special treatment is nonsensical. The agency is given the power to adjust the funding to take into account healthcare costs, and there are other reasons for high healthcare costs than low density. 

 

* For states that obtained 1332 waivers under the ACA (exactly two states as far as I can see—Alaska, and Hawaii) an additional 500 million dollars is made available. (p. 44).

 

* It imposes penalties on states whose costs with respect to certain beneficiary groups exceed that of the national average by more than 25%. (p. 81). It exempts from this low density states. It is likely that this benefits only Alaska, and maybe North Dakota, if it benefits anyone at all. 

 

* The states with separate poverty guidelines as of 2017 get additional federal match funding (FMAP). (p. 141-43). This benefits two states—Alaska and Hawaii, the only two states in that category. Alaska will get a bump of 25% of the average spending of the other states. Hawaii will get 15%.

 

* It keeps in place certain funding for Native Americans (p. 138). This benefits states with high Native American populations. At 16.5%, Alaska’s share of Native Americans (Alaska Natives) dwarfs that of other states. New Mexico and Oklahoma follow, with 9.5% and 8% respectively, with a few other “high percentage” states hovering at around 5%.

 

One interesting tidbit. Vox reported that states that recently expanded Medicaid under the ACA would also get additional money. I expected that this would also benefit Alaska, as Alaska expanded Medicaid only in 2015, as did a couple of other states—Indiana and Montana. But as it turns out, a state would have had to have expanded sometime in 2017 to get this perk. (p. 42).  (NB—CNN reports a 2015 cut off.  It’s either using a different version of the bill or got this wrong).

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Microsoft Set To Demo VR/Mixed reality Physician Education Platform

Dr. Simon Kos had big shoes to fill when he took over the role of Microsoft Chief Medical Officer from Dr. Bill Crounse last year. Dr. Kos said himself that they were some “big scrubs to fill”. However, at the time he had already been with Microsoft for six years and in Health IT for more than a decade before that, so he was no doubt up to the challenge.

As Chief Medical Officer, Dr. Kos is responsible for providing clinical guidance, worldwide thought leadership, vision and strategy for Microsoft technologies and solutions in the healthcare industries. He made the move to Health IT after working a few years as a Medical Officer in Sydney, Australia. It was then that Kos decided to go back to school to study software engineering, and later his MBA. He then worked with  InterSystems and Cerner and helped them to implement e-Health initiatives in Australia. In 2010 he joined Microsoft as a Health Industry Manager “with the appreciation that improving health and healthcare was about more than just putting in EMRs.”  Even back then Dr. Kos had the vision to know that the future of healthcare would be in the data analytics and the AI applications that Microsoft would eventually release.

In a recent conversation, with the team here at Health 2.0, Dr. Kos talked about Microsoft’s current framework of digital transformation and highlighted their four pillars; Patient Engagement, Clinician Empowerment, Advanced Analytics, and New Models of Care. As a once practicing doc, he knows that technology needs to help not hinder the healthcare workforce and that AI will be able to improve diagnosis speed and accuracy without replacing or interfering with the clinician. He is a fervent believer that it is important to be constantly evaluating the tech models that may not be viable today but will be in the future. He is excited about Microsoft’s work on patient chatbots and VR/Mixed reality physician education platforms and will be demoing that technology on the Health 2.0 Stage on Monday, October 2nd.

Register today! 

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An Op-Ed Ghostwriter Speaks

By WILLIAM S KLEIN

Is it “a breach of trust” for a publication to publish an opinion piece that was written with the participation of public relations professionals?  That was the conclusion of a recent article in Health News Review, a publication that bills itself as “Your Health News Watchdog.”(“Another ‘breach of trust’ at STAT: patient who praised TV drug ads says pharma PR company asked her to write op-ed”).

The article traces the origins of an op-ed that appeared in STAT, the respected medical blog published by the Boston Globe,  headlined  “You can complain about TV drug ads. They may have saved my life.” Health News Review managing editor Kevin Lomangino found that a public relations firm working for Gilead, a pharmaceutical company that makes the hepatitis C drug Harvoni, had reached out to a patient named Deborah Clark Duschane and asked her to write about her experience with drug ads.

Lomangino quotes Charles Seife, a professor of journalism at New York University, who called the situation a “breach of trust.”

“The whole point of ghostwriting is to hide the hand of an actor — to make an industry position seem like it’s coming from an unaffiliated individual,” Seife said. “That’s deception. It’s meant to disarm the natural skepticism that we have when an industry makes self-serving statements. And when someone tries to disarm our skepticism, well, it ain’t good.”

As a professional ghostwriter, who has been hired by public relations professionals to work with authors on op-eds that have run in respected publications, I disagree.

I would argue that the whole point of a ghostwriter is to help someone with an important or interesting perspective to step onto some of the world’s most prominent journalistic stages and contribute to an urgent policy debate, with a well-crafted argument that might actually succeed in persuading intelligent readers to change their minds, adopt a position, support a cause or even part with some of their hard-earned dollars.

Sometimes, believe it or not, a prominent medical researcher, physician or clinician is not equally gifted as a writer.  This is also true of Nobel Prize winners, elected officials, captains of industry and lawyers—all of whose prose you can find on op-ed pages most days of the week.  When you see a politician’s or celebrity’s byline on a newspaper page, do you believe they wrote it all by themselves?  Why should it be any different for a doctor or patient writing about prescription drugs?

Every day, op-eds appear in print and online about which two things are true.  One is that they express a sincere point of view of a credible authority.  And two is that they advance the professional interest of someone else.

An op-ed promoting renewable energy may be beneficial to a maker of solar panels.  The opinion of an organic food grower may be good news for Whole Foods/Amazon.   A solution for traffic congestion will cause advocates for mass transit to take to Twitter.

Is the pharmaceutical industry entitled to a special category of outrage?  Do the billions of dollars at stake in the development and marketing of prescription drugs carve out a hypocrisy exemption other interests can’t claim?

For it’s hypocrisy that’s at work here, not greed and self-interest.  It is hypocritical for editors to think that the op-eds they print spring fully formed from the keyboards of their bylined authors when they know better than most how hard it is to write an intelligent paragraph.  It’s hypocritical for media critics to decry the hidden hand of public relations in op-ed columns when they understand that a public debate over urgent issues depends on the participation of stakeholders in those points of view, some of whom have budgets to spend.

It’s also hypocritical for authors to collect fees for opinion pieces that do not represent their own personal points of view or deeply held beliefs.  Fortunately for the reading public, by and large that doesn’t happen.

My job as a ghostwriter is to act as a collaborator with authors and a meditator between them and a larger audience.  An editor’s job is to evaluate a prospective op-ed and accept or reject it on its own merits—not because some PR person tried to “place” it.

In fact, I advise my clients to submit op-eds themselves, from their personal e-mail accounts. This practice may deprive PR firms from bragging rights to “deliverables” when justifying their fees, but I think it preserves the integrity of the relationship between author and reader.

Opinions are intensely personal, authentic and highly prized.  They can change, but they can’t really be bought.  Readers should be able to assume that the opinions they see in an op-ed represent the true beliefs of the author, and not the outcome of a transaction with the highest bidder.  That’s how journalism works.  (It may not be the way the internet works, but that’s another story).

It would be a scandal if PR firms could write a check to a prominent authority  and place his or her name on a ghostwritten piece that doesn’t reflect that person’s views.  But if communications professionals are involved in expressing authentic viewpoints of serious experts on urgent topics, and readers benefit from enjoyable and persuasive prose, it’s no harm, no foul.

William S. Klein is a professional ghostwriter. 

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Interview with Paul Black, CEO, Allscripts

Paul Black is CEO of Allscripts and he’ll be with me at Health 2.0 on October 1-4. Paul has been CEO of Allscripts for about five years, taking over from Glen Tullman who grew the company aggressively by acquisition over the previous decade. Paul has been steering Allscripts through a pretty big transformation for the past few years, and they’ve been the major EMR vendor that has most aggressively reached out to the startup tech community. This is an edited transcript of an interview we had in late August. — Matthew Holt

Matthew Holt: Paul thanks for talking with me today, but also we’re going to have you on for a quick chat when you’ll be on the main stage at Health 2.0, of which Allscripts has been a great supporter. Your colleagues Tina Joros and Erik Kins have been there for many years  but not you, so I ‘m thrilled to have you coming in early October. Paul, welcome!

Paul Black: Thank you very much. It’s a pleasure to be on the call with you today.

Matthew: Let’s dive in to the current state of play. There’s been some changes over the last five to seven years since the HITECH dollars came in, as more and more physicians, and more and more hospitals put in electronic medical records.

Obviously, Allscripts, was, I think, it’s right to say, built by Glen and Lee Shapiro via  lot of acquisitions, especially with the Eclipsys purchase, with the goal of becoming a big player in that meaningful use world. And obviously, you have your old company, Cerner, and your friends from Wisconsin, Epic, who have been very dominant becoming a single platform for many large integrated delivery systems.  Can you give me your sense of where the mainstream enterprise EMR market is at the moment?

Paul: I think that the mainstream EMR market in United States is becoming a mature market. And by that I mean it’s a marketplace in which almost every institution, almost every hospital, almost every post-acute facility, almost every ambulatory facility, has some semblance of an electronic medical record system. And certainly, they have an electronic billing set of capabilities. So, from that standpoint, almost everybody has something with regard to the ordering the management of and the documentation surrounding a clinical series of events.

Matthew: Give me a sense of how you think that’s changing in terms of the split between the integrated systems which are covering in-patients and out-patients, with physicians using the same system on both sides of the fences were, and the continued, I would say growth, but probably more accurately the continued existence of a large ambulatory-only segment of the market? After all that’s different for not only the way that the health systems and medical groups organize, but also the way that they’re served by organizations like you and Epic and many others. Is that system integration continuing or do you think that trend is kind of stopping?

Paul: I’ll take it from a couple of different angles. One is from an integration at the industry level, what has been vertical integration of large integrated delivery networks, or large multispecialty groups, especially practices, or in some cases, payers who are acquiring assets.  I tend to see that while there was a lot going on over the course of the last four, five years, I’m starting to see people be more focused on what they’ve already acquired, and looking at operational efficiency and looking internally to ensure that they’re gleaning the expected returns, both clinically and financially,  of the original goals of how they built those enterprises. That means from a culture standpoint, from an operation standpoint, and from a financial standpoint.

So, I don’t sense that there is as much of a, if you will, a go-go attitude to the continuation of acquisitions.  I don’t think it’s necessarily been a conscious pause, but in some cases there’s been a lot of affiliations and acquisitions that have caused people to really have to  make sure that they’ve done the things they need to do to really operationalize and to optimize the assets and the people that they are now a part of a new overall enterprise. I think from an industry standpoint of the people that serve that marketplace, us and some of the companies that you mentioned today, I see it’s just a natural progression of the other point that you’ve started with about where do we find ourselves in the state of the industry.

Again, this is more of a U.S. statement, but fundamentally, there are three organizations now that are $2 billion and above, Cerner, Allscripts and Epic, and that you have one that’s a pretty good size and growing which is Athenahealth.  And then below the line, if you draw a line there, you’ll find seven or eight organizations that are anywhere from the $80 million to $400 million revenue organizations that serve the marketplace, Quality Systems, eClinicalWorks, CPSI, Practice Fusion, MEDHOST, Meditech, GE to be specific.

There’s a scale component that comes into R&D efforts for the ability for us to continue to all be relevant to this marketplace. The lack of scale, I think, over time, will be an impediment to folks being able to be a full service provider to these large organizations, whether it’s a large integrated delivery network or it’s a large ministry of health in a certain country, or it’s a large multispecialty group practice.

Specifically, are you able to continue to innovate on top of the EMR that you have? Are you really investing in a population health strategy? Do you have a robust and true answer for post-acute all things outside of the four walls of the hospital, all things outside the four walls of clinics? Do you have a precision medicine platform that is EMR-agnostic? And finally, do you really have an answer for these organizations who all are looking for a consumer answer to how they compete and how they service the people from time to time in their catchment area as patients?

Matthew: Right.  Actually, you really helpfully laid out the next set of topics for us today today. Tell me a bit about your strategy and what your belief is as to how the customers you are serving, will they be from other physician groups or integrated systems?  And the ones who are working with the other players you’ve mentioned, how are they doing in two areas?  One is, moving data around between competitive systems – the whole interoperability piece.  The second is opening up to allow other technology companies to use their platform the same way that we are seeing, in more general technology, such as the App Store and the Google Play Store.  So, give me a sense of about those two.

Paul: On the moving around data part of the question, I see that as a result of all these platforms that have been invested in over the last 10 plus years, and certainly the acceleration of the deployment of these solutions over the last three plus years as a result of the stimulus program — Meaningful Use, one, two, and now three.

There are a lot of different EMRs that are out there today that have data inside of them that are important for organizations to be aware of and have access to, as you are truly becoming accountable clinically and financially for that patient population. The ability to get that data to truly harmonize it, meaning I’m going to store “Paul Black” in a record only once, even though I may be represented in multiple different electronic medical records because I have been a patient there and I have a medical record number established with that organization.

But to do more than the EMPI (master patient index) component which is a decades old technology, but to truly get that information in there but also harmonize it, has to do with me being represented as having an allergic reaction to Penicillin in that record only once, not seven times because it’s in seven different electronic medical records.  And being able to understand that a prescription that’s written in a system that might be using First Databank is actually the same prescription that’s written in a system that uses Multum as its vernacular for how those solutions and medications are counted out and actually prescribed.

That kind of data harmonization is available today, certainly from Allscripts. There’s other people that are working on that, but that is part of the complexity that is in fact, a reality of connecting multiple disparate electronic medical records.  But as I remind everybody, it’s 2017, computers have been solving algorithmic issues, and large linear programming issues for decades, back to the 1950’s, and that’s why computers were invented. And the solutions that we have will solve for that.  That thing gets you to a great state of having a bunch of information in a central repository that we call the community record and the community record is manifest in areas where you have multiple different electronic medical records in a community that are served up — and through a harmonization process — put into one location.

That gives you the capabilities to perform your analytics and the analytics is where a lot of people start when they talk about population health.  From our perspective, analytics is a byproduct of having all the data in one spot and then once it’s cleansed, once it’s really harmonized and deduplicated, that’s when you really can have an effective statistical work done around that dataset.  That then, once you have the “aha!” moment – the IBM Watson commercial moment – you actually have a workflow system that takes that actionable insight back down into the workflow of the caregiver at the bedside, at the clinic, at the emergency room, at a behavioral health clinic, wherever that might be, to really to make that insight actionable.  So that’s a big piece of our view of how you move the data. Connect, harmonize, analyze and transact.

To me, the transaction has to be done in the context of the workflow and that would begin my other concept around this which is if I send too much information back down to a physician and they receive data overload, I call that “shouting”, where they received way too much information. If I’m a cardiologist. I may not see new events that I’ve told the computer that I want to see, as a cardiologists, since the last time I saw this patient. I’m not terribly interested in lifelong history of those persons. I know them. They’re sitting in front of me. Tell me what’s new, tell me what’s changed and give me the community information about this patient. They find value in that.

So that concept around “shouting” versus what I call “whisper” are valuable insights that are provided to them that they get high clinical or financial value because they have that data available to them in a synchronized way, in workflow-centric way, where I didn’t have to log in/log out of one the myriad of different electronic medical records. So that usability concept, that workflow concept, that UI, is really important to making these systems work in the real world of having multiple electronic medical records.  

I’ll now flip to the second part of your question around opening up the platform. It’s interesting that we started doing this in 2007. As you well know, 2007 is a pretty important year. That’s when the iPhone was invented, but it’s also the year that Allscripts came out with the concept of having an open system.

So, it’s not just a concept inside the company, it’s a philosophy, it’s part of the culture. We have 40 plus people that sit inside of our company and we help third-party application programmer and program writers access a relatively deep layer of API, allow them to build applications on top of and build their own, if you will, ecosystem on top of Allscripts’ platforms. We now have over 4,000 certified application program interface engineering folks that supplement, if you will, our engineering team, but importantly, are building solutions that are industry-specific, that are workflow-specific, that are disease-specific, that will allow someone to benefit from this vast investment our clients have made. They add value to that through other clever interfaces, mobile devices, capabilities around scales or whatever it might be from a consumer standpoint that people are looking for. We are creating that ecosystem for entrepreneurs wanting access to this big network, access to a data layer and access to a company that wants to work with them.

So, the opening up of the platform has been something we’ve been advocating and doing for 10 plus years.  We are excited about the Meaningful Use, one, two, and now three requirements around open access and data sharing.  As both from a philosophy and culture as well as from an actual technical set of capabilities, we welcome that for the rest of the industry.  We think that’s very important.  No one community, no one system, no one physician office is only going to have one set of data input in one supplier of all of those technologies. That just doesn’t exist in any other industry and certainly doesn’t exist in this industry, nor will it ever.

Matthew: Thanks for that long and cogent answer because it was a set of complex questions!  So, let’s end with what comes out of this.  I think you guys are ahead of the curve here as an enterprise vendor– you’re moving with this open API and your work with Microsoft Azure you’re creating that that app store approach.  You’re starting to see the other players in the industry come that way.  Now there’s a bunch of back and forth about the FHIR standards and about how open the various app stores from the other players actually are, etcetera, etcetera. But we’re heading in that direction where a lot of the value and of the activity in the workflow and the analytics will be in these plug-in apps, that are using Allscripts, Cerner or Epic as kind of a base layer.

What do you think the future is for companies like Allscripts and for that matter Cerner, Epic and the other players we’ve mentioned in terms of working with this multitude of other vendors?  Is it going to be a situation where a typical customer won’t really care who the underneath layer is and will be interacting much more with applications from multiple different vendors and just assuming that the data will able to talk to each other? Or, do you think it’s more likely that over time, in order to maintain some market share, players like Allscripts, Cerner and Epic will actually start taking on-board more and more of those functions that you mentioned, like population health management or personal medicine initiatives?  Do you think it’ll be a more diverse, open ecosystem in the future or do you think those new solutions will be brought within the bigger companies in order to maintain market share?

Paul: I think it’d be a combination of both. There are 492 electronic medical record companies in United States that were certified by the ONC to be certified electronic medical record provider for meaningful use one and two.  I think that, again, now that the platform is pretty much digital across the entire United States, there’s lot of a people that are looking at this and saying, “The platform itself, the transaction machines, if you will, the EMRs, are in place.  How can I build an ecosystem that sits on top of or alongside of that in order for me to create value for myself, my company, my family and then my constituents?”  So, I think you‘ll see a lot of that that goes on.  I think that we’re seeing it today and as I’ve said earlier, we encourage that.  We have over a 167 different companies that use our solutions that we represent those 4,000+ engineers, and then we have our own clients that write their own applications as well.  And some of those clients actually resell them, so it’s a pretty neat set of capabilities that we enable, and we work very diligently on.

I think that to the core of the question though, is this just disruptive to the major electronic medical records suppliers?  I think it is if you don’t embrace it, meaning that someone will eventually say, “I can’t wait for your engineers to build everything that I want to build on my health care system and I have to be a little bit more nimble.  I have to be a bit more entrepreneurial. I have to also innovate in my geography”. And if I’m sitting on a platform that doesn’t encourage or allow for that, I think that could be a way for you as an electronic medical records supplier circa 2015, 2014, 2013 and 2012, to get disrupted.

I think most of the people in this business understand that and are, in some way, shape or form, embracing it, and I think that those who don’t will find themselves in trouble.  I think the other component of this is that there is a substantial amount of this called “brick work,” or the laying of the pipe, if you will, the connection to all of the different departments, the codes, the bills, you know, the orderable procedures, this doc like to order it that way.

There’s a lot of really important hard work that’s been accomplished over the last 30 plus years. So, for somebody to come in with some new-age technology and think that they can replace what I call these transaction systems, I think that will be a longer timeframe where that gets disrupted. I’ve seen lots of people come in and under-appreciate the complexity of say a pharmacy order. There are 72 different data elements that have to interact in order for that order to be done successfully between the pharmacist, the nurse, the lab, the physician, the phlebotomist,– all the drug allergies, all the checking that goes on than the actual delivery of that medication to the floor of the clinic.

It’s not a seven or eight data field transaction. This isn’t finance. This isn’t debit and credit cards. This is very complex stuff and the outcome has a very important impact clinically, i.e., if you order the wrong thing, you can create an adverse error. So, to me, it’ll be a long time before those transaction systems get fully disrupted, but for those of us that are in this industry who think that that will never happen, I think that would be a warning that people should heed. Someone will figure out a way to do it in a more clever way and it may create a new platform that would be disruptive to those of us who have been doing this for a long time, and those of us that have been doing this for a long time, need to disrupt it before somebody else does.

Matthew: There are couple of different options who might be those disruptors. We talked about going outside the four walls of the hospital and obviously we’re moving to an environment in, which chronic care management is going to be the future, more or less. There are some hiccups, I think, in the way HHS is now thinking about paying some of the stuff.  But anyway, assuming we are heading towards that world of more preventive chronic care management, do you think that a big outside tech company – I was talking about Apple and Amazon and some extent, Google – might start putting those pieces together from the outside such as the consumer’s home? Or is it more likely that a well-funded startup focusing on one disease like a Flatiron or Integra Connect in the world of cancer might come in and start chipping away with technology and service solutions and data solutions at the core of provider activity? Where do you think the most likely entrance for this disruption will be?  And, give me a sense of when you think things will look very different?

Paul: I’ve been doing this for a while and there have been big cap entrants into this marketplace from time to time and big cap entrants have come in and come out. There’s a pretty long history of that happening where they look at it and say, “This is a really large industry, we should come in and we should try to figure out how we could be a major player in it.”  I do think there will continue to be large players that come into it and I think the difference in 2017 and beyond is that the new entrants, whether it’s Salesforce, IBM Watson, Google, Microsoft or Amazon, will come in with a different approach. And that is, with a mobile-centric solution that has to connect to all these backend systems, but come into it with either disease specific, some sort of consumer-driven approach to how to make the experience of the patient or the mother or the caregiver for an elderly parent or something like that, a much easier thing to manage than what it is today, and we applaud that.  We think that’s great.  We’re actually working on a lot of that ourselves.

I think that would be the entrance and then over time, they would not realize it’s not sufficient just to do some chronic care management and they’ll figure out how to work upstream if you will. At the other end of the spectrum with some of the companies that you’ve mentioned where you start out, I’ve also seen that happen. And quite frankly, there’s a lot other companies that are in a marketplace today that have gotten to be to the $200 million, $300 million, $400 million size, but there’s a reality to being relevant to the entire industry that requires so much R&D investment to fill out all of the different specific workflows and content in order for you to ready on day one, roll a pickup up to the front door of the hospital or the back door of the clinic and say, “Here is your new system and it’s ready to go.”  Or, “Turn on this URL and it’s ready to go and everything that you need is ready, it’s already pre-built.”

That requires a lot of investment, that requires a lot of time and the landscape, quite frankly, is littered with a bunch of people who have come in who have had brilliant solutions for one specific medical condition, or one specific medical discipline. As they’ve moved from that one to multiple different specialty types, they haven’t really got to the scale that you really need to have in order to be relevant to not only do that, but also do these other components around the rest of the population health to the rest of the post-acute conversation to precision medicine piece and consumer.

Matthew: Yeah, I believe as one political leader said recently, health care is actually quite complicated.

I think it’s certainly true that we’ve had big players come in. I’m always hearing that Amazon is doing this or Apple is doing that or Google is doing something else.  As you said, there’s a bunch of places they could start and they eventually will move back upstream.

I think the evolution of both the delivery side as organizations, both new and old, will continue as they figure out how to reach all these consumers, which haven’t really cared about other than when they’ve been within their four walls for the past decades or actually thousands of years. There is a way that the new technology-based care delivery organizations will make a huge difference. But that’s not for the next few years, and I think any of us who’ve got a few gray hairs know that this isn’t Snapchat. We’re not changing how a bunch of clinical people operate in three years. Your words of wisdom are well-heeded, and people have to knuckle-down – there’s a lot to be done. Anyway, that’s my commentary.  

I’ve been talking to Paul Black. He is the CEO of Allscripts.  He’ll be at Health 2.0 next month on a panel that’s normally called, “What’s Next With Interoperability.”  We’ll be talking about all these kinds of issues. Joining Paul will be Don Rucker from ONC,  Tate Gilchrist from Cerner, Arien Malec from Change Healthcare, Ryan Howells from the CARIN Alliance group and Loni Rae Kurlander from Medal.  We will dive into some of the topics we touched on today and a few more . Paul, thank you very much for your time today.  I’m looking forward to seeing you in a few weeks.

Paul: Thank you very much, Matthew, and I look forward to seeing you and your fine constituents there as well.  

Paul Black is CEO of Allscripts. Matthew Holt is founder/publisher of THCB and the co-founder of Health 2.0.

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