Health 3.0 Vision: Implications for Providers, Government and Startups

Written with Jonathan Bush, CEO, athenahealth

In Part 1, we laid out the failings of Healthcare 1.0 and 2.0 that have primed us for the renaissance that is Health 3.0. While there have been many failings of the 1.0 and 2.0 era, there are also positive and necessary elements that must be brought forward. It’s hard to argue that it’s not an especially challenging time for nearly anyone in healthcare. We have epidemic levels of burnout amongst doctors, only 20 percent of physicians report being engaged, healthcare organizations are struggling to keep up with every-changing reimbursement and quality rules, and government, while well-intentioned continues to inadvertently stall rapid-pace innovation. Without a common vision and framework of what a new health ecosystem (3.0) should look like, we’ll remain where we are, failing to activate the full potential from our collective passion, resources and efforts. Even eight Olympic-caliber rowers can’t make headway without a common goal and view of the course ahead.

In the next generation Health 3.0, the fragmented, uncoordinated healthcare jumble we know today must be replaced with a unified interplay of these four key elements –

1. Health & wellness services
2. The purchasing practice of health & wellness services
3. The technology used across the many workflows and corners of healthcare
4. The role of government

Healthcare is frequently a jumble of uncoordinated silos organized around medical technology, rather than people. This has led to a sub-optimal experience for both patients and clinicians. This is only made worse by by incentives that, too often, run counter to optimizing health outcomes.

As part of the Health 3.0 framework there will be top-level implications for the following audiences

Healthcare provider organizations

There are major trends that make healthcare 3.0 a once-in-a-career opportunity (or threat). Experts expect $1 trillion of annual revenue to shift from one set of healthcare players to another over the next decade. This is a byproduct of the transition to purchasing healthcare with accountability baked in.

• Sell Health Services Conveniently & Be Accountable for The Value You Deliver: Various new primary care models such as onsite/near-site clinics and direct primary care have broadened their scope of services (remote monitoring, health coaching, etc.) well beyond what they’ve offered in the past and the top performers readily put their fees at risk (e.g., Vera Whole Health, Privia, Iora Health, etc.). Medicare Advantage programs are taking off like wildfire with the top performers delivering care in a far different model than volume-driven models. If you’re a healthcare provider, this is the future! We expect Medicare Advantage to continue to grow and Medicaid Advantage to follow closely behind. This can’t be dismissed as fringe when two early adopter organizations (CareMore and HealthCare Partners) were acquired for over $5 billion and there has been over $1.2 billion invested in next generation primary care models in the past couple years. Sadly, we hear of too many organizations focusing their energies on trying to cling to the past fee-for service way of doing things and even enacting anti-competitive practices such as threatening doctors in their communities who don’t refer to them (e.g., blocking data and patient flows). Our message to you, is don’t be scared, be brave. Be the among the early organizations that figure out and master how to thrive in the inevitable future.
• Millennials, They’re a Comin’: If you thought boomers were a big deal, millennials dwarf them and are transforming markets. This has already had a devastating impact on a local oligopolist market (newspapers) that has similarities to healthcare. In another area of health, so-called Big Food and Big Soda have had their worst earnings in decades as a result of millennials purchasing much differently than their parents essentially bypassing entire sections of the grocery store. In light of the fact that healthcare’s legacy design is nearly a perfect polar opposite of what millennials want and value, organizations that thought they were entitled to their patients’ kids are in for a rude awakening. For many provider organizations, private employers are their most lucrative revenue stream. With millennials already the biggest chunk of the workforce and expected to be 75% of the workforce in 10 years, that doesn’t bode well. As millennials wake up to the reality that they will be indentured servants to the healthcare system if the status quo doesn’t change, expect their voices to be heard like never before. Health 3.0 is just what millennials are looking for.
• Destructive Doctor Relationships Will Destroy Hospitals’ Success: By no means is it doctors, alone, that are feeling abused in the “Healthcare 2.0″ system. However, as this article points out, the economic impact of doctors leaving in droves will harm health systems. The ZDoggMD video below highlights the rising revolution of nurses, doctors and clinicians who are saying “enough” and leaving for organizations focused on theQuadruple Aim.

Government officials

With Health 3.0, government will experience implications within the many roles it plays:

• Be a smart buyer: There very well be no government entity, at the local, state or federal level that isn’t struggling with budget challenges – health benefits being their second biggest cost after wages. As one public entity found, the best way to slash healthcare costs was to improve benefits (e.g., greatly improved access to value-based primary care). Innovative new healthcare delivery organizations can serve a broader audience faster if the government is an early adopter of higher-performing health benefits. The employee and government entity can both win when employees get access to superior care models that also happen to result in lower total health spend. Money freed up can contribute to the social determinants of health that governments can impact.
• Don’t rob from Peter to pay Paul: Public health and various social determinants of health are impacted by governments. Sadly, we have seen that out-of-control health benefits steal funds from public health and social determinants. For example, social and economic factors drive 40% of health outcomes whereas clinical care drives approximately 20%. Wise government leaders recognize the opportunity for economic development 2.0 — playing the healthcare card. We’ve intuitively known that healthcare spending comes at the expense of other household spending and that it has created a middle class economic depression, however the latest Brookings study demonstrates that more clearly. .
• Why accept in healthcare, what we’d never accept out of healthcare?: Imagine if the local, state and federal government contracts for road and highway construction did not require them to be built with smooth connections between them. Absurdly, we spend taxpayer dollars to tax-exempt healthcare organizations yet allow them to block easy exchange of vital patient information that puts clinicians in a difficult position of operating with incomplete information. Naturally, impairing our clinical teams harms patients. Collectively, trillions have gone to healthcare organizations lacking modern connectivity. Nowhere in our society are more lives in jeopardy. It would be like military generals unable to see the full battlefield. Worsening that situation is limited ability to have two-way communication to address a crisis situation. We see this in action today with Zika. Modern, clouded-based systems can rapidly identify and respond to public health threats identifying regions and individuals at greatest risk. Outdated systems requiring manual updates imperil babies unnecessarily.
• Get out the way!: Sadly, many well-intentioned government efforts have had damaging unintended consequences. Government officials should adopt a Hippocratic Oath of sorts. Too often, their humility arrives too late and we see mea culpas that illustrates mistakes of past policy initiatives  and we hear confessions from those most closely involved. Government should get out of the business of defining technology innovation and what connectedness looks like and into the business of rewarding it. Stop dictating how technology companies share data and information; demand that the private sector deliver the right outcomes — information flowing from all clinical data sources — and then actually let the private sector complete that work. Read more here on what the next president of the United States can do to unbreak healthcare here.

Technology startups

• Innovate with the Like-Minded – Where’s that Puck Going? Avoid the hazard of selling to large healthcare organizations too early in a company’s development which is often the terrible advice investors give (i.e., land a big account). Innovations take time to incubate in smaller organizations before expanding to larger health systems. Typically, traditional large healthcare organizations aren’t the ones that are ahead of the curve on Health 3.0 (and thus not the type of early customer you want). Further, there are entirely new digital health opportunities that span beyond traditional healthcare systems. In the population health era, a true population health manager who may be a health commissioner of a city, will look beyond simply the sick care system that is only driving 20% of health outcomes. Don’t think where healthcare is, think where health-related services might and should go. That can be more fertile ground for a startup in their early years. A good rule of thumb is don’t pursue a provider that is bigger than your current install base.

In future pieces, we’ll expand on items highlighted in the schematic above. For example, there are several references to transparency. True transparency is far more than simple pricing information. In follow-on pieces we’re working on, we will outline a vision for how local, state and federal governments can enable the highest performing health ecosystem. While federal policies get the most attention, the old adage of all health being local is true in many respects. It’s been said that zip code is a better predictor of health than DNA code. Healthcare 1.0 and 2.0 were all about the less than 1% of one’s life spent inside of a clinic or hospital. Health 3.0 explicitly prioritizes the “other” 99% of one’s life.

Health 3.0 is an exciting world where hospital CEOs aren’t put in the conflicted position of being rewarded as though they were a hotel GM trying to fill beds. Health is in the community and health systems can rejoice that there is finally a set of financial incentives that are aligned with their missions. Unfortunately, perverse incentives have put hospital CEOs in an untenable position where their mission said one thing and the financial incentives directed them to do exactly the opposite.

The great news is that there are many hospital CEOs who are just as excited about Health 3.0 as the hundreds of thousands of clinicians in the “tribe” that convenes on the ZDoggMD Facebook page and in the real world. Naturally, they also need a path forward. To that end, while 3.0 is the vision, Dave and Leonard Kish curated a set of guiding principles for success in the new 3.0 health ecosystem. It pulls together insight from dozens of leading thinkers on the future of healthcare. For example, Jonathan expanded on the guiding principle Monopolies On Medical Knowledge And Information Are Unethical.

Make no mistake, the endeavor to transition to Health 3.0 is the defining struggle of our generation. Healthcare 1.0 and 2.0 have had hugely negative consequences:

• A 20-year long economic depression for the middle class is a direct byproduct of an under-performing healthcare system. This has resulted in the most unique presidential election in our lifetimes;
• The largest generation in history and the largest chunk of the workforce, millennials, are on a path to indentured servitude to the healthcare industry if we don’t change our course.

We have epidemic levels of burnout amongst doctors as a result of the over-correction from Healthcare 1.0 which had its own shortcomings;

Successful struggles in our past such as civil rights were driven by grassroots movements. Whether it was civil rights, climate change, or improved food, media and film played a catalyzing role. It’s not hard to imagine that if MLK was alive today, you’d find him using the tools of the day whether it was YouTube, Facebook livecasts or satirical films. The following are examples of how media and film are being used in the Health 3.0 movement:

• Earlier this year, ZDoggMD, wrote and performed EHR State of Mind (watched over 1 million times on Facebook and YouTube) that was an anthem to let doctors be doctors and move beyond today’s stifling electronic health records that, too often, has turned doctors into glorified billing clerks;
• Recently, ZDoggMD launched an anthem to unbreak healthcare with Lose Yourself (video embedded below). He plays the role of an Attending Physician guiding his interns and residents to not lose themselves in the morass of Healthcare 2.0. Rather, he calls them to be leaders in the movement to Health 3.0;
• Dave is the Executive Producer and Jonathan is a contributor to The Big Heist that will be the Super Size Me/An Inconvenient Truth/The Big Short of healthcare. We have been assembling a world class film-making team behind some of the iconic TV shows and films of our generation to create this satirical, follow-the-money film. We realize the only way to reach the broad general public is to be highly entertaining in a non-partisan manner. We will highlight the collateral damage from Healthcare 1.0 and 2.0 while highlighting the leaders already living the Health 3.0 vision.

We believe this is an opportunity for all of us to be on the right side of history for the biggest challenge of our generation. We realize all of us have contributed, whether we knew it or not, to the wildly under-performing status quo. Now it is time for us to collectively unbreak healthcare.

To that end we’ll share our view of the path forward in future pieces. We invite you to weigh in as it will take all our wisdom and energy to make this happen. Stay tuned for more details to be filled in.

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Dave Chase is the Managing Director of the Quad Aim Fund, Executive Producer of The Big Heist (the first fiercely non-partisan satirical film to address healthcare), co-founder of the Health Rosetta Institute (a LEED-like organization for healthcare) and author of the forthcoming book, “CEO's Guide to Restoring the American Dream - How to deliver world class healthcare to your employees at half the cost.” His recent TED talk was entitled "Healthcare stole the American Dream -- here's how we take it back."

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