A Marketplace for Health Care

"Consumption is the sole end and purpose of all production; and the interest of the producer ought to be attended to, only so far as it may be necessary for promoting that of the consumer."
--Adam Smith

Carol is a health care marketplace that basically allows you to purchase care packages for what you need. Say you have a sore throat and you're worried it might be something worse. Using Carol's body chart, you click on the throat region, scroll down to sore throat and click on the test, treatment or procedure that most suits your condition. In this case, the options are mononucleosis (mono) symptoms: evaluation & treatment and sore throat: evaluation & management. Clicking on the latter leads to a "compare care packages" page where you can select a vendor based on price and facility.

This is a really innovative way of shopping for health care services. With a "shopping bag" as the checkout cart, bright colors and stylistic fonts, it feels more like you're shopping for clothes on Macy's site than buying an MRI for your knee. The prices are within reason but for now I only see people using this as supplemental insurance (especially for dental care) or if they're lacking insurance for some time. If I were old or poor though, several things would prohibit me from taking advantage of this service; (1) ready access to the internet, (2) tech-savvyness (3) scope of care...oh and the fact that Medicare and Medicaid exist.

What's hard for everyone is terminology. I had no idea what blepharoplasty was until I clicked on it (its eyelid surgery). On the other end of the coin, now I know exactly what it is! Its a great way to learn about health care; the real costs, different insurance models, and how it can be delivered.

Right now we have very little choice. Not anything that's affordable for sure. Carol, while a work in progress, is making headway in providing consumers options to choose from. Making health care more transparent is business everyone benefits from.

EDIT: For a lot more on Carol, check out Scott Shreeve's insightful & detailed commentary here.

Use-Now-Adapt-Later

"I hear and I forget. I see and I believe.
I do and I understand."
-- Confucius

On my hunt for decent (and free) project management software, I discovered the "Use-Now-Adapt-Later" principle. Google promotes this approach through its retrospectiva, a web-based software project management tool it offers as a free d'load. In the end, I went with Access 2007.

But I just the found the principle so intuitive and simple. I mean its nothing more than learning by trial-and-error. You buy a new tv or a computer, what's the first thing you do? Turn it on and start using it! Who really reads the instruction manual right away? I learned most of Excel, Access and even building a blog this way.

You always need the by-the-book folks (they're the ones who write the instruction manuals!), but to really learn and retain something, it has to be contextualized. Yet rarely do we go on an excursion or start a project without a plan. "Think before you act" is overdone. We think too much! Sometimes you just have to jump in and feel it out.

The Doctor-Patient R'ship

How hard is it to find a physician in a new city!? Even if you have access to your insurer's tome (or maybe a small pamphlet) of participating physicians, its tough to know who to pick when you don't have a point of comparison. Even if you ask a neighbor or friend, word-of-mouth is unreliable because there are just too many factors that can make a visit go from great to terrible. Not considering that every patient is literally unique, from genetics to demographics to presenting symptoms. A fact of medicine that's too often overlooked.

Comparing physicians on efficiency though is hard. Dr. Thomas Lee's put together a quick FAQ to explain why. Click below for a better view.

Basically what patients want physicians just aren't ready to give, and for good reason. "Assymetry of information" gets thrown around a lot and its true. The knowledge gap between physicians and patients is enormous, and middleman websites can't make up for 10 years worth of education. Zagat wants to rate physicians on trust, communication, environment and availability. I'm not sure if our loved ones would pass that test. The bridge has to be built on effective communication, where the definition of "effective" is agreed on by both parties. Not third party payers, vendors, clearinghouses, or websites. Its not a round table discussion; its a one-on-one meeting.

Quick! Fill in the blank!

Get rich ____, grab a ____ bite, get in a ____ workout. Everyone's in a rush! All the Zen, the yoga, the meditation fly out the window when there's a deadline to meet, dinner to cook, and people to meet. Like taking prescription pills, we do "healthy" things as necessary, to counteract all the un-healthy things that make up our daily lives. Unfortunately one thing doesn't completely offset the other.

Breathing isn't something that needs to be jotted down in our day planners (remember those!?), whoops, blackberries. As we are forced to focus on the opportunity cost of time more and more regularly, setting priorities make us better decision-makers in every arena, whether it be work, home, or the grocery store.

This great post by Jane Sarasohn-Kahn on slow food and overall slower living kindled the idea for this post. She ends with suggesting a "slow health" movement:

There are certain aspects of modern life that require more than a minute or two of our time. Health is one. Perhaps we should start a Slow Health movement? One contributor to a Slow Health movement would be to pay primary care clinicians to spend more time with patients to listen and to advise. For now, though, let's at least work on ourselves and with those whose lives we touch (who may be consumers or other health stakeholders) to slow down when it comes to analyzing and consulting with health information. Oh, and while I'm thinking about it, cooking and eating as well....

"Code Blue" stat!

Hospital red tape makes casinos and airports better places to have a heart attack and survive! All due to a delay in providing an electic shock with a defribillator. The NYTimes article comments:

In the real world, doctors and nurses do not always run fast enough. Expert guidelines say the shock should be given within two minutes after the heart stops, but the study found that it took longer in 30 percent of the cases.

Certainly disappointing, but hospital guidelines that require a physician's presence at the time of defibrillation are not necessarily to blame. There's a purposeful hierarchy in hospitals that helps faculty and staff work together to make life and death decisions more effectively on the fly. But there's no question that staff can receive better training that can then help them distinguish when a physician's presence is absolutely required.

The article makes a great case for basic defribillator training that could prove true for many other technical functions performed in hospitals.

Dr. Saxon said the automatic defibrillators should be used more, along with the type of heart monitoring now given mostly to cardiac patients. Not everyone needs such monitoring, she said, but it may be in order for those who are very ill with kidney problems, diabetes or pneumonia, even if they have no history of heart problems. Their information would be transmitted to a computer network that would send out an alert if needed. In addition, she said, automatic defibrillators could be installed in every hospital room.

“You can get them for $500 on eBay,” she said. “It wouldn’t even take a nurse. You could train the cafeteria workers if you wanted to.”

So maybe, as in most strict bureacratic organizations, the hierarchy could benefit from being a little more flexible...

Rethinking the school Lunch

I've been thinking about how horrible food is in school cafeterias since I was in middle school. I'd bring food from home and still be tempted to grab a tray full of chicken nuggets, french fries, one of those tiny cups of ice cream and maybe even a discounted soda all for less than $5. I used to wonder why instead of fries and a soda, fresh fruit and milk weren't a viable option. I would later learn that it's simply a cost issue; fruits and veggies are just more expensive than canned or commodity produce subsidized heavily by the gov't. But change is on the horizon.

• Here's what a chef from Berkeley is doing to help.

• Mayor Bloomberg's on a crusade to get whole milk out of New York schools.

• Brian Klepper is promoting doctors to lead the charge on this issue before it gets out of hand.

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Ask Better questions, get more Involved!

Online social networks like Friendster, MySpace and the more recent Facebook have been around for a while now, just about 5 or 6 years. In internet years, that's ancient history! One of the greatest positive externalities to emerge though has been online patient forums like PatientsLikeMe, where people with various diseases have found others to share stories with and talk in general about their personal experiences.

With health care now a 2 trillion dollar industry, everyone wants a piece of the pie. Patients are slowly realizing that they are the centerpiece of the equation and networking sites, medical specialty resources, patient advocacy programs, you name it are all helping them get a stronger foothold by asking the right questions.

Doctors are essential in tearing down the paternalistic structure and increasing the value of patient-physician interactions. With so little time spent with a patient in an exam room, a physician must ask extremely pertinent questions hopefully with foreknowledge of the patient's concerns. Technology is key here; fax, email, best case a web portal to communicate to the doctor the reason for the visit prepares both patient and physician to get past the "sooo, what brings you in today?" phase. Having a mental framework in place allows for treatment options, medication compliance and follow-up to be that much more on target.

There are a lot of people campaigning for this kind of change. NYTimes has a wonderful piece that fleshes out the responsibilities of both patient and doctor even before they meet called "On the Same Wavelength With the Doctor". This is the perspective we need to shake up how things have always been done.

Debating Recession, Building Snakes

Merrill Lynch (but not other banks) think we're already in a recession. They sardonically refute the other banks with,

"To say that the backdrop is 'recession like' is akin to an obstetrician telling a woman that she is 'sort of pregnant'," the report said.

Got it. Most people do think we're headed towards some sort of downturn though. A definition is appropriate here :

The NBER defines a recession as "a significant decline in economic activity spread across the economy, lasting more than a few months".

It bases its assessment on final figures on employment, personal income, industrial production and sales activity in the manufacturing and retail sectors.

On the health care end, we're figuring out ways to avoid using the knife altogether. The i-Snake is a new tool being developed for minimally-invasive heart bypass surgery. I've seen the scars resulting from the old way of doing CABGs, and what they're trying to do here is have "smaller scars, reduced hospital stays and shorter recovery times." Pretty amazing...

Also, if you're having trouble waking up, maybe the SnūzNLūz alarm clock might help. For every push of the snooze button, it sends an amount of money you preset to your most hated charity. Love the common usage suggestions at the bottom of the article,

Are you a butcher? Set your SnūzNLūz to donate to PETA
Are you a republican? Set your SnūzNLūz to donate to the ACLU!

The evolution of a Process

Interface -> Interoperate -> Flow. That's the gist of what makes a system go from local to global. You have to speak the same language - interface - before you can work together as a culture - interoperate - and have a smooth, efficient, cross-functional machine - flow. Each of these terms encompasses hundreds of thousands of people doing different jobs to make it all work in sync.

The financial sector is a step ahead of the rest. Financial Times says a model for direct trading across global borders is projected towards the end of the year, mainly because the interfacing component is coming together quickly:

"SEC staff have been working on a proposal for “mutual recognition” between the SEC and other regulators that would allow the US watchdog to rely on foreign regulators’ standards as US investors trade abroad...

...As part of the new SEC approach, a foreign exchange would be allowed to install a trading facility on the desk of a US broker, provided that the exchages’ home-country regulators’ rules were deemed “comparable” to the SEC’s."

There is a huge demand for this type of service:

"The policy shift, backed by SEC chairman Christopher Cox, has been prompted by the increasing appetite of US investors for foreign securities.

Nearly two-thirds of American investors have holdings in non-US companies, a 30 per cent increase from five years ago."

The odd thing to note here is that while you must interface first before you can interoperate, the demand for interoperability - the desire for culture change - is what leads to interfacing - the desire to speak the same language.

It's what the education and health sectors are lacking. Parents have to want to have the same standards across all public schools, patients have to want to have their records be available everywhere. This isn't as personally sensitive as money, so either we don't care or we're not being informed about the potential of possibility.

At least someone's trying to bridge the GAAP.

Why health care is a Different animal

What an amazing post by Bob Wachter on The Health Care Blog!! It talks about why, compared to other industries, health care is a different animal...with a few similarities of course. Aviation and finance are commonly (and too casually) presumed analogous to health care. Bob really breaks down the thought process of why this isn't the case most of the time but also why this may be a fair analogy some of the time. You need at least a little perspective to work from. Excerpt below.

I continue to find analogies from other industries useful, but we must recognize their limitations. Simple solutions that worked so well in the [fill in the blank] industry often fail in healthcare because our workplace is like a dozen industries rolled into one. For example, a busy hospital and its workers may face these challenges:

• How to move a part (like a pathology specimen) seamlessly down an assembly line, just like Toyota does.
• How to get an important piece of data (like a discharge summary) from place to place, just like FedEx does.
• How to make difficult, weighty decisions (like whether to do open up an abdomen) under conditions of overwhelming uncertainty, just like a field general or a business CEO does.
• How to deal with major and only partly predictable changes in capacity needs (like when the “bus shows up” at 7 pm in the Emergency Department), like McDonalds does at lunchtime.
• How to providing “expectation-surpassing” customer service (so that we ace our Press-Ganey survey), just like the Ritz Carlton or Nordstrom does.
• How to innovate, both with processes and technologies (a consuming interest in an academic medical center like mine), just like Apple does.
• How to teach wildly disparate learners (like the ones on my team when I’m ward attending), just like a high school teacher does (or would do, if her class included freshman, sophomores, juniors and seniors).

Think about it for a second. Can you conjure up another industry that confronts more than two or three of these challenges? I can’t. And not only are all these conditions present simultaneously in most healthcare organizations, there are times when a single doctor or nurse confronts all of them!