While health insurers are somewhat effective in driving value in appropriate pricing and utilization of sickcare, …
… they remain largely inept at using their massive data capabilities to personalize health improvement resources for you and me.
Rapid adoption of virtual (i.e., telehealth) healthcare visits during the pandemic helped offset an even worse crisis, but the vast majority of those encounters relate to reactive sickcare, not pro-active health improvement.
Forbes
Jeffrey H. Margolis
Apr 27, 2022
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Introduction
In my experience, most people tend to idealize the past.
Whether formalized in eulogies, evoked in our personal memories, or put into sentimental songs like “The Way We Were” (which I must admit I still consider one of the most poignant songs ever produced as sung by Barbara Streisand and written by Marvin Hamlisch), most of us tend to emphasize the good things and suppress the pain and conflicts of the past.
The present is quite a different situation, as even people of great equanimity often take for granted those things which are good and direct their energies towards those things which are irritating or bothering them.
When we are hit with unfamiliar shocks like pandemics and wars, we focus on the crisis and further lose track of the overall picture.
In today’s world, social and conventional media kick in to encourage us in finding somebody to blame and the narratives of polarization get amplified and refined based on audience response.
When thinking about the healthcare system in its pre-pandemic state, the way we were is certainly not the way we want be, so let’s not yearn for it or try to recreate it!
Next Chapter: Moving Beyond the Purgatory of COVID-19 Politicization
Regardless of political leanings, it’s quite clear that the embedded culture of sickcare kicked into high gear when COVID-19 came onto the scene.
The government and scientific community came to understand the significant threat of a novel disease; applied biotechnology to analyze and understand the threat; developed anti-viral therapies and vaccines to treat and diminish the impact of the virus; and the U.S. spent big-time to counterattack the disease.
Today, the scientific and medical establishments are hopeful that as the virus mutates (and subsequent strains weaken) we have the technology and tools to play whack-a-mole as we do with influenza strains and have it settle into a perpetual human endemic like the common cold.
Regardless of political leanings, it’s quite clear that the embedded culture of sickcare kicked into high gear when COVID-19 came onto the scene.
I recognize that there is an emotional, polarized argument looking to either praise or blame Democrats, Republicans, government agencies, and even rock stars for the relative effectiveness of policies and efforts.
And I marvel at the spread of misinformation, sound bites and click-bait that keep people arguing-but I am resigned to the reality that this happens across all topics these days.
As a hospital board member watching daily statistics in a major population area, I looked at the math and have little doubt that the development and administration of vaccines and anti-virals is a huge positive in putting out the pandemic fire.
To me, the impressive mobilization of our nation’s sickcare efforts was not a surprise.
That’s what we have historically done exceedingly well-react to an acute illness and treat it.
I’m glad the healthcare establishment is pretty good at treating disease, as I likely would not be alive if it were not so.
But it’s time to move beyond the COVID-19 blame-fest and discuss something upon which nearly everybody agrees: the people with extant health conditions suffered and perished at a much greater rate than those who had better overall health before and during the pandemic!
The fancy name that the industry applies to this phenomenon is called co-morbidity.
In simple terms, co-morbidity simply means that another condition (e.g., obesity) when combined with another condition or illness (e.g., COVID-19) results in usually worse outcomes (e.g., more severe illness or death).
To me, the impressive mobilization of our nation’s sickcare efforts was not a surprise.
The Pre-Pandemic Healthcare System was not OK and it’s not OK to go Back
What do you think has happened during the pandemic regarding addressing overall health status in the United States?
If you guessed that our population’s overall well-being along the dimensions of physical, mental, and social health all declined, then you’ve been paying attention.
To add to the fun, the U.S. is experiencing high consumer inflation, stressing the financial health of many. It’s important to know that physical, mental and social health were all in decline prior to the pandemic.
…the U.S. is experiencing high consumer inflation, stressing the financial health of many. It’s important to know that physical, mental and social health were all in decline prior to the pandemic.
Rapid adoption of virtual (i.e., telehealth) healthcare visits during the pandemic helped offset an even worse crisis, but the vast majority of those encounters relate to reactive sickcare, not pro-active health improvement. Ouch!
Rapid adoption of virtual (i.e., telehealth) healthcare visits during the pandemic helped offset an even worse crisis, but the vast majority of those encounters relate to reactive sickcare, not pro-active health improvement.
You would hope that that almost every influential leader in healthcare today understands the situation.
I have good news on that front, as I am privileged to interact with healthcare executives, policy-makers, and investors on a regular basis.
The good news is that almost all healthcare leaders understand what’s going on. The bad news is that almost none of them are in a position to do what they know is right. Let me explain.
The good news is that almost all healthcare leaders understand what’s going on. The bad news is that almost none of them are in a position to do what they know is right.
Health system executives are compelled to provide healthcare services to bring people through the doors of emergency rooms, urgent care centers, and hospitals, not to keep them out.
Physicians go to medical school to practice cognitive medicine and perform increasingly specialized diagnostics and procedures to diagnose and treat illness and disease.
The more specialized you are, the more you get paid. Yet mental health practitioners are still fighting for reasonable compensation (i.e., reimbursement) for patient interactions.
Pharma and biotech executives need to research, develop, and sell new therapeutics that produce big revenue and sustainable margins and must pay for the cost of the many failed R&D attempts to produce viable therapies.
Health system executives are compelled to provide healthcare services to bring people through the doors of emergency rooms, urgent care centers, and hospitals, not to keep them out
The U.S. government first focuses on ensuring access to all of these sickcare capabilities for low-income and elderly individuals as does the military and many labor unions.
As I mentioned in a prior article, there is bi-partisan support for managed care principles.
The U.S. government first focuses on ensuring access to all of these sickcare capabilities for low-income and elderly individuals as does the military and many labor unions.
… there is bi-partisan support for managed care principles.
Systematically, it is health insurers (i.e., managed care organizations) and self-funded employers that have an economic stake in the concept of “an ounce of prevention is worth a pound of cure.”
And while health insurers are somewhat effective in driving value in appropriate pricing and utilization of sickcare, they remain largely inept at using their massive data capabilities to personalize health improvement resources for you and me.
…while health insurers are somewhat effective in driving value in appropriate pricing and utilization of sickcare,
they remain largely inept at using their massive data capabilities to personalize health improvement resources for you and me.
Why bother to perfect personalized benefits that optimize health if the employers and government are going to pay the sickcare costs anyhow?
Just manage the super-sick people (i.e., those with many co-morbidities) and you’ll make a profit.
Why bother to perfect personalized benefits that optimize health if the employers and government are going to pay the sickcare costs anyhow?
Just manage the super-sick people (i.e., those with many co-morbidities) and you’ll make a profit.
It’s a nearly perfected Catch-22 as all the executives run around conferences saying the right things, and genuinely believing it, as they continue to do what they do.
And just to be clear, it is not capitalism or profit motive that creates the problem here-as every person and entity has a need to get paid-it’s bad systems design.
And just to be clear, it is not capitalism or profit motive that creates the problem here-as every person and entity has a need to get paid-it’s bad systems design.
A Practical Solution to Do the Right Thing — Health Optimization through Two-Axis Personalization
All of the current incumbent players, and many of the high-growth early stage companies and so-called “unicorns”, that purport to be disruptive, need to make their way from reactive sickcare to proactive health optimization.
To do so requires a mash-up of:
- “Don’t throw the baby out with the bathwater.”
- Conquering the Innovators Dilemma, described by Clay Christiansen, where incumbents must embrace discomfort and probable pain to remain relevant.
- Crossing the Chasm, as put forth by Geoffrey Moore, where the ideas that can move us forward need to move from embryonic to material scale (no small feat in a $4B industry) in a reasonable amount of time.
All of the current incumbent players, and many of the high-growth early stage companies and so-called “unicorns”, that purport to be disruptive, need to make their way from reactive sickcare to proactive health optimization.
Healthcare is too big and vital of an industry segment with too much embedded incumbent momentum to turn even 45 degrees, much less change direction.
However, I believe existing industry leaders, innovative capital players and newer entrants, and even bi-partisan government efforts can achieve what I refer to a two-axis personalization to support both clinical care and daily living.
To accomplish this:
1.Accelerate personalized clinical care and precision medicine.
Keep investing in sickcare, but more rapidly move from diagnosis and treatments based only upon traditional bio-metrics to applying multi-omics technology (e.g., genomics, metabolomics, proteomics, micro-biomics, glucomics, etc.) in the daily clinical practice.
2.Ensure that benefit plans include personalized resources to support daily living.
Include non-traditional physical health resources (e.g., fitness, nutrition and sleep, etc.), as well as those that support mental health, social health, financial health, and purpose in a new definition of comprehensive benefit plans.
Ensure that such benefits can be included in the definition of member-benefits-ratio (also called medical-loss-ratio or medical-cost-ratio) so that employers and insurers are not penalized in administrative costs for doing the right thing.
Healthcare is too big and vital of an industry segment with too much embedded incumbent momentum to turn even 45 degrees, much less change direction.
If we fail to do these things, we will go back to the way we were. And in that world, we spend too much and too little value out of the healthcare industry.
About the author
Jeff Margolis is widely recognized as a healthcare IT and strategy entrepreneur and systems design innovator. He is a Senior Advisor for Blackstone and the former Chairman and CEO of Welltok and TriZetto.
Originally published at https://www.forbes.com.
