Consumerism: Patients Need Partners

Recent reports have been gloomy on the consumerist movement in health care.

The Center for Studying Health System Change released a report recently that indicated today’s patients still find physicians how they used to: through word of mouth and referrals from other physicians.  Patients have also used quality and price information sparingly to aid in health care decision making.

The WSJ Health Blog highlighted (another CSHSC) report that concluded the number of patients who have utilized retail clinics “turns out to be modest.”

What’s going on?  Three possibilities:

  1. Patients are still spending someone else’s money (all health care dollars flow from households, but patients never actually touch it and don’t have the ability to use the cash in another fashion, as they say: perception is reality).
  2. Resources to compare quality and price information are slim (but growing).  We don’t agree on what constitutes quality (metrics or outcomes or patient experience) or how to report price (charge or cost, discounted or not?).
  3. Trust is still a factor.  This interweb thing is still relatively new…especially to health care.  Could it be that patients still trust their personal (mostly offline) networks more than an online network (which, by the way, seems the way people will find physicians: through online networks (word of mouth) accompanied by data)?  It should also be noted that the majority of patients utilizing health care services today are older and thus, much less likely to be comfortable with depending upon online resources for decision making.

A BusinessWeek article highlights consumerist proponent Regina Herzlinger and her approach to health care reform.  The article states that Herzlinger’s ideal world would contain:

  • Consumers tailor their own health-care coverage, navigating in a national insurance market.
  • Everyone must buy insurance, and the federal government maintains strict oversight to ensure price and coverage fairness.
  • Small, disease-specific hospitals care for patients who don’t need all the services offered by medical centers.
  • A national database contains the prices and outcomes for procedures at every hospital and clinic, so consumers can make informed choices.
  • Individuals get generous tax breaks to buy their own insurance, with subsidies for those with low incomes.

Here’s the important part:

Herzlinger doesn’t want anyone but consumers managing. Only then, she says, will innovations be unleashed that improve quality. “People can choose from 240 models and makes of cars pretty intelligently,” she says. “Why do we assume they can’t do the same when it comes to their health?” She notes that her suggestions are “relatively low-cost,” which makes them even more attractive given the financial crisis.

The idea sounds good in theory (and it may prove to be the solution in action).  But, as of right now, this young movement has failed to truly take hold (young is the operant word, here).  There are likely multiple causes, but the most significant is this: health care is complicated.  That has not, and will not, change overnight.  We have normative behaviors that have been ingrained since the beginning of modern medicine and that, very basically, takes time to change.

Although somewhat controversial, programs being offered by companies like OptumHealth (a subsidiary of UnitedHealth) can act as the perfect bridge into consumer-driven health care in situations that allow for analysis and discussion.  These companies provide free assistance to patients and families when they seek treatment by helping them assess quality (there are some concerns, rightly so, that an insurance company particpating in such decision-making may have a conflict of interest).

From the Minneapolis Star Tribune:

… OptumHealth and a variety of competitors are compiling sophisticated report cards that rate hospitals and medical centers by critical measures such as staff expertise, patient mortality, outcomes and cost.

Their reach is huge and growing. OptumHealth alone serves some 40 million health plan members and managed 5,000 transplants last year. The national Blue Cross and Blue Shield Association, with a similar strategy, covers 100 million people.

Their conclusion so far: Given a choice and guided by an expert like Imig, patients generally will head for the highest-quality center, even if it turns out to be far from home, friends and family.

Talk to any physician; no one expects or wants individuals to be self-diagnosing even though information is available on every disease and treatment options.  The same goes, at least for now, for quality and cost data: patients need partners.

The Opportunity of the Challenge

Challenging times hold great opportunity.

The Health Care Blog has Amanda Goltz’s review of last week’s Institute for Healthcare Improvement‘s National Forum on Quality Improvement in Health Care.  Among her criticisms is a lack of provider participation in Health 2.0:

The fact that the session billed “Geeky Trends for Experts” is just a basic overview of tools that other industries have been using for a decade tells us something about health care. Patients are the exception here, as they are well-organized on the Web and growing, but as long as hospitals, physician groups, insurers, quality officers and safety improvement organizations remain so behind the curve, patients’ ability to leverage the Internet to manage their health will be limited.

It’s great that one patient with COPD can talk to another about her shared condition, but what about asymmetrical and timely communication with her doctor about a new medication? Or what about instantaneous notification to her case manager’s PDA if she is away from home and goes to the ED? Integration of values collected through her home health monitoring system into her EMR? Daily podcasts on managing fluids?  A “dealing with your HMO” wiki?

I know all of this is in the works, but we need to do more to create physician and hospital leadership in this area (italics mine). “Build it and they will come” will work with patients seeking advice or shared experiences; it won’t work with overworked, overwhelmed physicians or hospital administrators just trying to keep the hospital financially sound, clean, safe, and in line with mandates to report thousands of metrics to CMS, TJC, Leapfrog, etc.

Very. Well. Put.

Carol shifts strategy

You may recall a Minnesota company that debuted an online marketplace for health care services a few months back.

Well, it’s not working out.  Carol has announced a shift in strategy.  From the Minneapolis Star Tribune:, a Twin Cities start-up that drew national attention for its efforts to create an online medical marketplace, has cut 25 jobs, or a quarter of its workforce, a sign that consumers may not be ready for the trend known as consumer-driven health care.

Bloomington-based Carol has struggled to attract users to its year-old website, which it bills as a Travelocity for health care.

Medical providers never got comfortable with the idea of posting their services online for comparison shopping and consumers “didn’t know what to do with us,” said Carol’s chief marketing officer, Marcia Miller. The economic downturn and the pressure to produce results finally forced a shift in direction.

What are they going to do now?  Focus on providers.  Again, from the Star Tribune:

Carol’s two consumer websites — in the Twin Cities and Seattle — will remain up. But the company will now focus on consulting and software services aimed at hospitals, clinics and physicians.

It will help providers repackage services in ways patients can understand, rather than in the current system organized around insurance payments. It may also rent the Carol software platform for hospital and clinic groups to include on their own websites — backing off from the original goal of allowing users to compare directly among providers.

Interesting.  Wonder if they always had a back-up plan?

The Potential of Health 2.0

Carol Diamond and Clay Shirky from Health Information Technology: A Few Years Of Magical Thinking? (via ReadWriteWeb):

The challenge of thinking of IT as a tool to improve quality requires serious attention to transforming the U.S. health care system as a whole, rather than simply computerizing the current setup. Proponents of health IT must resist “magical thinking,” such as the notion that technology will transform our broken system, absent integrated work on policy or incentives.

Optimism abounded throughout the two days in San Francisco—as well it should when a group of pioneers embarks upon new territory.  But whispers of what it could be–bubbly–were heard throughout.  My feeling on what will prevent a bubble pop is the inherent potential in Health 2.0: helping patients muddle through health care and managing their wellness.

There were very cool technologies on display—some completely new, others focused on helping health care catch up to the rest of the internet-dependent world.  There are a few success stories.  Some companies are on the brink of success.  But it’s quite practical to think that there will be some failure, probably even a lot.  That’s the nature of new.

A way to reduce that chance of failure?  Focus on h-e-a-l-t-h (the broad definition).  But the focus of Health 2.0 is health, you may be saying, it’s right there in the title.  Yes, it is/was for many of the companies touting their utilities.  But for a few (maybe more) their focus on profit was completely transparent.  I don’t think that model will work.

So in my (no skin in the game) humble opinion, here are two areas where the people of Health 2.0 need to focus in the coming months:

Integration – I like Scott Shreeve’s definition best: “New concept of health care wherein all the constituents (patients, physicians, providers, and payers) focus on health care value (outcomes/price) and use competition at the medical condition level over the full cycle of care as the catalyst for improving the safety, efficiency, and quality of health care.”

Most Health 2.0 companies are working with patients (obviously), physicians (obviously), and a few with payers (by the way, they have the cash, so unless your plan is game changing, it would be best to include them).  But throughout my two days at Health 2.0, I was disappointed to see an almost blatant neglect of working with providers (who I’m going to call hospitals/clinics/points of health care delivery).  The providers have the data (tons of it).  They are the facilities where an astounding amount of care is delivered (even a Hello Health patient may need to visit a hospital).  If Health 2.0 is to realize its true potential, hospitals etc. must be included in the game (Google Health and Microsoft Health Vault have began a few partnerships, but this area remains flush with opportunity).  Which leads to the next point…

Collaboration – The tools available today are astounding.  A patient (sorry, I’m old school on calling health care users patients, the term consumer connotes dirty images in my mind) can price compare services.  A patient can enter labs data into a PHR.  A patient can price shop for insurance coverage.  A patient can participate in communities.  A patient can manage their health care expenses simply.  A patient can find information on physicians.  A patient can compare quality (it’s getting better).  And this is all precisely the problem.  As a patient myself, I have no desire to visit eight different websites to manage my health.  I have trouble enough managing my money with five different institutions.  I want to visit one place.  One site where I can do it all.  The company that is able to bring together the tools that have been created to a single location where patients can easily use/share/create health information will lead the Health 2.0 transformation of health care.

That’s why Health Vault and Keas excite me the most.  Keas has been quiet (understatement) on what they are trying to do.  But their “sneek preview” at Health 2.0 gave me the inkling that they may be creating a platform that brings together a cadre of services in one location.  We wait to find out.  Health Vault could be the killer app in this equation (that’s what we’re all waiting for, isn’t it?).  A talk that took place after Health 2.0 actually provided more insight.  Health Vault is building a platform on which others can build applications to help patients manage their health (think iPhone App Store).  Acquisitions need not happen to make this work, the tools just need to work together.  For this reason, I think acquisitions will be fewer than what has occured in the Web 2.0 world.

Anyway, these are the opinions of a humble observer.  There is reason to be optimistic for what Health 2.0 will do for patients, but first it must become much easier for patients to utilize multiple tools (and include the providers!).

I think the sign of true success for Health 2.0 will be this: when we drop the 2.0 and simply use these tools to manage our Health.

Health 2.0 Thoughts: Clay Shirky

It’s Wednesday, a whole week removed from the opening of Health 2.0.  The bad thing about posting a week later: everything has probably already changed.  And so, still relevant or not, this begins a yet-to-be-decided part series on thoughts from Health 2.0.

Clay Shirky had a great keynote.  Here are some selected comments (most likely a mix of my own words and his, with my comments in the parentheses):

  • Most valuable thing connected to the internet: people
  • Patient-Centric Medicine: internet is implementation layer
  • TRUST is the key (recurring theme throughout the conference) for information to flow
  • The changes made to the Catholic Church by the Second Vatican Council can be used as a metaphor for the changes going on in health care (very impressive metaphor, IMO); Vatican II shifted the focus of the church from the leaders to the parishioners, Health 2.0 is shifting focus of health care from health care deliverers to patients (I’d even argue it is shifting us from health care to health)
  • We’ve always had informal health care conversations, you just couldn’t see them before (innocent conversations around the table…)
  • When you give new people access to information things are are going to get weird, and they are

New tools to find medical information

MedPedia, a wiki for everything (read: e-v-e-r-y-t-h-i-n-g) medical, launched last week.  From MedGadget:

A group of American medical schools is working on a project to essentially collect and organize all medical knowledge in a Wikipedia-like form. Access to MedPedia will be available to all, but editing rights will be limited to M.D.’s and Ph.D.’s in relevant fields of research. Harvard, Stanford, the University of Michigan, and Berkeley will kick off the site with initial content and work with the rest of the medical community to make it comprehensive. With that in mind, the project organizers are calling on all M.D’s and Ph.D’s to register to become editors of what they believe will be the largest and most complete encyclopedia of medicine in history.

Google Knol, a tool similar to Wikipedia + Squidoo, launched last week, too.  From Knol:

The Knol project is a site that hosts many knols — units of knowledge — written about various subjects. The authors of the knols can take credit for their writing, provide credentials, and elicit peer reviews and comments. Users can provide feedback, comments, and related information. So the Knol project is a platform for sharing information, with multiple cues that help you evaluate the quality and veracity of information.

Common theme: content created, edited, and distributed by experts for the reading pleasure of all.

It seems everything old is new again.

I am a fan of MedPedia.  For physicians, being able to easily search and access information that has long been stored in medical journals is a definite improvement. I’ve witnessed physicians using Wikipedia for a quick once over of a not-often-discussed topic.  Now, not only can they do a quick refresher with MedPedia,  but they are able to make confident clinical decisions based upon the content.

I’m skeptical of Knol, but warming.  It may have its place in medical search as well.  Bob Wachter, a partner in the creation of Knol, explains its usefulness:

So if you search Google for your favorite health care topic (migraine, or MI, or leukemia, for example), you’re likely to see a Knol – at this point, undoubtedly one that I commissioned – in the search results. The Knols are layperson oriented: I asked authors to write the Knol that they’d want their mother or best friend to read if they had just been diagnosed with the illness. There are also a few Knols on broader medical issues; for example, I wrote Knols on patient safety, quality of care, and hospitalists.

Bertalan Meskó raises this contention:

So I will have to find out which Knol is better. In Wikipedia, we merge different “Knols” into one article. So the readers can only see the best version. Doesn’t it sound better?

I believe in the wisdom of crowds (maybe because I’ve been a Wikipedia administrator for years now). You can pay people to create you a database of information; you can let people fight who can come up with the better article. But it can never be as accurate as Wikipedia is.

Don’t we have enough information?  More is always better—as long as the organization of the information is functional.  Finding it, understanding it, and trusting it is what MedPedia and Knol are trying to improve.

On a related note, I’d be willing to offer that many medical information searches start with Google.  Well, a new search engine, Cuil, launched on Sunday specfically taking aim at the search giant.

The launch was laughable.

Seth Godin’s post sums up what many are thinking on Cuil vs. Google:

Once there’s an icon in place, it’s there because it’s working. It serves a purpose, it carries useful information and performs a valuable function.


Google, of course, is the Marilyn Monroe of search. I have no doubt that someone will develop a useful tool one day that takes time and attention away from Google, but it won’t be a search engine. Google, after all, isn’t broken, not in terms of solving the iconic “how do I find something online using my web browser” question.

Bringing it all together, Seth provides advice:

The challenge for organizations is this: the easiest projects to start and fund are those that go after existing icons. The search for the “next” is easy to explain and exciting to join because we can visualize the benefits. But success keeps going to people who build new icons, not to those that seek to replace the most successful existing ones.

Are these tools differentiated enough to replace Wikipedia, Squidoo, and Google?  Will they exist in a crowded competitive environment?  Or will they languish in mediocrity?

Collectively, we watch and–maybe–participate.

Health Advisory

We seek tax advice from accountants. We seek financial advice from financial planners. We seek health care advice from…well, doctors.

At least that’s the way it should be. But an overburdened system with underfunding in important high-advice areas like primary care, combined with misplaced financial incentives, make a physician’s time an especially scarce resource.

This usually means short visits with a provider for patients who are passive during appointments.

The internet, of course, is changing all of this through the emergence of Health 2.0.

We now can complete our tax returns online. We can invest using online services. Health care, however, has been slower to adapt. It still lacks the “killer-app” to make the internet truly industry altering.

The complexities of health care delivery are the reason for this slow adaptation—which is good. It allows for the opportunity to do it right, something especially important in this industry.

There are vasts amounts of information available on everything medicine. But it can be daunting for a patient not familiar with the intricacies of the industry. That should be okay, because a patient can search for information, collect and gather, and show up to an appointment armed with questions for a physician.

The breakdown in this Xanadu comes at the appointment. Physicians just don’t have the time to spend 30+ minutes with each patient. Fifteen minutes is pushing it.

But patients want to be informed. Read this post at Health Management Rx for an enlightening example.  Jen has written about the “middle eighty,” the constituency of patients in the middle.  The theory, adapted from sales, goes something like this: ten percent of patients are super-involved in their health care, ten percent of patients are completely passive, and the middle eighty percent is awaiting online tools to help them become more involved, but only after those tools have proved their value.

Targeting the “middle eighty” is where health care online will transform the industry.

The Associated Press wrote last week about a new service cropping up in health care to serve the “middle eighty,” albeit primarily offline.

In the vein of tax and financial advisory, health care advisers are beginning to solve patients’ health care headaches like finding a doctor and negotiating payment.  Organizations have been the primary purchasers of services thus far, mostly in an attempt to lower their health care coverage burden.

The recent trends in health care, including reduced employer support of health insurance and Medicare complexities, have forced the burden of managing health upon the “middle eighty.”  They’re being forced to become proactive in their health decisions.  And they’re looking for help.

The current service offering by these health care advisers is just a start. Once this industry moves to the online world with all that it has to offer–content, community, commerce and advisory to help a patient make sense of it all (coherence)–will it truly be industry altering.  Jen et al. call it Health 4.0. I call it health care transformed.

Innovation: new websites aim to cut costs

Came across a couple of innovative health care websites (read Health 2.0) in the last couple of days.

The first is SharedFunding, an employer focused company that manages high deductible health plans for companies. The website says:

Through our research we determined that when an employer purchases a high deductible health plan, and provides a benefit for the employee “below” that deductible, the employer appreciates significant savings.

SharedFunding has already saved employers a phenomenal amount of money by allowing them to appreciate strong benefits at lower costs. And, our technology and service liberates you and your employees from the complex web of healthcare claims processing.

The second is a startup from Minnesota called Carol. The Star Tribune has an article about the new company. The Health Care Blog has an interview with CEO. The company provides a marketplace where consumers can quickly self-diagnose and then select a provider that will provide treatment. From the Star Tribune:

Ankle pain? Click on the matching body part and two options pop up. For $199, doctors at Sports and Orthopaedic Specialists will check out your ankle, review your medical history and recommend treatment. TRIA Orthopaedic Center lists a similar package for $213 — and a reminder that they are the team doctors for the Vikings and Timberwolves. What did patients think? Read user reviews. Will your health plan pay? Tap in your details and find out.

The website is easy to navigate. It’s a great idea. I think the best part is that it allows consumers to make a health care choice based upon price.  OK, something I like even better is this notion of bundled services.  Providers who use Carol list their services in one nicely-priced package.

The website allows consumers to compare services by different providers and lists exactly what the price covers. They do have a section that contains a quality statement by each provider–this could be improved. So far, not too many providers have signed up, but I think it is only a matter of time for providers to take action as more consumers start using the service.

What is adenoma? Give me a second…

Whether it is a function of less access to primary care physicians or the importance of the always-burgeoning internet…Web 2.0 has hit health care. Actually, this post is pretty late to the party…

What is Health 2.0? Go here. Some examples: iMedix, RevoultionHealth, Medstory, Healia, Xoova, Organized Wisdom, and (less 2.0 than the others) the industry’s gray lady: WebMD.

Its impact, I feel, to this point has been muted. But its time is coming. What will be the impact of Health 2.0 on health systems?

Hospitals will have to take into account the impact of these websites on the delivery of care. It is this notion of the
patient as a partner in the deliverance of care. Obviously it is the way it should be–patients participating in tandem with their providers.

But there are some consequences. With added knowledgeable in tow, more questions will be asked as patients feel better informed, which will increase the likelihood of lengthier conversations with providers. All good. But providers will need to spend more time with patients (like more than five minutes) and that means patient throughput will decrease. Given the current state of reimbursement in this country where we reward for more care, not better care, providers may not be able to see as many patients in the same amount of time.

Health 2.0 means changes for hospitals and providers, can we explore what some of them are?

BTW: adenoma.