charges, costs and reimbursement – a difference WITH distinction

 

We need to stop confusing charges with costs. If we want to affect what we pay for healthcare, relative to value, we need to talk about costs.  If we are talking about consumers’ ability to price compare, average reimbursement is more relevant. Charges are made up numbers.

 

CMS is touting this:

 

But are charges the right thing to focus on?

What each provider gets paid, their reimbursement, may be more relevant to most healthcare consumers. As a country, concerned about healthcare’s rising costs and its total percent of GDP, perhaps we should be asking providers to get clear and open about true costs.

paris marathon: a musical in three parts

There are things you just don’t do. You don’t put metal in a microwave. Never drink a Coke and eat Pop Rocks. Forget about feeding Gremlins after midnight. And absolutely don’t arrive 36 hours before a marathon in another country.

For those of playing along, that’s called foreshadowing.

J’arrive

I arrived in Paris around noon on Friday. Paris in the Spring is, well, Paris in the Spring. There’s a reason there are songs, movies and expressions about the Parisian springtime (granted, they are mostly in French, but trust me).

Everything is a lovely shade of pale greens and pinks and white blossoms. The willows by the Seine shed the chaff of their buds in a blizzard of light wisps. Couples canoodle, dogs trot a little lighter in their steps and rosé wine appears on outdoor tables.

I dropped my stuff at my hotel. After a stroll around les Jardin des Tuileries I turned my aim back towards the 6eme. Saint-Germain-des-Prés is my adopted home in Paris. I know its winding streets and juxtaposed upscale-meets-bohemian character as well as I know my neighborhood in Richmond. Saint Germain is also home to what I consider to be the best Irish bar outside Dublin. I had bite and a pint or three and called it an early night.

legumes

Saturday

The race expo was huge; think Atlanta airport, but full of runners. And that’s no surprise. 50,000 lean, mean, quick stepping machines signed up to run the 42.25km course. Part of the process involved handing over a signed medical form from your doctor. There was some nuances lost in the translation of the form, and indeed the process itself. American physicians, short of approving kids for school sports, aren’t accustomed to filling these things out. My trepidation about my form’s validity were assuaged when a young volunteer traded my form for a race bib.

I wonder why there’s a foam rubber sponge in the race bag? Welp, won’t be needing that…

expo

I picked up a few souvenirs and headed back towards the heart of town. The expo was held at one of the city’s large convention centers, a few metro trains and a bit of a walk from my hotel. Paris is known for being a walking city, which is great when you are working off that baguette and patê; not so great when you are attempting to save every joule of energy in your legs.

That evening, I went to the restaurant on the first floor of the building I once called home. Aux Charpentiers is a venerated, traditional restaurant in the 6eme. The waiter and chef were obliging to my request for a vegan meal, although I’m fairly sure the laughing I heard in the kitchen was at my expense. Would monsieur care for a glass of wine? Why yes, monsieur certainly would! One glass won’t hurt my run, right? And hey, this is Paris!

On the stroll back to my hotel, I popped into a bakery and acquired a baguette for the morning’s breakfast. I may have also stopped in for another pint of Guinness. Can’t hurt, right?

pint.

Part 1 – The Champs

Get to bed early, you’re advised. Get a good night’s rest they tell you. Don’t stress about the race, they say. I don’t know who they are, but at 3:00 am, as I lay in bed wide awake, on the morning of Sunday April 6th, I could have strangled them with the shoelaces of my running shoes.

The Marathon de Paris embarks from the famed Champs-Élysées, or as my friend Jarrett calls it, the chomps. I was signed up to run with the 4:00 hour pace group, the largest subdivision of the 50,000 runners expected that morning. I arrived three hours early because, well, I was up.

As it turns out, arriving early was wise. The French extend their liberal views on all things bodily to race-day facilities. In our coral of approximately 15,000 runners, there were two portajohns. Two. 1 + 1 = 2. That was it, for facilities with a closed door. But, for the gents, there was a bank of plastic, portable urinals. Imagine, if you dare, a knee-high plastic trough, facing the hoard of people…well, at this point you should probably stop imagining.

So, there we were. 50,000 new friends, forged in excitement and anticipation of heavy legs, swollen feet and soon-to-be heaving lungs, standing in the morning sun’s shadow of the Arc de Triomphe.

pre-race

The race organizers were apparently smitten enough with a French cover of Mackelmore’s Ceiling Can’t Hold Us to put it on repeat for the morning. For two hours, we listened to Guillaume Lorentz’s version of the jam. The announcers crackled to life. It was time for the pre-race warm up. Like a well heeled squadron of the North Korean army, we pumped our arms into the air, in sync to the beat.

As 9:30 rolled around, our group of 4:00 runners marched towards the start. With the decided lack of ceremony with which every marathon commences, we toed the startling line and were off towards the Place de la Concorde.

Running with The Boss

My plan for the first leg of the race was to queue up an audiobook. Spoken word should keep me slow and out of my own head. I settled in to Peter Carlin’s bio of Bruce Springsteen and started counting steps per minute.

My goal was to start off around 9:30, maybe 9:00 mins / mile. Our hoard snaked past the Concorde monolith and towards rue Rivoli.

Bruce’s first band, Steel Mill, had a huge following in Richmond, Va. Who knew? Apparently it was the only place they got gigs outside of the Jersey shore…

1…2…3. I check my pace, I’m doing a steady 8:30/mile. Too fast, but I feel fine. Hey, what’s the worst that can happen?

Is that a marching band all dressed like Mario and Luigi from Mario Brothers? Yep, apparently it is!

1…2…3

Oh wow! We’re running along side the entire Louvre museum!

At mile 4, we narrow to squeeze past the crowd and into the expansive Place do la Bastille. I’ve heard people say to be careful about running the chicanes in a marathon. Take too many curves too wide and you add up to a quarter mile to your race. In the Bastille’s 500-foot wide roundabout, it’s easy to see how that could happen.

Part 2 – rock out

Paris is flanked on the East and West by two large public parks. At mile 6 we enter the Bois de Vincennes. I’ve had about as much of Bruce’s history as I can take, I’m ready to rock out. When I pull my phone out of my pocket, I see a text from my friend and fitness coach:

Andrew1

I hit shuffle on my Paris Marathon play list.

Top 40 pop helps me turn my feet over faster and faster. Throughout the park, every half mile, there are more preposterously strange musical ensembles. We pass a group dressed like they are ready for a medieval hunting expedition, and they are all playing the french horn. I imagine them, along with the Japanese drum circle, playing along to my mix.

We leave the park around mile 10 and head back towards the city. The course follows the Promenade Plantée, a collection of beautiful shops tucked into the old roman viaducts.

Since Parisian streets can be quite wide, the race directors paint a blue line down the absolute center of the course. It is there, primarily for the elite runners, so they run the shortest, most direct route; a true 42.2km.

I pick up the blue line at mile 10. For a mile, I try and make each step land on the line. Keep on the blue line I tell myself.

I check in on my legs. Feeling ok. But something’s not quite right. I push the idea out of my head.

If you wake up and don’t want to smile…if it takes just a little while…open your eyes and look at the day…you’ll see things in a different way

To take my mind off whatever is creeping in, I decide to focus on the crowd. For everyone with whom I make eye contact, I try and think of something nice about them. Oh how nice, they brought their young kids out to see the runners… For others, it was something like, that’s wonderful, a whole family holding a sign for their dad.

I’m counting on a karmic bonus, and thinking good thoughts has to help, right? Still, you’d be surprised how quickly you run out of nice things and dip into the observations about appearance, those sunglasses look great on her.

At the 20km mark, the Europeans celebrate the race’s halfway point. Now, I’m no mathematician, but 20 is not half of 42.2. I refuse to celebrate their false victory.

A smaller, less ceremonial marker notes the passing of mile 13.1.

Shake-shake-shake-ah-shake it! Shake-shake-shake-ah-shake it! Shake like a Polaroid picture.

Heeeyyy-yaaa! Was that out loud? I think I just sung along out loud!…oh look, there’s the blue line!

Mile 14 has a water stop. The French, ever the ones for elegance and ceremony, don’t hand out cups of water. No, instead they hand out full bottles of French mineral water. With the caps still on. For nutrition, they offer orange slices, banana segments and marshmallows.

Now, at this point, if you are thinking: hey, a full bottle of water and healthy snacks, what’s not to love about that? I offer the following:

water stop

That, dear reader, is what happens when 50,000 water bottles are opened, and orange rinds, banana peels, and marshmallows are cast underfoot over the stretch of a quarter mile of cobblestones. It is, in short, an orthopedic surgeon’s dream come true.

It’s alright if you love me…It’s alright if you don’t….I’m not afraid of you running around, I get the feeling you won’t…

Back around the Bastille. The water is doing it’s job. Bruce’s guitar is slamming and I get a second wind.

I prove it all night…

We’re running along the river again. I’ve lost track of what mile or kilometer we’re passing. I’ve run out of nice things to think about people in the crowd. How much further? Damn-it! It’s too early to think that thought!

En mass, we dip off the main road and down to the footpath along the river. Suddenly the crowd is high above us, looking down from the flood walls and bridges. French race supporters, as I’m learning, are an austere lot. Most don’t smile, or cheer. While there is a non-stop wall of people, only a scant few hold signs, or ring bells.

For the first time, I have a straight shot view of the masses of runners in front of me. This is my tribe, these are my people

When I arrived, in my own set of clothes….I was half a world away….Do not fear what you don’t really know…

We enter one of Paris’s underground tunnels. This one happens to be the longest, almost a mile. After a few seconds, things get pretty dark. I take my headphones out so I can hear the cacophony of feet and moving bodies.

Is that…? Naaaahhh. But wait….I think I do hear something….and there seems to be lights….laser lights in fact… and a disco ball…and….fog?

It is at this point where I start to question things. I cannot see daylight in front or behind me. And yet, the sounds of Abba are growing louder the closer I get to what appears to be a discotheque. And there, in the middle of Paris’s longest traffic tunnel, the one where Princess Diana perished in a horrific car wreck, is a mid-race disco.

What sort of Dali-esque nightmare is this? That is the actual thought crossing my mind. But instead of picturing the real Salvador Dali, I keep seeing Adrian Brody pop into my head.

Dali

At last, up ahead, daylight breaks. We’re out of the tunnel and back on the streets. The Eiffel Tower is in front of us. And that’s when it all comes together.

Tower

Monsieur Lapin!

In french, pacers are called rabbits, or more correctly, les lapins. Rounding a slight curve, I see the 4:00 rabbit. That’s my rabbit! Survivor’s Eye of the Tiger starts playing.

I’m chasing Monsieur Lapin. My pace recovers.

9:25….9:15….9:00…8:50… I’m shoulder to shoulder with Monsieur Lapin.

Rising up…back on the street….did my time, took my chances… I’m air-guitaring for all I’m worth.

Together, we tick off two miles, me and Monsieur Lapin. Mile 17 turns into 18 and 18 into 19. I might just run this race today….

Pas aujourd’hui, Pax aujourd’hui

At mile 21 we enter Paris’s western most park, Bois de Boulogne. Bois de Boulogne is home to Roland Garros Stadium, where the French Open is played. It is also known for its large gathering of transgendered sex workers. And now, it can additionally be known as the site where I hit the wall…hard!

It is a hurting thing…you don’t want to talk about it….pain in your heart, well it’s taking your breath away…

Really, I’m conscious enough to ponder, that’s the song that comes on my iPhone at this moment? Thanks for nothing John Hiatt!

Did I mention my no-fast forward policy? Yeah, I’m regretting some of these song choices now.

We pass a German oom pah band, all in lederhosen, many with a horn in one hand and a glass of Riesling in the other. I kid you not when I say a good number were also holding sausages.

I could be hallucinating.

Mile 22. I’ve slowed to a crawl. I’m trying to put one foot in front of the other. It’s not happening. Not today. pas aujourd’hui.

and I don’t think its weird….that the one thing you fear…is losing the one thing….

I make a pact, a d’accord as the local say. Next water stop, I’m walking. Seriously, not that psych-myself-out-keep-running-BS from the Richmond marathon. This. guy. is. walking!

Why are there still so many people?

1…2…3

Where is that water? Why don’t they drink more water? Why don’t they… and that’s when it hits me. Why don’t they drink electrolytes? There has’t been any Gatorade, no Poweraid, and not a salt-covered pretzel in sight. Where was that oom pah band? Surely they have pretzels. They held out on me!

That’s when I notice runners dipping sponges into buckets of ice water along the course. Where the hell did they get spon…..oh damn it! That’s what the foam rubber sponge was for!

1…2…3

I need water badly. At mile 24 there’s a station. I slow. I stop. I grab two bottles and ask the volunteer to take the caps off. I’m done.

It’s going down…I’m yelling timber….you better move….

I move into a walk-run cycle. I make myself little deals.

If I can get to that lamp post, I’ll walk 100 feet

Andrew2

I couldn’t will my thumbs to reply even if I wanted to. Though, I’m nonetheless grateful for the encouragement.

I start to think about what isn’t working. I keep giving myself permission to fail. Pas aujourd’hui, I tell myself, not today.

Oh where do we begin, the rubble….or our sins….and the walls kept tumbling down….

I start to list off the poor decisions I made. I started too fast. That glass of wine last night, what was I thinking? I regret racing (and setting a PR) in the 10k less than a week before. Absolutely don’t arrive 36 hours before a marathon in another country you bloody idiot!

As we leave the park, Paris is laid out before us. I’m still shoulder to shoulder with 50,000 of my new best friends. Slowing or walking requires darting to the shoulder or grass to avoid being run over. And there’s something different about the crowd. Is that actual cheering?

It is cheering! And its coming from the transgendered community who call the Bois de Boulogne home. They are standing on 8" platform shoes, decked out in Elton John-style sunglasses and they are screaming their heads off.

The blue line! The Blue line is back! I pick my head up and see the Arc de Triomphe in the distance.

through the mud and beer…the blood and the cheers…so if you’ve got the guts mister…if you’ve got the balls….if you think it’s the time, to step to the line….then bring on your wrecking ball!

Pax aujourd’hui

I’m going to run Paris today. I’m going to finish this race. It’s the first time it feels real. I choke up.

I speed up.

1…2…3…

The crowd narrows. More Parisians join in and are cheering. I’m running non-stop. It’s not my ideal pace, but I’m moving forward.

42 km.

I sprint towards the finish with borrowed energy.

I cross the sensor pad and crash into a wall of other finishers. Many, like me, are dripping with tears and sweat. We push and shove. And there’s more effing cobble stones and banana peels. Oh Paris, I love you!

Finisher

moores law in healthcare – three predictions for massive disruption

Je n’ai fait celle-ci plus longue que parce que je n’ai pas eu le loisir de la faire plus courte. —Blaise Pascal
Translation: I have made this longer than usual because I have not had time to make it shorter.

As Appley as it gets

A while ago I was challenged to write about what an Apple-like approach to healthcare might look like. That challenge has been weighing on me. For starters, we’re all over Appled aren’t we? Maligned anecdotes about Steve Jobs and the iPhone make their way into almost every presentation remotely related to innovation or technology. Triteness aside, I’ve been stalled because Apple is really a philosophy, not a series of steps or lessons learned. (Although, they are nonetheless methodical.) Instead, what I’ve been kicking around in the ole noggin are three notional predictions, which I’ll assert are inevitabilities which will fundamentally disrupt healthcare delivery as we know it today.

What follows is about as Appley as I’m likely to get. Despite big-bang product launches, Apple actually plays the long game. They introduce small features into products to affect user behavior years before a flagship product takes advantage of those reprogramed behaviors. That’s how they disrupt.

I believe there are three meaningful, unstoppable trends, in our current world which will significantly alter healthcare. The steps taken towards these inevitabilities, along the way, are the what will define the innovators and leaders. They are the ones who see this future and know how to drive towards it. The three trends are:

  • Tools and culture which favor individual empowerment
  • The commoditization and automation of diagnosis
  • Accelerated globalization of treatment options

But wait, there’s Moore

Don’t worry, I’m not going to leave you hanging. I’ll attempt to rationalize each of these points and explain why, particularly when considered as a bundle, they are a powerful force for disruption. And to prime that pump, we have to talk about Gordon Moore.

Moore, the co-founder of computer chip foundry Intel, in 1965 posited computer chips would double in speed every two years. Moore’s Law The speed increase, according to Moore, was inevitable; a fact, it will happen.

Before we put on our propeller hats, and geek out over processor speed, suffice it to consider a few examples of how this actually plays out. Sure, computers have gotten faster. Remember that first home PC you had, with its external disk drive and green-screen monitor? What? You aren’t old enough to remember that? Get off my lawn! We also see Moore’s Law in effect in the general progression of technology. Consider how cell phones have advanced, exponentially, since the 1990s.

Cell Phones

What Moore’s Law describes is a general absoluteness about the advancement of technologies and processes. It might be thought of as Newton’s First Law applied to manufacturing and society, rather than mass. In other words, some things continue to advance, and that’s the fact, jack.

The three prognostications I’ve laid out are examples of trends which I believe will follow Moore’s law. They will continue, they will evolve and they’ll be an increasingly powerful force on healthcare.

Just ask a travel agent

The internet is a wily enabler. Its vast interconnectedness, often terminating at the tips of end user fingers, works like a stream of water slowly eroding mountains of rock. When we step back and observe with some time or distance, we call that erosion disruption. Nearly every industry has been affected by the rapid increase in our technological interconnectedness over the past 20 years. Although, how we view the effects depends entirely on if you are the stream or the mountain.

Consumers are the streams. Customers, end users, call them whatever you like, they are the ones seeking the path of least resistance. In healthcare we call them patients. They want what is most effective, simple, desirable and affordable to them.

Mountains, on the other hand, prefer not to be moved. It takes a long time to build up a granite wall. And, according to Newton, an object at rest tends to want to stay put. Companies and industries —intentions and altruism aside —are often large, resting forces.

There was a time when, if one wanted to travel, particularly on a complicated international trip, one used a travel agent. Sure, they still exist and can provide a great deal of value, but according to a 2010 survey Travel, nearly 78% of airline tickets were purchased online. 40% were sold directly through the airlines and 38% were sold through online channel partners (think Expeida and the like).

Anyone who remembers the days of travel agents remembers the travel industry didn’t love this trend at first. But consumers did. Travelers showed what they desired was affordable, simple, direct access to shop for travel and make their own choices in the comfort of their own homes.

There was a time when we had to go to a shopping mall for things like books, wrapping paper, and new jeans. Enter Amazon.com. There was a time when buying music meant buying a physical object. Enter Limewire and Gnutella. And you thought I was going to say iTunes didn’t you? The online music sales industry grew out of a consumer hack. People wanted to download music because it was easy! It was the path of least resistance. The desire path as designers say. Figuring out how to sell it online only came after the stream eroded a path through the mountains.

This is happening in healthcare too

Tools and culture which favor individual empowerment

The internet provides us the tools for increased consumer empowerment. If we look to Amazon, iTunes and Expedia, we affirm our culture already favors consumer empowerment. Today, we see this in healthcare selectively, although it is more evident on the fringes.

In the main stream delivery system, providers are implementing patient portals to view notes, lab results, and share some limited communication with their providers. Avant-garde and large provider organizations with sophisticated resources are starting to crack that most desired nut: online appointment scheduling (see above re travel trends).

As consumers of healthcare observe what they can do in other industries, they begin to seek those same experiences in healthcare. These desires include online scheduling, easy asynchronous communication (think emailing your doctor), one click prescription refills, etc. Put it this way, if you are given the choice between shopping on Amazon or driving across town, waiting for an hour, disrobing, waiting some more, and walking out with a piece of paper you now have to physically deliver to another building and wait some more…. well, you get the point. The stream is starting to eat away at the mountains.

On the fringes of healthcare, we see some examples of consumerism empowerment in action. Several companies are experimenting with online, Skype-style doctors appointments. We also see empowerment taking off among quantified selfers, those of us who casually (or…cough…obsessively) track data about our steps, diet, sleep, etc. The companies who provide those services are inherently customer-focused and provide easy to use tools and direct services to customers.

For a last example, consider the genetic testing company 23AndMe.com. I’ve called 23AndMe.com the Netflix of spit. You go to their website and purchase a kit. They mail you the kit, you spit into the test tube and return it in the provided mailer. A few weeks later, you get a rich genetic profile. Setting aside concerns about their process and the presentation of the data, it doesn’t get much easier than the 23AndMe.com process. You never leave you house.

It is simply inevitable. As a matter of culture, we will continue to seek out paths of least resistance to enable consumer-centered solutions.

Patient experience, the movement around re-centering processes and healthcare deliver around patients, is an example of this trend towards true empowerment. And, while it is an early bellwether, many who are deeply involved on the front lines of patient experience will attest, it’s still about getting a proverbial seat at the table.

Real empowerment comes when consumers of a service are able to get what they need or desire in different ways; ways which short circuit the people who didn’t let them sit at the table in the first place.

Your destination is ahead, on the left

The commoditization and automation of diagnosis

A friend recently remarked: “the real economic product of the healthcare system is a diagnosis.” In many ways, that is in effect what is being purchased. Without a diagnosis, or a working hypothesis, doctors cannot order labs, or tests or write prescriptions. A diagnosis is the widget which the factor produces.

Clinician readers may take rightful umbrage at the following oversimplification. A diagnosis is the logical conclusion of a series of data inputs. Blood pressure + lab results + family history + observational data = diagnosis. Are there other, extremely important, more nuanced points to consider when making a diagnosis? Of that, I’m 100% positive. Nonetheless, a diagnosis essentially a distillate of data points.

Take, for example, strep throat. The generally accepted way to determine strep is through a rapid strep test. The rapid strep test can be done in a doctor’s office and provides results which are definitive enough to conclude a diagnosis. The data point is the test result + your sore throat and fever. Your doctor then writes a prescription for whatever is generally regarded as the best antibiotic for step these days.

What happens when a version of that rapid strep test is made available to home users? If the test has the same degree of accuracy, isn’t the home diagnosis just as valid? What if the testing device could electronically transmit its diagnosis to a pharmacy? Couldn’t then the pharmacist -if our regulations allowed it- dispense the appropriate medicine?

By the way, this isn’t pie-in-the-sky stuff. This year, the Scanadu device will come to market. Scanadu is an in-home diagnostic device which includes a small, hockey puck-like sensor and an in-home urinalysis machine. Scanadu have also announced ScanaFlu, an in-home rapid strep test. How long do you imagine it will take before Scanadu enables patients to transmit those in-home results directly to providers and pharmacies?

Dr. Petrov: [Ramius has taken the Political officers Missile key and kept it] Sir! The reason for having two keys is so that no one man may…
Captain Ramius: May what, Doctor?
Dr. Petrov: Arm the missiles Captain.
Captain Ramius: Mmm, thank you for your concern Doctor
Red October

I get it. There are laws and stuff about this today. Yawn. #SorryNotSorry. They will change. It’s inevitable. Our laws, regulations and processes often evolve to match the current state of the art. See also the power of consumerism. When the traditional players don’t keep up, the stream finds a way to erode the mountain. Maybe the local mega pharmacy won’t accept the Scanadu diagnosis, but I’m sure an enterprising mail order pharmacy will.

We see further support for the automation and commoditization of diagnosis in IBM’s Watson. From IBM:

Physicians can use Watson to assist in diagnosing and treating patients by having it analyze large amounts of unstructured text and develop hypotheses based on that analysis.
Watson can then identify the key pieces of information and mine the patient’s data to find relevant facts about family history, current medications and other existing conditions. It combines this information with current findings from tests, and then forms and tests hypotheses by examining a variety of data sources—treatment guidelines, electronic medical record data and doctors’ and nurses’ notes, as well as peer-reviewed research and clinical studies. From here, Watson can provide potential treatment options and its confidence rating for each suggestion.

Hummm….that sounds an awful lot like automated diagnosis to me. But it will never take the place of a physician’s expertise, right? There was a time when pilots didn’t have GPS instrumentation. Today, I don’t know a single pilot who would consider going up without a GPS. Can you still fly a plane without GPS? Absolutely. But GPS allows you to focus on actually flying, rather than navigating.

If Watson can make an accurate diagnosis, what does that change? It means patients can know their diagnosis without leaving home. They can research treatment options, if they so desire. They can research which providers are the best at treating their condition. Providers, in the mean time, can start treatment plans, rather than spending time on the diagnosis. Pretty soon, both patients and providers are copiloting the plane, rather than looking at the map.

When we apply Moore’s law to something like 23AndMe.com, Scanadu and Watson, its not far fetched to imagine a small bluetooth gizmo into which one feeds a single hair. In a few seconds, you get genetic data on your phone. A few seconds later, a cloud service renders a diagnosis. Within five minutes, an evidence-based, personalized treatment plan is emailed to you. But Nick…DNA sequencers are huge and expensive and the tests take forever to run… To which I offer the cell phone picture above.

At this point, there is also an obvious connection between these first two themes. If consumers of healthcare desire more empowerment and autonomy, and we short-circuit the traditional process by putting reliable, accurate tools in their hands, then they also become more responsible for the end result. Isn’t that what we in the empowerment movement so desire? Isn’t that also what providers who speak about patient activation also want?

Bingo jet had a light on

Accelerated globalization of treatment options

Just as technology has enabled connections which make our world feel smaller, so too have advancements in travel. From the US, we can be in Europe in less than a day. We can fly from coast to coast in less than six hours. And, increasingly, people are considering if a few hours by car or plane is worth it for better, newer, or more cost-effective treatment options.

Consider the following:

In 2012 Lowes hardware stores inked a deal with Cleveland Clinic. Cleveland Clinic became the sole provider for Lowes employees with specific heart conditions. The value proposition goes something like this: Cleveland offers a recognized name in quality —we’ll set aside an analysis or discussion regarding the validity of that assumption —and Lowes offers a statistically predictable amount of business. A special price is agreed to. Lowes, even when covering the travel cost for employees and a family member, saves money and gets better quality results.

Aravind Eye Hospital in India does more eye surgeries than any other place in the world. It treats nearly 2 million patients a year, for remarkably less than most hospitals in the United States, and it treats nearly two-thirds of those patients for free. It is generally regarded as one of the best facilities for eye care quality in the world.

Rochester Minnesota is a town of roughly 150,000 people. Most towns that size which are fortunate enough to have a towered airport, have runways averaging 6,000 feet. The main runway at RST is over 9,000 feet long and capable of landing medium sized international jets. RST also has immigration services for international flights. What’s in Rochester that warrants a such a sophisticated airport? The Mayo Clinic.

Meanwhile, where I live in Richmond, Virginia, we have 11 licensed hospitals. Eight of which are large, traditional community hospitals and one is a large academic medical center. Of those eight, seven offer most of the same services: OB, general surgery, diagnostic imaging, orthopedics, emergency care, etc. At the risk of sounding anti-capitalistic, does it make sense for seven hospitals to all do the same thing, with different processes, standards, outcomes and costs? Or might I be better off flying to India for my eye surgery?

My point in these vignettes is to consider the globalization of treatment options. As our world gets smaller, our ability to specialize treatment options and concentrate them into true centers of excellence becomes not only a reality, but an important consideration.

In fact, the VA has had this model for many years. The VA recognizes it is better for quality and costs to concentrate expert providers in key centers, and move patients and families to those centers for treatment. We also see this today in cancer care. May patients, albeit most often those with resources, consider traveling to the Kennedy Center, Sloan-Kettering, MD Anderson or Stanford. Steve Jobs famously traveled to Tennessee for his liver replacement.

See! I told you every discussion of disruption had a mention of Steve Jobs.

As an inevitability, these high-volume, high-quality centers will increasingly emerge. Insurance companies will recognize the bang for their buck and deals will be stuck where airfare, hotel and treatment are bundled into one payment. Need a knee replacement? Your options may be Denver, Bar Harbor and Juno. Or something like that…what do I know, I’m no cartographer.

There will, of course, be intermediate steps along the way. You might travel 2,000 miles for a knee surgery. But you probably aren’t going to get on that flight 3 times a week for physical therapy. Some things, like politics, are local. But, as our national discussion of quality and cost evolves, we’ll be forced to ask when volume, specialization and concentration matters. Maybe all hospitals don’t need to offer the same services.

Sushi, in the mountains?

These three inevitabilities play off each other, don’t they? We desire consumer empowerment, we’re building the tools to circumvent the system and enable that empowerment and we’re seeking out the best options for acting on that empowerment. These things will happen, because they always happen. The technology will come to enable them, because Moore’s Law shows that it always does. And we’ll broaden our geographic view of our options. After all, the best sushi restaurant I’ve ever been to is in the middle of Colorado. If my Yelp app on my iPhone tells me FedEx can get raw fish to Aspen, we can surely get the blind to India.