The future is's just not evenly distributed.  Or so goes the original quote from science fiction author William Gibson.

That's also the line the Alternative Futures group used in describe their futuristic model of primary care.

Challenges abound

We hear about the challenges facing healthcare from every angle; and it's not just those of us intrenched in the industry who are talking about them. Last week, the Washington Post's Ezra Klein published a story titled: Why an MRI Costs $1,080 in America and $280 in France.

 There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher. That may sound obvious. But it is, in fact, key to understanding one of the most pressing problems facing our economy. In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish. Workers would have much more money in their pockets. Our economy would grow more quickly, as our exports would be more competitive.

It is not all about high costs either. The American Medical Association predicts the US will have a shortage of over 91,000 physicians by 2020. JAMA illustrates the point by suggesting primary care doctors will need to double their patient panel size from 2,000 patients to 4,000.

But there is a plan, right?

There are no shortage of plans or experts to talk about them. CMS has announced initial payments to ACO pioneers will come this sparing. The Patient Centered Medical Home model is gaining popularity. Payors are also chiming in, at HIMMS conference, Aetna's CEO hinted at major changes to the commercial insurance industry:

Aetna CEO Mark Bertolini caused quite a stir when he said at a Las Vegas conference a few days ago that the insurance industry as we know it is, for all practical purposes, a dinosaur on the verge of extinction.


Bertolini ticked off a number of reasons why providing basic health insurance to Americans was no longer viable — changes in demographics and the economy and, of course, health care reform at both the state and federal levels. What he did not say was that the standard operating practices of the industry were simply not sustainable and actually contributed more to the demise of the business model than any external factors.

The future is here

In their white paper, Primary Care 2025: A Scenario Exploration, Alternative Futures explores four scenarios around primary care in the US. They lay out cases which range from status quo to, what the author's suggest, is a futuristic model.

I Am My Own Medical Home A different “surprisingly successful” future for primary care that bifurcates between advanced, effective, efficient,cost-competitive, integrated delivery systems and sophisticated and personalized self-care, supported by advanced knowledge technologies that allow people to take over many functions of primary care for themselves.


More important were the disruptive technologies that developed throughout the 2010s that put more and more control of health and health care into the hands of patients. New smartphone “apps” monitored a person’s diet, physical activity, and sleep patterns, and collected this data in personal health records (PHRs). New biomonitoring devices that measured blood pressure, blood chemistry, and even blood flow noise within the body could alert people to changes in their health. Lab tests conducted by the device at home, or sent by mail to a lab, provided a low-cost alternative to similar services previously provided in formal health care settings. Social networks, both in large population platforms like Facebook and Google, and in targeted networks like PatientsLikeMe, helped to formalize and extend the informal relationships that had always provided a large share of people’s health-related information.

These things aren't futuristic. They aren't imaginary, pie in the sky, would-be-nice-to-have things. They exist today. It's what Gibson means about the future being here, just not evenly distributed. Because these tools and their users, known as quant selfers, are not mainstream - or at least in the boardrooms of provider organizations, they are often discounted as fringe; unevenly distributed among the population of "normal patients."

Addressing the minority tastes

Chris Anderson, editor of Wired Magazine speaks about niche groups whose interests he calls minority tastes. The thing about niche interests, Anderson calls out, is we all have them. They are likely some of our favorite things - a fringe band, a campy TV show, a strange food. They are the unique things that make

Anderson has written about catering to minority tastes in The Long Tail. Graphically, if you were to measure the interest in a product or service, there has traditionally been a drop off point; a point when the market is saturated with users or the producer has hit their capacity to supply the thing. Anderson speaks about record sales. There was a point where a stores shelves could only hold so many CDs, so store owners had to chose which albums to carry. Once buyers had purchased the top selling albums, the curve dropped off.

In the digital age - we can all agree, that future is  here and evenly distributed, right? - these things have unlimited capacity. There is no feasible capacity limit for the number of tunes Apple can sell on iTunes or videos Netflix can deliver via streaming. So, there is no reason to limit the availability of the store's supply and there is no limit on the customer's interests.

Rather than dropping off, the distribution just spreads out over a larger range of a more shallow audience or smaller production.

Clear as mud?

In healthcare, we often wait for things to tip. For example, we need a market size to be substantially large enough to warrant building a new MRI center, otherwise, the curve dropps off too soon and we don't make enough to support it. There is also that ever-nagging fear of the unknown, or new things. Look at EMR adoption.

Those constraints don't apply for embracing virtualized care, quantified self models, and medical management. Why? Well, the future is here. We know people are using FitBits, the Zeo Sleep Manager, iPhone glucometers, and blood pressure cuffs. We don't have to wait for them to tip into a larger market segment.

How do we do it? Here are several lost cost, high impact ways:

  • Engage ePatients - ePatients are patients who actively seek to participate in medicine. Think about hosting an ePatient speaker for a board meeting or design session. ePatients are the ticket to understanding the long tail in healthcare. They have niche interests and are not evenly distributed, but they want access to data and electronic communication with providers and understand the value of holistic relationships as well as retail models. They represent the future, and they are here.
  • Embrace Quant Selfers - encourage those interested to upload data through an EMR patient portal. It doesn't require any effort, but it could provide a world of returns (on health)
  • Build online patient support communities - facilitate spaces for patients to engage with each other, and form support and knowledge groups.
  • Engage with patients online, on the sites they use, in a way that adds value. This cannot be overstated. Marketing messages via social media, while they may provide incremental volume, do very little to affect the health of your followers. The meaningful use of social media in healthcare starts with focusing on outcomes.
  • Share data - Publish data on case volumes and quality. Hey, CMS has made their claims set public, what do you have to lose?


Below, Chris Anderson speaks about the long tail: