by Dave Chase
42.Leveling the empowerment playing field – Engagement and empowerment are different. Individuals are often most engaged, but least empowered. A partnership between individuals and clinicians is when health is optimized.
43.“Patient engagement” is backwards – “Patient engagement” is valuable, but backwards. Individuals need the health system to be engaged with them regularly, and not just during visits.
44.“Individual centered” engagement – An engaged individual is very different from “patient engagement” (h/t Gilles Frydman). One is individual centered, one is health system-centered. Achieving full health is the goal, not engaging with the health system.
45.Engagement for avoiding the health system – An individual can be engaged with their own health without entering the health system at all (h/t Hugo Campos). The goal of an individual is often to become/stay free of the health care system. Engaging means empowering them to do so.
New Economics
46.Choose wisely – Choose wisely. Oftentimes, less is more.
47.Prevention – Oftentimes, early is better than late.
48.Overtreatment – Overtreatment is one of health care’s greatest challenges. In many cases no treatment is much better than treatment.
49.Sustainability – A system that profits more from people with “problems” than those without and has a default set at “treat more” is destined to collapse due to its inherent unsustainability.
50.Evidence-based care delivery – Systems will become better aligned to better prevent overtreatment and undertreatment, driven by individual’s access to information, informed by statistics.
51.Empowering a patient to make rational economic choices – Individuals enter the health care system to get measurements; to be diagnosed; and to seek answers, treatment and learn. Individuals will seek alternatives outside of expensive, inconvenient care centers. This will drive positive overall change in the health system.
New Education
52.Scaling medical education for the future – Medical education will be made continuous, engaging, and scalable in the age of increasing clinical demands and limited work hours.
53.New approaches to learning – Medical educators will make thoughtful use of technology and learning design. Those that excel will learn how MOOCs, community engagement, social media, simulation, and virtual reality might change the face of medical education.
54.Harnessing the data deluge – The flood of new medical information is impossible to keep up on for any one person. Physicians and other care providers will be enabled by better systems for filtering what’s valuable for an individual’s care.
55.Rapid evolution – Effective medical education must and will evolve rapidly to focus on care delivery and the use of digital tools in care delivery.
56.Physician as community manager – Medical education will recognize that because only 10–20 percent of health outcomes are driven by clinical care, physicians must also be stewards of community transformation. Physicians are in the best position to be good partners within a multidisciplinary alliance enabling community transformation.
New Data Ownership Rights
57.Individual Rights – An individual’s access to and management of data about him/herself is a fundamental human and property right. Why is it easier to have your medical data hacked than for you to get access to it? (h/t Eric Topol)
58.Monopolies – Monopolies on medical knowledge and information are unethical.
59.Single Patient Record – Now that all information can be connected all the time, there should be only one record of health data that comes from an individual, controlled by the individual. Problems with HIPAA and “information blocking” are symptoms of a broken, pre-Internet, paper-driven era.
60.Property Rights in a Distributed System – Platforms will be developed to enable the rights and transactions around health data property. These platforms will be decentralized, yet enabled to focus on the individual in an instant. Be prepared.
61.Patients Right to Data About Them – Individuals have a right to any data that comes from a measurement of an internal state of their body, including medical devices.
62.Immediacy of Access to Health Data – Individuals have literally died, waiting for their lab data. An individual’s lab and other data should be made accessible to individuals as soon as it is available.
63.Data Doesn’t Cause Medical Harm – Medical regulations exist to protect individuals from medical harm. Data, ideas, and information in the hands of individuals causes no medical harm.
64.Safe Access to Data Without a Doctor’s Permission – Individual may have access to metrics and analysis about their own body without a doctor’s permission as long as accessing that data poses no significant medical risk.
65.Right to Privacy – Individuals have a right to health data privacy. Rights to sharing must be established with the individual it originates from, or their legal agent, in advance of sharing.
66.Health Information Anti-Discrimination – Health data collected about an individual cannot be used to determine a person’s access to capital (credit ratings), employment, education, housing, or health care services. This will be legislated and empowered by new technologies.
New Roles and Relationships for Providers
67.Misaligned Incentives Impair Providers – Misaligned reimbursement schemes have impaired providers from doing the primary job of healing and have often robbed them of their humanity. Paying for value will help them get the job of healing back.
68.Enlightened Providers Partner with Patients Who Guide Their Care – The enlightened clinicians who embrace these guiding principles, combined with empowered individuals guiding their own care will become a powerful competitive advantage.
69.Maintain Trust in Health Professionals – Some of the most trusted professions are nurses, doctors, and pharmacists. With the trust individuals have in these professions, they activate us to do things we wouldn’t normally do. Respect this trust.
70.Whole-Person View of Health – World class teams require a holistic view of a person’s complete health, which includes not just their physical health but also their mental health.
71.Embracing the Science of Behavior Change – Relationships are fuel for motivation and behavior change (both positive and negative). Motivations, triggers, and ease of action are keys to enabling behavior change.
72.The Importance of Relationships – Aim to motivate, teach, consult, and enable. Clinicians cannot expect participation in a care plan (e.g., “adherence”) without mutual understanding. Recognize that when an individual is not incapacitated, they are in control of whether they fill prescriptions, follow a care plan, etc.
73.Health care Extends Beyond the Walls of the Clinic – The best care is and will be collaborative beyond the walls of any one institution. Just as “the smartest people work for someone else,” the smartest providers practice outside of this clinic and this hospital. The smartest provider may, in fact, be a collective, or the crowd. New ways to open communications will drive better care.
74.Flipping the Clinic – Many times, the best place for interaction between the clinician and an individual isn’t at the clinic. We can flip the clinic. Much of what has been done at a clinic visit can be done more effectively in the comfort of an individual’s home via email and other digital tools or in social settings like churches or community organizations.
75.Embracing Data to Deliver Better Care – The most relevant providers will learn and will be conversant in data analytics and tools. They will be experts in care delivery, not just diagnostics and traditional medical science.
A New Competition in Life Science & MedTech
76.Embracing the New Science Within the Leadership – Tomorrow’s leaders will redesign development and trials to capitalize on the aforementioned new science dynamics and mobile technologies.
77.Embracing Partnerships Beyond the Traditional Ones – New and nonobvious partnerships will need to be forged to ensure leade
rship in the future. Alliances with health tech and consumer health/Internet companies will be as important as alliances with academic medical centers have been in the past.
78.Broadening the Value of PostTrial Relationships – Posttrial relationships with individuals will allow cocreation and insights not possible before. That is a largely untapped opportunity. ResearchKit is just the beginning.
79.Openness to Engagement – The individual’s relationship to a device or therapeutic may be as profound as their relationship to their doctor, or more so. Be available and open to engagement to make improvements.
New Health Plans, New Health Benefits
80.Fee for Service Is Dying – Fee for service is dying. Transition now in every way you can.
81.The Dirty Secret of Health Plans – The dirty secret of health plans is that higher care costs have, counterintuitively, led to greater profits for the plans. This is changing. Winning health plans will capitalize on the opportunity to fundamentally rethink plan design to be optimized for the fee-for-value era.
82.Catalyzing Patient Engagement – Catalyzing patient engagement will lead to better care and a more competitive offering.
83.The Next Dirty Secret – The next dirty secret of health plans is that they are money managers. The longer they hold onto money, the more they make. Employers and unions are driving the next wave of health care innovation, protecting their employees and members.
84.Investing in Members’ Financial Security – Rather than reflexively denying claims and building up a mountain of ill will, insurance companies should invest resources in protecting their member’s financial security.
85.The “Negaclaim” – Customers will, in effect, “self-deny” their own claims. A new metric for success is the “Negaclaim”—an unnecessary claim avoided. This isn’t about denying care. Just as energy consumers aren’t interested in kilowatt hours, individuals aren’t interested in health claims—they want health restored and diseases prevented.
86.True Informed Consent – When individuals are fully educated on the trade-offs associated with interventions, they generally choose the less invasive approach.
87.“Essential Access,” the Corollary to “Essential Benefits”—The ACA defined “essential benefits” but there will be a corollary about rights to “essential access” as part of coverage. Any modern health plan offering will include virtual visits, transparent price info, updated provider directory, same day e-mail response, next day test results, etc.—all eminently doable with today’s modern technology.
88.Rethinking Benefits Design and Procurement – As the second or third biggest expense after payroll, CFOs & CEOs are failing in their fiduciary responsibility by being overly passive in how they procure health benefits. A rethought health care purchasing plan drives direct, financial returns, but most importantly, enables your valued employees to do what they desire — realize their full potential. Elements are defined at healthrosetta.org.
89.Aligning Laboratory Testing and Genomics – Genomics and proteomics information and testing will be key components of personalized medications, tailored to provide the best dose/response relationship in each patient. Because of their importance, these tests and genomic information must be covered by health plans and insurance.
New Health System
90.Transitioning Care Beyond the Walls of the Clinic – Hospitals have provided amazing service for the last 100 years, but location is becoming less important for health care. Care can happen almost anywhere at lower cost. What conditions hospitals treat, and how hospitals serve their communities will dramatically change over the coming decades.
91.Reimagining Technology in the Fee-for-Value Era – Health systems, your technology procurement process must be up to the task. Systems grown and optimized for the waning fee-for-service often have the polar opposite design to what will optimize the fee-for-value era. Virtually every new health care delivery organization that is outperforming on Triple Aim objectives, has deployed new technology reimagined for the fee-for-value era.
92.Focusing on Communication Over Billing – Outside of health care, millions of organizations have reformulated how they interact with their ultimate customers with better communications tools. Next generation health care leaders understand that tools will focus on communication over billing.
93.Borrowing a Page from the Newspaper Industry – Health system leaders, learn from the another local oligopoly in your community, the venerable daily newspaper. While they spent the last couple of decades worrying about cross-town and traditional media company competition, it was death-by-a-thousand-papercuts that has been their undoing. Newspaper executives dismissed an array of new asymmetric competitors including eBay, Craigslist, Monster.com, Cars.com, Facebook, Groupon, ESPN, CBS Marketwatch and more who stole advertising, media consumption or both. Health system executives are doing the same thing today, and the issue is the same: how valuable content will be delivered in the future. The content is different, but the issue of distribution is the same.
94.The “Forgotten” Fourth Aim – Winning health care delivery organizations recognize that the Quadruple Aim will deliver sustainable success. The “forgotten aim” is a better experience for the health professional. Layering more bureaucracy on top of an already-overburdened clinical team ignores that the underlying processes are frequently underperforming and that a bad professional experience negatively impacts patient outcomes.
95.Unshackling Innovation – Health care organizations wanting to reinvent can harness the new opportunities by unshackling their smart, innovative team members and outside thinkers to reinvent their organizations for the next 100 years. Those that enable their customers will emerge as the leaders for the next 100 years.
Appendix E
Health 3.0 Vision
“Healthy citizens are the greatest asset any country can have.”
― Winston S. Churchill
As health benefits get a major overhaul in the employer arena and policymakers determine where publicly paid health care programs will go, we believe it’s imperative to take a fresh look at how we’ve organized our health care “system.” One area of near-universal agreement is that we should expect far more from our health care system, given the smarts, money, and passion poured into health care. Simply shifting who pays for care does little to address the underlying dysfunction of what we pay for and how we pay.
A group of forward-looking individuals have developed a vision for Health 3.0 to address the future of care. It is a common framework to guide the work of everyone from clinical leaders to benefits professionals to technologists to policymakers. Each should ask whether their strategies, technologies, and policies accelerate or hinder the journey to Health 3.0. If Health 3.0 is the North Star, the Health Rosetta is the roadmap and travel tips on how to get there.
To fix health care, we need a common vision for the future―Health 3.0 We believe this vision encompasses four key dimensions.
1. Health Services (e.g. health care delivery and self-care)
What is the optimal way to organize health services so they build on the strengths of each piece of the health puzzle, rather than operating as an unmatched set of pieces (today’s world)? Innovative new care delivery models create a bright future (that some are already experiencing) where every member of the care team is operating at the top of his or her license and is highly satisfied with his or her role—a stark contrast to Health 2.0, where only 27 percent of a doctor’s day is spent on clinical facetime with patients.153 Put simply, they didn’t go to med school to become glorified billing clerks.
2. Health Care Purchasing
Underlying virtually every dysfunction in health care is perverse economic incentives. Various industry players are acting perfectly rationally when they do things that are counterproductive to achieving Health 3.0. The Health Rosetta and Health 3.0 outline the high-level blueprint for how to purchase health and wellness services wisely. We’ve seen how a workforce can achieve what one health care
innovator has described as “Twice the health care at half the cost and ten times the delight.”
3. Enabling Technology
Technology only turbocharges a highly functional organizational process when the proper organization structure, economic incentives, and processes are in place. Unfortunately, health care breaks the first rules I learned as a new consultant fresh out of school—don’t automate a broken process and don’t throw technology on top of a broken process. Sadly, health care is riddled with these two common mistakes, stemming from the flawed assumption that technology alone can be a positive force for change.
4. Enabling government
At the local, state, and federal level, government can play a tremendously beneficial (or detrimental) role in ensuring health care reaches its full potential. There are four main ways that government entities contribute.
1. As an enabler of health (e.g., public health and social determinants of health)
2. As a benefits purchaser, since government entities are large employers who can accelerate acceptance of new, higher-performing Health 3.0 care models
3. As a payer of taxpayer-funded health plans
4. As a lawmaking or regulating entity
The first item, in particular, is frequently overlooked as a powerful tool for testing and refinement of new models of care payment and delivery.
Failings of Health Care 1.0 and 2.0
Before defining Health 3.0 further, it’s important to outline the failings of Health care 1.0 and 2.0. Dr. Zubin Damania (aka ZDoggMD) describes the positive facets of Health care 1.0 and Health care 2.0 but also gives the two earlier eras of health care a stinging rebuke.
Behind us lies a long-lost, nostalgia-tinged world of unfettered physician autonomy, sacred doctor-patient relationships, and a laser-like focus on the art and humanity of medicine. This was the world of my father, an immigrant and primary care physician in rural California. The world of Health care 1.0. While many still pine for these “good old days” of medicine, we shouldn’t forget that those days weren’t really all that good. With unfettered autonomy came high costs and spotty quality. Evidence-based medicine didn’t exist; it was consensus and intuition. Volume-based fee-for-service payments incentivized doing things to people, instead of for people. And although the relationship was sacred, the doctor often played the role of captain of the ship, with the rest of the health care team and the patients subordinate.
