The hinge point of change in Ireland?

by joeflower on April 22, 2015

Sheep in fieldDateline: Lahinch, County Clare, Ireland

I’m sitting over the seawall and embankments of this seaside town in the west of Ireland, watching the Atlantic waves crash and dribble onto the shingle in what must be their most peaceful mood on a surprisingly warm April evening. I’ve been talking to a friend, a retired Irish nurse, trained in London, who spent her career working mostly in the United States. Many of her relatives are doctors. Of the Irish healthcare system, she says, “I don’t understand it. Nursing I understand, but not the system here.”

I’ve just come from Dublin, where I addressed the second annual Master Class of the Irish Health Services Executive, bringing together executives, managers, and practitioners from across the whole national system. Irish healthcare has enormous weaknesses, not least of which is that when the “Celtic Tiger” era collapsed in turmoil in 2009, their funding, already low by percentage of GDP and constant dollars, took a 22% cut almost overnight — and the cuts came across the board, rather than managed to target true waste or create new efficiencies. But it also has its great strengths, not least of which is the willingness to convene conferences such as this one, drawing top people from across the sector to ask the big questions: How can we do this better? How can we create more resources within the system by becoming lean and smart?

My discIreland flagussions with officials in the counting houses of the Irish government, with clinicians, with entrepreneurs and major employers, with average Irish citizens over the last month had a fairly consistent theme: We used to pour money into healthcare. It leaped up year after year. Then the crash and slash came, and since then funding has been flat for six years. Now for the first time we have put some more money back into healthcare — but we want to see results. We don’t want you just to increase salaries that were cut. We want to see fewer people on gurneys on hospital hallways. We want shorter wait times to have a surgery or see a specialist. We want palpable improvements.

Though the situation may seem quite different from the American experience (vast overspending, budgets the size of planets), that challenge — how to wring more real value from the dollars and euros spent — is exactly the same.

The top presenters and the discussions centered around them all wrestled with the question — Dr. Richard Rumelt, an expert in strategy from UCLA; and Dr. Robert Wah, president of the AMA, on shifting medical practice to bring real value to the patients. Tony O’Brien, director general of the Health Services Executive (whose brilliant idea it was to convene this deep, free-ranging discussion) sat for a grilling from health policy analyst Dr. Sara Burke. I delineated the toolkit, the strategies and tactics being tried in the U.S. and across the world to bring about a Healthcare Spring. I challenged them to make this moment in 2015 the time when healthcare in Ireland turns the corner and begins to develop something new, surprising, lean, powerful, astonishing.

Will these strategies and tactics work in Ireland? I don’t know, honestly. It depends on how bold they are willing to be. But I do know that there were revolutionaries in the room, willing to risk something to make healthcare work for the Irish people. There are people like that in every system I talk to.

People came up to me afterward, a surprising but not surprising number, saying some version of, “Funny you would use the term ‘revolutionary.’ I had never thought of that term. But yes, I am one. We have to change this and we can.”


The urgency of the truly transparent

by joeflower on April 13, 2015

hands exhibiting the cloud computingThe ginormous spring HIMSS (Health Information and Management Systems Society) meeting is ending. The big big subject this year? Interoperability — the ability of different systems to link up, transfer data, and actually operate through each other. Here’s why it’s a big deal:

The lack of real transparency and interoperability across the larger systems we are building, across accountable care organizations, even into other institutions that our customers may go to, often even within our own organizations, the failure to produce truly clinician friendly customizable interfaces in most of healthcare IT, the failure to create open systems that can work directly with other pieces of software — all of these together are a patient safety and quality disaster. When a clinician cannot get the real information on a patient in a way that is instantaneous, accurate, accountable, in an interface that helps them to insight rather than getting in their way, patients suffer.

Epic, the dominant force in the market, claims its systems are interoperable, but that is true only for very special use cases, and for a limited definition of “interoperable.” This week Epic announced a new open systems approach, but it was merely talking about APIs through which other vendors can build software modules that can connect into the Epic mothership, not about connecting to other EHR systems across town. In the meantime some organizations are joining the CommonWell Health Alliance to bring together non-Epic data standards. Many providers are dragging their feet from a combination of IT fatigue, stretched budgets and a “What’s in it for me?” attitude. The Office of the National Coordinator (ONC), the federal agency in chargretro-style-cloud-computing-concept_zkY-s0Lde of trying to whip all this into shape, has set a goal of true seamless healthcare data exchange real soon now. Well, by 2025. And it considers that an ambitious goal.

Quite simply this situation is killing people. But the disaster goes beyond that. Lack of interoperability makes the vision of truly seamless care across accountable care organizations, let alone regions, impossible. The vision of the Next Healthcare beyond the tipping point is built on a seamless data universe centered on the patient and the patient’s family and caregivers, not on the hospital billing department. Not getting the information flow right will make the hope of better, cheaper healthcare much harder to reach.

The bars to making this work are mostly not technical. Building these vast information systems is very hard.  Making them open and interoperable is not the hard part — if the will is there in the vendors, the providers, and the payers to do it.


Pharma and Volume-to-Value: The Big Throwdown

by joeflower on April 8, 2015

cal-0814-cl2-martia-arts-16The collision between the “volume-to-value” movement and the pharmaceutical and biotech industries over the next few years will have a powerful impact on them and on the healthcare industry and on us as customers, patients, and payers.

On the one hand, pharma is perhaps the part of the healthcare industry least exposed to direct price regulation under the Obama reforms. The actual costs of pharmaceuticals have been rising as a percentage of what people spend on healthcare, and are seen as the part they have the least influence on. At the same time, many new drugs for cancer and other life-threatening diseases have come with astonishingly high price tags, often not fully covered by insurance (due to the high deductibles and co-pays of the new plans), and with few ways for regulators or the market to push back on them. The public perceives these huge price tags as threatening people with a Hobson’s choice of bankruptcy or death. In the volatile political atmosphere of the 2016 elections, this leaves the pharmaceutical industry highly exposed to political attack and actual new price regulation.

On the other hand, the pharmaceutical and biotech industries also potentially offer some of the best answers to bringing the cost of healthcare3d person sitting on red question mark. down through the use of personalized medicines, smart medicines, new methods of administration such as implants, as well as the possibilities glimmering at us from recent research of real breakthroughs in such important chronic disease areas as Alzheimers, diabetes, addiction, behavioral medicine, and functional medicine. For the most part, though, these answers remain potential. We will not see them adding to the “value” side of the equation until they become fully integrated into a system that is at risk for the health of its customers and using every trick in the handbook to bring those costs in line.

Who decides?

Importantly, who will be the decision-makers? That is broadening rapidly. In the old days, the buyers were just the doctors, and the price-setters were just the sellers — the pharmaceutical industry and the pharmaceutical distributors. Then increasingly the ranks of decision-makers came to include the hospitals and health systems and their buying consortia. Then major retail chains began negotiating prices down for the most common drugs and health plans began dictating generic replacements whenever possible. In the post-Obama world, the decision-makers in market setting for pharmaceuticals are coming to include everyone involved in healthcare costs: Clinicians and healthcare institutional leaders; inventors, entrepreneurs and investors; employers; insurers; government regulators; and consumers themselves.

Increasingly, all of these players will have at least some of the three basics that constitute a real market: reliable information, ability to choose, and incentive to choose well.

What’s the value?

Traditionally, the pharmaceutical and industries have defined the value they bring to the customer as simply the benefit of the drug: Does it cure, does it palliate? We are driving rapidly toward a future in which that value will be defined in a much more multi-variate way: What is the actual benefit, at what cost, delivered both to the patient and to the medical and payment systems supporting the patient in the context of systemic, connected, always-on care? That’s a big, big difference, and a much harder challenge to meet.

The pressure is already on.


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I talk to people all the time in health care at big civic gatherings; board retreats; conventions of nurses, physicians, managers of medical groups and accountable care organizations and health plans and device manufacturers. I give a talk, sit on a panel, run a discussion — and the rest of the time I listen, over […]

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The “Obamacare killer” Supreme Court Case: What you need to know

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Here are the three things you most need to know about last week’s “Obamacare-killer” King v. Burwell Supreme Court case:

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It’s time to toss the business-as-usual model. The emerging Default Model of health care not only does not work for health care’s customers, it cannot work.

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So you spent millions to billions of dollars on information systems over the past few years, right? Maybe you should Junk it and start over.

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Health care is fragile. It survives in a much narrower band of circumstances than most of us realize. An increasing number of vectors both inside and outside the sealed world of health care could overwhelm and kill your institution. In an increasingly high-variance world, your survival depends on getting green, lean, resilient and smaller.

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Will some of these new technologies actually transform health care? Which ones? How can we know?

There is an answer, but it does not lie in the technologies. It lies in the economics. It lies in the reason we have so much waste in health care. We have so much waste because we get paid for it.

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