[By Joe Flower, from the May 17, 2010, issue of H&HN Weekly]
The country seems to have shifted in less than 18 months from a
slogan of “Yes We Can!” to “Oh, well…” and a shrug, then back to “Cool!
I think. What was that, really?” Hopes for a true rebirth of health
care turned into the Year of Screaming Inanely, then took that long
slide from what we might hope for to what we might settle for. Yet
suddenly it seems like things are popping up all over the place, like
mushrooms on a forest floor in springtime. New projects and initiatives
are emerging from little companies, big companies, garage startups,
info-giants and mega-industrial combines.
It looks just as if, frustrated by a glacial and refractory
legislative process, Americans and American companies have taken
matters into their own hands, not with torches and pitchforks, but
devices and codes and business models, all trying to figure out some
way they can help make health care better, faster and cheaper. It is as
if Rosie the Riveter of the World War II poster were once again flexing
a muscle and saying, “We can do it!”
Better for Less
“Better, faster and cheaper?” The glib management saw is: “Quality,
cost and speed—choose two.” The received wisdom is that you can do
things at high quality and low cost, but it will take a long time. If
you want high quality at high speed, it will cost a bundle. If you want
low cost and high speed, you can’t have quality.
But health care does not fit that wisdom at all. In health care
“speed” translates to “accessibility,” in terms of coverage,
availability of services and convenience, as well as sheer rapid
And uniquely in health care, the management saw is wrong: You can
have all three. The Dartmouth Center studies repeatedly show that
efficiency and effectiveness go together in health care. There is no
clinical advantage to making the process more clunky, difficult and
expensive. And more is not better in health care—doing more tests and
more procedures actually correlates not just with added cost, but with
worse outcomes. Efficiency, convenience and low cost are
This is the giant prize at the center of the labyrinth of changing
health care: We could do it better for less. Much better, for much
less. And more and more companies are heading straight for that prize.
Let me give you a few examples. They sometimes are big, bold
actions, and sometimes are things that seem like details from the
outside, but could turn out to be very large.
CVS/Caremark, for instance. The CVS pharmacy chain has been growing
very quickly over the last 15 years, swallowing up Revco, Arbor,
Eckard, Sav-On, Osco and Longs, ballooning from 1,400 stores to over
7,000. In 2006, it bought MinuteClinic, a chain of retail clinics, and
began expanding it to almost 600 locations today. In 2007, CVS merged
with the massive pharmacy benefit manager Caremark, with some 64,000
participating pharmacies, to become CVS/Caremark. The combined
organization is now the largest provider of prescription medicines in
The interesting detail? CVS/Caremark has decided to use its massive
market footprint to do something about chronic disease, starting with
diabetes. It goes beyond the more usual passive education programs to
aggressively get out and work with patients by, for instance, sending a
nurse to your house to show you how to test your glucose level, how to
use insulin and how to regulate your diet to keep the disease in check.
And the PBM side of the company is working with the pharmacy part so
you can walk into any MinuteClinic to get the same advice, or get your
A1c score tested, any time that is convenient, instead of having to
make an appointment at a doctor’s office. There is likely a convincing
business model to such services, but these kinds of direct patient
services are much harder to pull off than another PBM deal or opening
another store. They are the kind of thing a company has to want to do.
A Leader in Efficiency
GE Healthcare, with 46,000 employees, headquartered in the United
Kingdom, is one of the largest vendors of medical equipment in the
world, owning (to take one example) 80 percent of all the anesthesia
machines in the United States and 60 percent of the machines in the
world. Like all of General Electric, the world’s largest corporation,
GE Healthcare is highly focused on quality, and the processes by which
it continually hones its products and abilities.
But GE Healthcare has come to realize that this mindset, so natural
within GE, is not shared by its customers, who often think quite
differently, and have quite different concerns and incentives. Within
the past year, it set out on a major program involving all its major
executives, down to the manager level, especially in the service
division, which interacts with the customers on-site every day for
years on end, to better understand the customer—how the industry works,
how it makes its money, how it gets things done, why quality and
efficiency in processes are only beginning to be understood across much
of health care.
They are doing this, GE executives tell me, not only to work with
their customers better, but also partly to influence their customers,
to educate them to the way GE thinks about quality and efficiency. I
asked one GE Healthcare executive how this would help sales. If it were
really able to help its customers be more efficient, wouldn’t they be
more efficient, among other things, in using GE machines—and so
actually buy fewer units?
“That may happen,” he told me, “but we see that health care simply
has to change, and it will change, to be more lean and efficient. If we
help lead that charge, we will be identified in the customers’ minds
with a whole new way of working more efficiently, with less variation,
and better quality.”
New Approaches to Storing Health Records
Personal health records make up one big mushroom patch. Google
Health, for instance, provides a place where patients can keep their
health records. But here again, the revolutionary force is down in the
details. Besides plain old record storage, Google Health also provides
what may become a de facto standard for personal health records, making the CCR standard it has adopted into the MP3 of health records.
Equally important, both Microsoft’s HealthVault and Google Health
work like Apple’s iPhone: They provide an open platform with an API—an
application programming interface—for which anyone can design apps.
MDLiveCare, the see-a-real-doctor-online-right-now site I mentioned in
a previous column, is an app integrated with Google Health, as
OnlineCare is with HealthVault.
Similarly, SalesForce.com has invested in (and provided its
Force.com platform for) PracticeFusion, a free medical practice suite.
Its ChartShare allows any authorized provider to view and interact with
the patient’s chart—and its sibling, PatientFusion, gives the patient a
look at the chart arranged in one convenient interface. All of this
software is free.
The business models are all over the map. Like many things Google
does, Google Health does not really have a business model, except
Google’s belief (so far well-founded) that the more it can provide
storage and search and interface for every bit of information on the
planet, the more it will prosper. Google Health does not plop
advertising on your chart, and does not sell your information to
anyone. PracticeFusion supports itself through advertising and through
selling impersonal, statistical information about disease trends.
MDLiveCare asks for your credit card information.
Mostly, these companies seem to be in a kind of land rush. They see
health information as a nowhere-near-mature field, and they are staking
out the territory with little or no focus on profit for now.
If we want to imagine the true power of these patient interfaces, we
have to look even beyond today’s Internet browser-driven information
world to the new platforms arising right now: the smart phone and the
whatever we will call the generic version of the iPad. The iPhone is
not just a product, it is a platform. Though Apple is suing its
imitators, the platform will be imitated, copied, expanded and made
cheaper. The core of it is not the device, it is the combination of
cheap or free apps on a relatively open platform for which anyone can
The growth of this model has been explosive: More than 140,000 apps
are now available for the iPhone alone; people have downloaded more
than 3 billion of them. There is already a website dedicated just to
reviewing medical apps (iMedicalApp.com, of course), including patient
scheduler apps, charge capture apps, medical calculators and patient
The recently launched iPad will likely be another platform—similar,
but bigger and even easier to use, big enough to share, intuitive
enough for the non-tech-savvy, on which anyone can build any app,
especially including patient health care interfaces of every flavor.
Like the iPhone, it will launch a flood of imitators as well, and
manufacturers are already developing medical applications and
accessories for it.
None of these things will “fix” health care. But collectively they
route around its problems and head more directly toward the real value
we are looking for—the health of the patient, at the highest possible
quality and the least possible cost. Insurance reform can make health
care more available for more people. But collectively, these
innovations do what insurance reform could never do—actually make
health care better, faster, cheaper.
Cartoonist Walt Kelley’s character Pogo famously pronounced: “We
have met the enemy and he is us.” But Buddhist teacher Pema Chodron
much less famously pointed out that there is a corollary to Pogo’s
pronouncement: “I have met the friend and he is me.” In health care we
have for a long time been our own worst enemies, each defending our own
turf and way of doing things, often caught in a welter of mixed
incentives that would cross an investment banker’s eyes. In these
disruptive innovations, we can see the million ways we have of becoming
our own best friends.