Five tough lessons I had to learn about health care

Realistic conclusions and opportunities in health care.

Working in the health care space has forced me to give up many hopes and expectations that I had a few years ago. Forgive me for being cynical (it’s an easy feeling to have following the country’s largest health IT conference, as I reported a month ago), and indeed some positive trends do step in to shore up hope. I’ll go over the redeeming factors after listing the five tough lessons.

1. The health care field will not adopt a Silicon Valley mentality

Wild, willful, ego-driven experimentation–a zeal for throwing money after intriguing ideas with minimal business plans–has seemed work for the computer field, and much of the world is trying to adopt a “California optimism.” A lot of venture capitalists and technology fans deem this attitude the way to redeem health care from its morass of expensive solutions that don’t lead to cures. But it won’t happen, at least not the way they paint it.

Health care is one of the most regulated fields in public life, and we want it that way. From the moment we walk into a health facility, we expect the staff to be following rigorous policies to avoid infections. (They don’t, but we expect them to.) And not just anybody can set up a shield outside the door and call themselves a doctor. In the nineteenth century it was easier, but we don’t consider that a golden age of medicine.

Instead, doctors go through some of the longest and most demanding training that exists in the world today. And even after they’re licensed, they have to regularly sign up for continuing education to keep practicing. Other fields in medicine are similar. The whole industry is constrained by endless requirements that make sure the insiders remain in their seats and no “disruptive technologies” raise surprises. Just ask a legal expert about the complex mesh of Federal and state regulations that a health care provider has to navigate to protect patient privacy–and you do want your medical records to be private, don’t you?–before you rave about the Silicon Valley mentality. Also read the O’Reilly book by Fred Trotter and David Uhlman about the health care system as it really is.

Nor can patients change treatments with the ease of closing down a Facebook account. Once a patient has established a trust relationship with a doctor and obtained a treatment plan, he or she won’t say, “I think I’ll go down the road to another center that charges $100 less for this procedure.” And indeed, health reform doesn’t prosper from breaking down treatments into individual chunks. Progress lies in the opposite direction: the redemptive potential of long-term relationships.

2. Regulations can’t force change

I am very impressed with the HITECH act (a product of the American Recovery and Reinvestment Act, more than the Affordable Care Act) that set modern health reform in motion, as well as the efforts of the Department of Health and Human Services to push institutions forward. But change in health care, like education, boils down to the interaction in a room between a professional and a client. Just as lesson plans and tests can’t ensure that a teacher inspires a child to learn, regulations can’t keep a doctor from ordering an unnecessary test to placate an anxious patient.

We can offer clinical decision support to suggest what has worked for other patients, but we can’t keep a patient from asking for a expensive procedure that has a 10% chance of making him better (and a 20% chance of making him worse), nor can we make the moral decision about what treatment to pursue, for the patient or the doctor. Each patient is different, anyway. No one wants to be a statistic.

3. The insurance companies are not the locus of cost and treatment problems

Health insurers are a favorite target of hatred by Americans, exemplified by Michael Moore’s 2007 movie Sicko and more surprisingly in the 1997 romantic comedy As Good as it Gets, where I saw an audience applaud as Helen Hunt delivered a rant against health maintenance organizations. A lot of activists, looking at other countries, declare that our problems would be solved (well, would improve a lot) if we got private insurers out of the picture.

Sure, there’s a lot of waste in the current insurance system, which deliberately stretches out the task of payment and makes it take up the days of full-time staff in each doctor’s office. But that’s not the cause of the main problems in either costs or treatment failures. The problems lie with the beloved treatment staff. We can respect their hard work and the lives they save, but we don’t have to respect them for releasing patients from hospitals without adequate follow-up, or for ordering unnecessary radiation that creates harm for patients, or for the preventable errors that still (after years of publicity) kill 90,000 to 100,000 patients a year.

4. Doctors don’t want to be care managers

The premise of health reform is to integrate patients into a larger plan for managing a population. A doctor is supposed to manage a case load and keep his or her pipeline full while not spending too much. The thrust of various remuneration schemes, old and new, that go beyond fee for service (capitation, global payment systems) is to reward a doctor for handling patients of a particular type (for instance, elderly people with hypertension) at a particular cost. But doctors aren’t trained for this. They want to fix the immediate, presenting complaint and send the patient home until they’re needed again. Some think longitudinally, and diligently try to treat the whole person rather than a symptom. But managing their treatment options as a finite resource is just not in their skill set.

The United Kingdom–host of one of the world’s great national care systems–is about to launch a bold new program where doctors have to do case management. The doctors are rebelling. If this is the future of medicine, we’ll have to find new medical personnel to do it.

5. Patients don’t want to be care managers

Now that the medical field has responded superbly to acute health problems, we are left with long-term problems that require lifestyle and environmental changes. The patient is even more important than the doctor in these modern ills. But the patients who cost the most and need to make the most far-ranging changes are demonstrating an immunity to good advice. They didn’t get emphysema or Type 2 diabetes by acting healthily in the first place, and they aren’t about to climb out of their condition voluntarily either.

You know what the problem with chronic disease is? Its worst effects are not likely to show up early in life when lifestyle change could make the most difference. (Serious pain can come quickly from some chronic illnesses, such as asthma and Crohn’s disease, but these are also hard to fix through lifestyle changes, if by “lifestyle change” you mean breathing clean air.) The changes a patient would have to make to prevent smoking-related lung disease or obesity-related problems would require a piercing re-evaluation of his course of life, which few can do. And incidentally, they are neither motivated nor trained to store their own personal health records.

Hope for the future

Despite the disappointments I’ve undergone in learning about health care, I expect the system to change for the better. It has to, because the public just won’t tolerate more precipitous price hikes and sub-standard care.

There’s a paucity of citations in my five lessons because they tend not to be laid out bluntly in research or opinion pieces; for the most part, they emerged gradually over many hallway conversations I had. Each of the five lessons contain a “not,” indicating that they attack common myths. Myths (in the traditional sense) in fact are very useful constructs, because they organize the understanding of the world that societies have trouble articulating in other ways. We can realize that myths are historically inaccurate while finding positive steps forward in them.

The Silicon Valley mentality will have some effect through new devices and mobile phone apps that promote healthy activity. They can help with everything from basic compliance–remembering to take prescribed meds–to promoting fitness crazes and keeping disabled people in their homes. Lectures given once in a year in the doctor’s office don’t lead to deep personal change, but having a helper nearby (even a digital one) can impel a person to act better, hour by hour and day by day. This has been proven by psychologists over and over: motivation is best delivered in small, regular doses (a theme found in my posting from HIMSS).

Because the most needy patients are often the most recalcitrant ones, personal responsibility has to intersect with professional guidance. A doctor needs to master the arts of negotiation, inspiration, and active listening to find a plan that the patient agrees to and will stick to, and other staff can gather around the patient to shore up good habits as well. This requires the doctors’ electronic record systems to accept patient data, such as weight and mood. Projects such as Indivo X support these enhancements, which traditional electronic record systems are ill-prepared for.

Although doctors eschew case management, there are plenty of other professionals who can help them with it, and forming Accountable Care Organizations gives the treatment staff access to such help. Tons of potential savings lie in the data that clinicians could collect and aggregate. Still more data is being loaded by the federal government regularly at Health.Data.Gov. ACOs and other large institutions can hire people who love to crunch big data (if such staff can be found, because they’re in extremely high demand now in almost every industry) to create systems that slide seamlessly into clinical decision support and provide guidelines for better treatment, as well as handle the clinic’s logistics better. So what we need to do is train a lot more experts in big data to understand the health care field and crunch its numbers.

Change will be disruptive, and will not be welcomed with open arms. Those who want a better system need to look at the areas where change is most likely to make a difference.

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  • Really fantastic post Andy. What a great way to take and highlight 5 major challenges in healthcare.

    My biggest concern though is that it might take a silicon valley type event to flip healthcare on its head. Otherwise, we’re going to see a lot more of the same going forward.

    I posted previously about the idea of Treating a Healthy Patient ( ) which hits to the heart of some of the points your making and could provide a real catalyst for change in healthcare. It’s the path to that new model of care which isn’t so clear.

  • Andy,

    great article, here in Europe it is different with some countries exactly the oposite, but that is mainly because the health system is mainly run by the state like the NHS in the UK or in Denmark or it is very much the same once care ownership is not state run, like in Germany. The only thing on healthcare in terms of IT that the different groups could agree was HL7 as the interface XML deffinition.

  • The only one I can’t fully agree with you on is #3, the insurance companies. Not that it’s totally their fault, but when hospitals are signing contracts that call for cost “minus” for services such as lab and pharmacy there’s just no way to overcome that sort of thing, no matter how efficient one happens to get.

    Also, when insurance companies are sitting on 9-figure savings while hospital margins are 0 and the majority of hospitals can’t even break even… no, insurance companies don’t get a break from me.

  • Thanks for the comments. Yes, John, I liked the article you pointed to a lot and it goes great with mine. Mitch, you make a good point–and it looks like the vendors of EHRs rake in a good deal of cash also for products that most users complain about. I still think the big savings and improvements in care will come in smarter diagnoses and treatment plans (and their implementation).

    Cay, I’m not sure what you’re saying is different. Perhaps you’re referring to item #3 and getting insurance companies out of decision-making. The other advanced countries of the world are much better integrated than than the US, although HL7 allows too much diversity.

  • If anything, regulations only address the status quo. It’s no shortcut; only effective and responsive policies can make changes happen, coupled with efforts on the ground.

  • Hello John, thanks for your Article. We need more people who have given up hope yet. I hope that in the health sector in the future some changes for the better.

  • Robert LoNigro

    Terrific article Andy. Landed here via Paul Levy’s blog. I would challenge one statement you make:

    “Despite the disappointments I’ve undergone in learning about health care, I expect the system to change for the better. It has to, because the public just won’t tolerate more precipitous price hikes and sub-standard care.”

    I am hard pressed to find a constituency that believes care is sub-standard among John Q Public, and since the driving force of change is the governmen payors, NOT the Commercial/public sector (consider how difficult it was to control the cost of infused oncologic agents before CMS implemented ASP reimbursement), i do not personally believe that an appeal to the public garners much in the way of support for change. I find no appreciation for the concerns regarding cost of care to date, no desire for patients or providers to take on the risk of financial decision making, and in the latest potentially bipartisan Supreme Court reaction, it seems clear that there is little appreciation that our system is in the difficult condition you and I believe it is in.

    Bob Lonigro, MD, MS

  • Amber

    Health care costs boil down to two things:
    * The hospital can’t tell you in advance what the visit will cost;
    * The visit to the doctor/dentist/other medical professional depends upon what the insurance company will charge. I’m not talking about the copay, but the total amount that is charged, and recieved by the medical office;

    That prevents one from doing any type of useful price comparison between similar facilities.

    It is interesting that those medical professionals and offices that reject insurance are able to quote exact prices for any possible treatement, visit, or whatever, that one might require, that falls within their area of expertise.
    Equally interesting is that medical professionals and offices that accept insurance typically charge between 1.5x and 2 times the price of the insurance-rejecting offices. (IOW, the insurance accepting office charges, and receives US$1,000.00, the insurance rejecting office will charge between US$500 and US$750.00.);

  • Nice piece, Andy.

    I cant say I’ve learned the same about 2 and 3 however, and my take on each of your points is that yes, incentives (motivations) matter.

    We currently have a historical accident of a dysfunctional market driven by employee-sponsored insurance. Markets are pretty inept at changing their own entrenched rules that dominate how capital flows. When that happens, government, the ultimate rule-maker, is our only hope. (interesting that you mention regulations can’t create change, but then cite ACOs as a point of hope toward the end, aren’t ACOs a new type of regulation?)

    Each of your lessons has a root in incentives. We have to change the incentive structures to have meaningful change in health care.

    Incentives in payment reform can drive: 1. Patients to have even more immediate incentive in early life to have and maintain healthier habits 2. Create a world where case management pays so docs don’t have to do it. As you point out, others that can do it better, but they need to have incentives to delvier the value they cab create. Who would pay for it now under the current model? Only some enlightened orgs 3. and Docs, patients and insurers feel receive the benefits of implementing new technologies and having effective care plans and follow-through on discharge to keep down readmission.

    HiTECH is just about making sure the pipes get built, but that will be an enabler of new payment models, which will rely on information exchange. I thing of HITECH is a patch over a broken system built on misaligned incentives. Fiver years ago, now one could answer the question “who will pay” for new technologies, so somebody had to step in. No one but the Feds could ever make the cost/benefit numbers work. Under new payment models (a re-architecting of incentives) aligned with health, the numbers are starting to work, and we see more evidence of it every day in systems like Geisinger. So, in the long term, maybe we wouldn’t have needed HITECH with the right incentives, but it has laid some important groundwork.

    Without real economic incentives, they won’t happen. The motivation isn’t there. Economic incentives can nudge each of the participants day in and day out.

  • Great points about the challenges of healthcare. There are 2 reasons I have for optimism. I have long said “healthcare is where tech startups go to die.” Here are three reasons why I think that is changing.
    1. There is a wave of disruptive innovators on the care delivery side of things. MedLion, WhiteGlove Health, Iora Health, Qliance, HiTouch Health, Atlas MD, Employer Direct Healthcare (I could go on). Unlike molasses-in-January type decisions, they have rational decision processes/timeframe and know that legacy software won’t meet their needs
    2. Look at for a couple examples of orgs bending the cost curve in VERY difficult situations — i.e., they aren’t skimming the cream
    3. It will be virtually impossible to succeed in the new reimbursement environment (and the deflationary economic environment that is inevitable) without recognizing a longheld belief — the patient is the most important member of the care team. In reality, little has been done to reflect that last point as there hasn’t been an economic imperative. When there is that imperative, I don’t think it’s an overstatement to say “everything changes.” This will require entire new categories of software that incumbent legacy vendors aren’t well positioned to address.

  • civisisus

    nice post Andy, but you can’t start the conversation about health care at the point someone is with a clinician.

    Because health starts before that. With people. Not patients. It starts with something that is “not sickness”.

    Until you’re ready to do that, you’re not ready to talk about health care, or health reform, or my health, or everyone’s health.

    You’re only ready, basically, to talk about doctors. And frankly most of us are just not that into them.

  • Andy great lessons, I entered the Medical Informatics world via years of Computer Science and telecom. You are correct in many fronts. But , we most accomplish change in our health system or it will truly fail or doctors will have to return to trading eggs or chickens for service. The one thing that can help is technology. Just as medical devices such as MRI have brought significant change to healthcare.

    It does take the school of hard knocks to realize that the culture of Healthcare is the differentiator. Many startup with very smart people haven’t learn this yet, but they will.

    In Silicon Valley I continue to meet with startups that have no healthcare people on their staff. Yes they do have them on the board but not in the trenches, marketing, engineering… But this is the reason many will fail. You always need domain experience.
    Many will fail as they did in 2001. Mostly because they didn’t understand the issues or domain that they are working in.

    Sometimes it take a generation to realize change.

  • Brad


    Very useful article. Your comments on # 5 are from the treating illness point of view and I agree from that perspective. Where governments need to focus in on education for PREVENTATIVE health and wellness strategies and lifestyles. People need to be educated as children and young adults to adopt appropriate behaviors. We saw this with wearing seat belts, not drinking and driving, brushing your teeth, stopping smoking, etc. It will take a generation but I believe you will see people adopting improved lifestyles that will lead to better health.

  • jim ryan

    i agree, as a young family doc who also is an active programmer it’s sheer hell. software development is too far removed from the users. we need to start from scratch (sometimes moving backwards is more cost effective). develop a system that is capable of providing a system that will fit with the generations of multimedia saturated humans living in a hardware/robotic near future. change in inevitable, but my patience is waining. while simultaneously using antiquated legacy software with my patients, while taking classes for free on machine learning the disparity is obnoxious.