If we look ahead to the next decade, it’s worth wondering whether the way we think about health and health care will have shifted. Will health care technology be a panacea? Will it drive even higher costs, creating a broader divide between digital haves and have-nots? Will opening health data empower patients or empower companies?
As ever, there will be good outcomes and bad outcomes, and not just in the medical sense. There’s a great deal of thought around the potential for mobile applications right now, from the FDA’s potential decision to regulate them to a reported high abandonment rate. There are also significant questions about privacy, patient empowerment and meaningful use of electronic health care records.
When I’ve talked to US CTO Todd Park or Dr. Farzad Mostashari they’ve been excited about the prospect for health data to fuel better dashboards and algorithms to give frontline caregivers access to critical information about people they’re looking after, providing critical insight at the point of contact.
Kathleen Sebelius, the U.S. Secretary for Health and Human Services, said at this year’s Health Datapalooza that venture capital investment in the health care IT area is up 60% since 2009.
Dyson, who started her career as a journalist, is now an angel investor and philanthropist. Dyson is a strong supporter of “preemptive health care” — and she’s putting her money where her interest lies, with her investments. She’ll be speaking at the StrataRX conference this October in San Francisco.
Our interview, which was lightly edited for content and clarity, follows.
How do you see health care changing?
Dyson: There are multiple perspectives. The one I have does not invalidate others, nor it is intended to trump the others, but it’s the one that I focus on — and that’s “health” as opposed to “health care.”
If you maintain good health, you can avoid health care. That’s one of those great and unrealizable goals, but it’s realizable in part. Any health care you can avoid because you’re healthy is valuable.
What I’m mostly focused on is trying to change people’s behavior. You’ll get agreement from almost everybody that eating right, not smoking, getting exercise, avoiding too much stress, and sleeping a lot are good for your health.
The challenge is what makes people do those things, and that’s where there’s a real lack of data. So a lot of what I’m doing is investing in that space. There’s evidence-based medicine. There’s also evidence-based prevention, and that’s even harder to validate.
Right now, a lot of people are doing a lot of different things. Many of them are collecting data, which over time, with luck, will prove that some of these things I’m going to talk about are valuable.
What does the landscape for health care products and services look like to you today?
Dyson: I see three markets.
There’s the traditional health care market, which is what people usually talk about. It’s drugs, clinics, hospitals, doctors, therapies, devices, insurance companies, data processors, or electronic health records.
Then there’s the market for bad health, which people don’t talk about a lot, at least not in those terms, but it’s huge. It’s the products and all of the advertising around everything from sugared soft drinks to cigarettes to recreational drugs to things that keep you from going to bed, going to sleep, keep you on the couch, and keep you immobile. Look at cigarettes and alcohol: That’s a huge market. People are being encouraged to engage in unhealthy behaviors, whether it’s stuff that might be healthy in moderation or stuff that just isn’t healthy at all.
The new [third] market for health existed already as health clubs. What’s exciting is that there’s now an explicit market for things that are designed to change your behavior. Usually, they’re information- and social-based. These are the quantified self — analytical tools, tools for sharing, tools for fostering collaboration or competition with people that behave in a healthy way. Most of those have very little data to back them up. The business models are still not too clear, because if I’m healthy, who’s going to pay for that? The chances are that if I’ll pay for it, I’m already kind of a health nut and don’t need it as much as someone who isn’t.
Pharma companies will pay for some such things, especially if they think they can sell people drugs in conjunction with them. I’ll sell you a cholesterol-lowering drug through a service that encourages you to exercise, for example. That’s a nice market. You go to the pre-diabetics and you sell them your statin. Various vendors of sports clubs and so forth will fund this. But over time, I expect you’re going to see employers realize the value of this, then finally, long-term insurance companies and perhaps government. But it’s a market that operates mostly on faith at this point.
Speaking of faith, Rock Health shared data that around 80% of mobile health apps are being abandoned by consumers after two weeks. Thoughts?
Dyson: To me, that’s infant mortality. The challenge is to take the 20% and then make those persist. But you’re right, people try a lot of stuff and it turns out to be confusing and not well-designed, et cetera.
If you look ahead a decade, what are the big barriers for health data and mobile technology playing a beneficial role, as opposed to a more dystopian one?
Dyson: Well, the benign version is we’ve done a lot of experimentation. We’ve discovered that most apps have an 80% abandon rate, but the 20% that are persisting get better and better and better. So the 80% that are abandoned vanish and the marketplace and the vendors focus on the 20%. And we get broad adoption. You get onto the subway in New York and everybody’s thin and healthy.
Yeah, that’s not going to happen. But there’s some impact. Employers understand the value of this. There’s a lot more to do than just these [mobile] apps. The employers start serving only healthy food in the cafeteria. Actually, one big sign is going to be what they serve for breakfast at Strata RX. I was at the Kauffman Life Sciences Entrepreneur Conference and they had muffins, bagels and cream cheese.
Carbohydrates and fat, in other words.
Dyson: And sugar-filled yogurts. That was the first day. They responded to somebody’s tweet [the second day] and it was better. But it’s not just the advertising. It’s the selection of stuff that you get when you go to these events or when you go to a hotel or you go to school or you go to your cafeteria at your office.
Defaults are tremendously important. That’s why I’m a big fan of what [Michael] Bloomberg is trying to do in New York. If you really want to buy two servings of soda, that’s fine, but the default serving should be one. All of this stuff really does have an impact.
Ten years from now, evidence has shown what works. What works is working because people are doing it. A lot of this is that social norms have changed. The early adopters have adopted, the late adopters are being carried along in the wake — just like there are still people who smoke, but it’s no longer the norm.
Do you have concerns or hopes for the risks and rewards of open health data releases?
Dyson: If we have a sensible health care system, the data will be helpful. Hospitals will say, “Oh my God, this guy’s at-risk, let’s prevent him from getting sick.” Hospitals and the payers will know, “If we let this guy get sick, it’s going to cost us a lot more in the long run. And we actually have a business model that operates long-term rather than simply tries to minimize cost in the short-term.”
And insurance companies will say, “I’m paying for this guy. I better keep him healthy.” So the most important thing is for us to have a system that works long-term like that.
What role will personal data ownership play in the health care system of the future?
Dyson: Well, first we have to define what it is. From my point-of-view, you own your own data. On the other hand, if you want care, you’ve got to share it.
I think people are way too paranoid about their data. There will, inevitably, be data spills. We should try to avoid them, but we should also not encourage paranoia. If you have a rational economic system, privacy will be an issue, but financial security will not. Those two have gotten mingled in people’s minds.
Yes, I may just want to keep it quiet that I have a sexually transmitted disease, but it’s not going to affect my ability to get treatment or to get insurance if I’ve got it. On the other hand, if I have to pay a little more for my diet soda or my hamburger because it’s being taxed, I don’t think that’s such a bad idea. Not that I want somebody recording how many hamburgers I eat, just tax them — but you don’t need to tax me personally: tax the hamburger.
What about the potential for the quantified self-movement to someday reveal that hamburger consumption to insurers?
Dyson: People are paranoid about insurers, but they’re too busy. They’re not tracking the hamburgers you eat. They’re insuring populations. I went to get insurance and I told Aetna, “You can have my genetic profile.” And they said, “We wouldn’t know what to do with it.” I’m not saying that [tracking is] entirely impossible, but I really think people obsess too much about this kind of stuff.
How should — or could — startups in health care be differentiating themselves? What are the big problems they could be working on solving?
Dyson: There’s the whole social aspect. How do you design a game, a social interaction, that encourages people to react the way you want them to react? It’s like the difference between Facebook and Friendster. They both had the same potential user base. One was successful; one wasn’t. It’s the quality of the analytics you show individuals about their behavior. It’s the narratives, the tools and the affordances that you give them for interacting with their friends.
For what it’s worth, of the hundreds of companies that Rock Health or anybody else will tell you about, probably a third of them will disappear. One tenth will be highly successful and will acquire the remaining 57%.
What are the health care startup models that interest you? Why?
Dyson: I don’t think there’s a single one. There’s bunches of them occupying different places.
One area I really like is user-generated research and experiments. Obviously, there’s 23andMe*. Deep analysis of your own data and the option to share it with other people and with researchers. User-generated data science research is really fascinating.
And then social affordance, like HealthRally, where people interact with each other. Omada Health — which I’m an investor in — is a Rock Health company that says we can’t do it all ourselves — there’s a designated counselor for a group. Right now it’s focused on pre-diabetics.
I love that, partly because I think it’s going to be effective, and partly because I really like it as an employment model. I think our country is too focused on manufacturing and there’s a way to turn more people into health counselors. I’d take all of the laid off auto workers and turn them into gym teachers, and all the laid off engineers and turn them into data scientists or people developing health apps. Or something like that.
[*Dyson is an investor in 23andMe.]
What’s the biggest myth in the health data world? What’s the thing that drives you up the wall, so to speak?
Dyson: The biggest myth is that any single thing is the solution. The biggest need is for long-term thinking, which is everything from an individual thinking long-term about the impact of behavior to a financial institution thinking long-term and having the incentive to think long-term.
Individuals need to be influenced by psychology. Institutions, and the individuals in them, are employees that can be motivated or not. As an institution, they need financial incentives that are aligned with the long-term rather than the short-term.
That, again, goes back to having a vested interest in the health of people rather than in the cost of care.
Employers, to some extent, have that already. Your employer wants you to be healthy. They want you to show up for work, be cheerful, motivated and well rested. They get a benefit from you being healthy, far beyond simply avoiding the cost of your care.
Whereas the insurance companies, at this point, simply pass it through. If the insurance company is too effective, they actually have to lower their premiums, which is crazy. It’s really not insurance: it’s a cost-sharing and administration role that the insurance companies play. That’s something a lot of people don’t get. That needs to be fixed, one way or another.
Photo: Rick Smolan, via Esther Dyson