Delivering care in the new virtual world…
For the last 10 years now – yes, it’s been 10 years – since I started The Fickenscher Files, I’ve been putting forward my annual top trends to prepare for in the coming year. This year, I settled on 8 major issues. As I considered all of the challenges facing health care, the predictions became a bit murky after the top 8 so I stopped at that point. At the outset, let me apologize since I’m actually a bit late this year in making my predictions. Usually, I get them out the first week of the new year. However, now that I’m working without a lot of support staff (I do almost all of the work on the blog these days 😊), it seems to take a bit longer to get the blog out the door and published. Regardless, I’ve been giving a lot of thought to what the major issues are that as leaders we should be monitoring in the coming year. Here’s my top 8 list for your consideration:
#1 The Promising Side of CRISPR Becomes Potentially Ominous – The announcement by the Chinese researcher that he had edited the germ line cells of a set of twins deserves our special attention. For those who are not facile in the genomics area, the germ line cells are those that pass along our genetic code to our children and the lineage. These types of cells are in contradistinction from the somatic cells which are cells that have a function but do not pass along their genetic code to future cell lines. CRISPR is the new and evolving technology that allows for modification of the genetic code. Essentially, it’s a highly technical method whereby the researcher removes and/or replaces snippets of DNA from the genetic code of our cells. When applied to genetically derived problems, it can be an amazing technology. For example, the US Food and Drug Administration recently gave approval for the testing of CRISPR technology related to treating sickle cell disease which is caused by a genetic disorder that produces abnormal red blood cells. However, the interventions made are not passed along genetically in the germ cells since the intervention relates to genetic changes in somatic cells.
Under “Quote(s) of the Week”, I noted Bill Gates response to the evolving questions on the use of genetic manipulation. I would go a couple of steps further. In my estimation, the public debate and discussion related to the use of CRISPR technology is every bit as important as the nuclear disarmament debate was in the 1950s. If we thought Mutual Assured Destruction (MAD) was a scary outcome, then consider the possibility of Serial CRISPR Applications Revising You (SCARY) outcomes! Society needs to be awakened from its slumber for this discussion. We are at the God Point of genetic manipulation and beginning the walk across the bridge of creation. It should cause us pause. Just as we made a societal decision to “control” the spread of nuclear weapons, we should also be considering – via a broad global discussion and debate – the spread of genomic CRISPR applications. While I’m a big fan of genomic research, I’m also a big fan of understanding how, when, where, who and what our technology does as part of its human application. These issues have not been untangled in the CRISPR debate. What are your thoughts?
#2 AI/ML Becomes Integral To Health Care – It seems that all of the prognosticators are suggesting a dominant role for Artificial Intelligence and Machine Learning (AI/ML) in health care. I’m one of the pack!! I’ve been predicting the coming of “Clinically Augmented Intelligence” for at least four or five years. Well, it’s a reality! AI/ML over the coming decade – yes, decade – will change the very fabric of how health care is delivered, what is delivered, where and how it is delivered; and, who delivers it. How about that for a disruptive change in business-as-usual? This phenomenon hit me smack upside the head in 2016 when one of my MITRE colleagues introduced me to a new AI/ML tool developed on behalf of the Veterans Administration. The tool was able to diagnose post-traumatic stress disorder (PTSD) with a 95% concurrence rate to experts in the field by simply listening to the conversation of PTSD victims. When I learned of the tool, I was quite excited not only for helping to effectively treat PTSD patients – but, also for the fact that the tool was essentially a “physician whisperer” in the exam room that could suggest to me options during the course of my exam. Applied to other problems like Parkinson’s disease, depression versus back pain or a host of other problems that patients present during the course of an exam, and the approach was going to change care delivery. It was clear that the capabilities used in in developing a tool for PTSD were generally applicable to a range of other illnesses and diseases. And, in fact, that is exactly what is happening.
Let’s take DeepMind, for example. It’s an AI/ML tool founded in 2010 and purchased by Google in 2014. It uses deep neural networks and learning algorithms where the computer system teach itself about clinical problems – real time. The use of the system allows the computer to get better and better over time! As an example, researchers at the University of Oxford have created an application called Watch, Attend and Spell (WAS) that trained DeepMind to lip read people talking on television with the sound turned off by simply “watching” the tube and using computer vision coupled with machine learning. The system watched over 5000 hours of silent news coverage and ended up being 5X better than trained lip readers in determining what was being said about half the time. Lip readers were successful only 10% of the time. And, that’s just the beginning. It’s just one of the applications where DeepMind has been deployed. DeepMind started with games like AlphaGo but is quickly moving into the non-gaming world of serving as an assistant for clinicians managing real problems. DeepMind is now being used to diagnose acute kidney injury, threatening eye conditions affecting eyesight and a host of other clinical areas. If only the sight loss application is considered, the software has the potential for affecting over 285 million people worldwide over the next 7 years – a figure that is anticipated to triple by 2050 in large measure because of the aging population.
In another example, DeepMind has been at work in the area of “cooperative AI/ML” where computer systems work as “partners” with a team of individuals to support multi-agent learning which has been described as a very tough problem to solve. While we may think that getting teams of people to collaborate, managing a team of computers coupled with people is even more complex. The DeepMind technology was again applied to a game which demonstrated that AI/ML computer agents spontaneously developed tactics similar to those used by human players in the game. Even more interesting was the fact that the AI/ML agents were even more successful than their human counterparts in “teaming”. Couple the technology with clinicians and the whole notion of how-where-who “value-based care delivery” will occur is altered and accelerated – most likely in ways we cannot even imagine in today’s world.
Long story short – AI/ML, in my estimation, is the most important disrupter on the health care horizon. The challenge will be in deploying comprehensive solutions rather than piecemeal solutions. However, with the right “learning” structure integrated into the solution, the overall impact of AI/ML will be tremendous.
#3 ACA Moves into The Amendment Stage – The shift in the US House of Representatives from Republican to Democrat control will have significant implications across the board. One of the most important changes will be in the health care political playbook. The Democrats will need to move from simply keeping the Accountable Care Act (ACA) alive to finally moving toward amendments to solve problems and make it better. As a lifelong advocate that “health care is a right”, I can be declared biased. ACA has: 1) been shown to slow the rate of increase in health care costs, 2) created a mandatory set of 10 preventive services that all insurance plans are required to offer as part of their benefits package for all Americans, 3) dramatically decreased the number of uninsured in the nation by creating tax credits for middle income Americans and expanding the Medicaid programs across most of the US; and, 4) lowered the projected budget deficit by $143 billion through 2022 according to the Congressional Budget Office. These are clearly results that benefit the American economy and the American people. At the same time, I would be one of the first to tell you that the ACA could be improved.
On the downside, we’ve seen an exodus from small business insurance plans in part because of incentives and in part due to continuing escalation of insurance costs. In addition, short-term costs for health insurance have gone up because people are taking advantage of their first-time use of certain preventive services. The problem is that the overall savings will not kick in for a while. In addition, the tax impact has been a bit uneven. For example, the “Cadillac tax” which is a 40% tax assessment on high premium plans has had some unintended consequences. The problem is that these plans are often made available for those workers who are in high-risk jobs which require the higher premiums.
The end result is that the ACA needs to be fixed – not discarded. I’ve said it before and I’ll say it again. Medicare and Medicaid when they were first created in the mid-1960s had issues as well. But, instead of dismantling the program – Congress went to work and fixed the program which continues to this day. I have not heard anyone suggesting that we should dismantle either program. They are part of the staple of commitments made by our nation’s government to the people. The same phenomenon is evolving for the ACA. So, let’s get on with the approach of debating the fixes. For a listing of the pros and cons check out this non-partisan website.
#4 Integration Moves from Horizontal to Vertical – Most of the industry integration has been on the horizontal front. Hospital systems have gobbled up hospitals. Physician groups have extended their reach by acquiring like-minded organizations. The pharmaceutical industry has consolidated along with the health information technology and medical device industries. But, the next wave which is only now beginning will be vertical in orientation. The CVS-Aetna merger of a retail pharmacy chain with an insurance company is only the first step. The same is happening with health systems getting into insurance. The entry of the big kahunas (e.g. Amazon, Google, et. al.) will only drive the vertical moves – which takes me to my next prediction…
#5 A GAMA-plosion (Google, Amazon, Microsoft, Apple) of Investments Moves from Millions to Multi-Billions in Health Care – GAMA (Google, Amazon, Microsoft, Apple) is clearly intending to play in health care. Why? Because health care is one of the biggest components of our nation’s overall Gross Domestic Product. It’s a huge opportunity for those focused on efficiency and effectiveness. Each of these companies is engaged in specific health care market plays. For example, Amazon is offering software that mines medical records for approaches toward improving treatment and cuttings costs in health care treatment. In another move, Amazon paid $1 billion for Pillpack, a company that packages prescription medications for delivery to the home. Apple is working with the US Department of Veterans Affairs to make available the health records veterans on their iPhones. These are but two examples on the horizon. Google and Microsoft are not far behind.
#6 Value-Based Care Delivery Models Will Only Expand – I keep saying it over and over. The US health care system’s future is inextricably tied to a move toward value-based care delivery. Our economic tolerance for the traditional fee-for-service model is waning at best. In fact, if we don’t shift gears toward the value-based models, health care will bankrupt the nation. As a Boomer, I’m part of the problem. When I talk with my Boomer friends and indicate that I’ve spent more health care dollars in the last 5 years than in the previous 63 years of life – almost all of them nod their heads in agreement. And, there are a ton of us out there that are beginning to stress the system. So, the move toward value-based care delivery is tied to economic survival. If one adds on top of that phenomenon the increasingly competitive economies throughout Asia and Europe which are moving other industrial production overseas – the issue of cost management in health care becomes even more of a dominant concern to sustain the competitiveness of American products.
In fact, Frost & Sullivan – a health care consulting and advisory firm – predicts that “…by end of 2019, up to 15% of global healthcare spending will be tied in some form with value/outcome-based care concepts” (emphasis added). Why? The problem is with those countries that are spending more than 10% of their respective GDP on healthcare. It’s also the countries with a large, growing elderly population. The key leaders on the list include the United States, Netherlands, Sweden, France, Germany, Canada, and Japan. From my perspective, those health care systems that aggressively develop value-based care delivery models will stand the test of time. The others will fall by the wayside. Mark my word.
#7 Virtuality Explodes – Perhaps the most disruptive short-term change will be the explosion in the use of virtual health care services. It’s very clear that upwards of 75% of primary care can be delivered using virtual services. However, the major impediment has been three major issues. First, licensure requirements have precluded providers offering services across state lines. The move by the Federation of State Medical Boards to use the Interstate Medical Licensure Compact will resolve many of those issues in the coming year. Second, as the nation moves toward “value-based care delivery” (SEE #6 immediately preceding this prediction), the ability to use health care professionals at the top of their license and simultaneously reduce costs will be an imperative that health care systems will not be able to ignore. And, third, the lack of integration of the splinter solutions and telecare options that are disconnected from traditional face-to-face care causes major problems in fostering and supporting good outcomes.
#8 Blockchain Moves Out of the Test Lab – The hype on blockchain has been fairly strong and there are a number of commercial product development companies that will no doubt be moving into the deployment stage in 2019. Companies such as Change Healthcare, Hashed Health, and Guardtime, among others are at the vanguard of a shift in how technology will manage and support changes in how health systems manage health information. Blockchain is not the end all/be all solution for health information technology. My friend and colleague, John Halamka, MD said it best in a 2018 interview, “Blockchain is not meant for storage of large data sets. Blockchain is not an analytics platform. Blockchain has very slow transactional performance. However, as a tamperproof public ledger, blockchain is ideal for proof of work. Blockchain is highly resilient”
From here on down the line, there are lots of other changes on the horizon but they pale in comparison to the first 8!