Entrepreneurship, Healthcare

Weaponizing Natural Selection

This weekend there was a fantastic article in the Journal about building antitrust momentum against Big Tech and the rising Techlash of 2016-2019.  It’s an incredible read and really shows you how far we’ve come since this puff piece about Chris Hughes’s second “startup”: the ’08 Obama campaign[1].

Review of “The Moral Animal”… or my take on Chris Hughes

At the same time, I just finished an incredible book on evolutionary psychology, The Moral Animal.  An oldie but a goodie, this book gave me insights about the Theory of Natural Selection that I had not encountered in any of my college psychology courses or other readings (Dawkins, Wilson, Etcoff).  It is pretty amazing the play-by-play of Darwin’s life that Wright lays out while simultaneously weaving in an explanation of the theory of natural selection and its many consequences[2].

One passage in particular toward the end of the book really piqued my interest.  As Wright details, despite it’s simplicity the Theory of Natural Selection has major implications for one of the most nagging questions humans have asked: is there such a thing as free will?  If all of our reward and punishment systems are biochemically-driven, “designed” by natural selection to promote fitness, do we really have any volition in the actions we take? Or are we all just justifying actions post-hoc as if we were a “rider atop an elephant”?

The sustained momentum of the Techlash is, I think, in large part driven by the fact that Americans at some level feel it deeply unfair that Big Tech is profiting off of our deepest impulses in ways that the broader public didn’t understand until now.  As an example, a former Facebook executive implicated “dopamine-driven feedback loops” in Facebook’s destruction of our society and comity writ large.

I can’t answer the question of whether we have free will and/or whether it is moral that companies are profiting off of their weaponization of natural selection.  But what I want to start to answer is, what if natural selection were weaponized for good?  What if all of the addictive impulses of our reward and punishment systems were leveraged by technology to promote social good?

Let’s take the healthcare industry as an example.  Most players in healthcare are driving toward the Triple Aim: lower cost, higher quality, better experiences.  What if we:

  1. Simplified Consumer Healthcare Apps to Drive Positive Feedback Loops?  People are really embracing the wearables trend[3], but counting steps has diminishing returns above a goal of 7,500 per day.  How do we as an industry gamify the treatment of chronic diseases like renal failure, diabetes, and obesity? Companies like Livongo lead the way toward reducing the overall costs of these chronic conditions, which represent up to 90% of all U.S. healthcare spending annually.
  2. Made Lower Cost Options the Default?  Research shows that defaults are perhaps the most important factor in creating long-lasting changes in human behavior[4].  However, when we sign up for health insurance plans, finding coverage and establishing a primary care relationship are among the most difficult things to do!  What if during the annual enrollment/renewal process payors automatically enrolled patients at the lowest cost (e.g., CVS HealthHUB, Walgreens VillageMD, local family medicine) clinic to deal with routine disease management conditions? Combining this with the ability to opt-out via a single button click would simultaneously lower cost and preserve consumer choice.
  3. Provided Better Visualizations for Probabilistic Outcomes? In his book Thinking, Fast and Slow, Daniel Kahneman describes how he and Amos Tversky moved the psychological mainstream from viewing humans as “probability calculators” to “heuristics users”.  Subsequent research has shown that humans are notoriously terrible at interpreting probability.  How can we advance the visualization aids and tools used in the delivery of healthcare to help people better understand their choices and what outcomes are likely to occur from various treatment pathways?[5]

I’m really excited to see announcements from CVS that they are continuing to disrupt healthcare with the introduction of “HealthHUBs”.  Structural changes that improve how we pay for and deliver healthcare is always welcome in my book.  However, Wright’s book opened my eyes to the fact that we are going to have to have more nuanced answers for how to fight millions of years of evolution that intentionally drives behaviors that, while once evolutionarily adaptive, are now being exploited by industries from Tech to Pharma to Food/CPG to drive sub-optimal outcomes.

[1] For Chris Hughes’s latest reversal into anti-tech crusader see his NYTimes op-ed on breaking up Facebook.

[2] Is self-delusion actually a wonderful trait for natural selection? Likely so.  The more authentic a deluder’s belief in their own delusion, the greater their ability to persuade other chimps of this delusion as “truth”.  What implication does this have for the definition of “truth”? This is left to the reader to ponder.

[3] For more on this see Apple’s CEO Tim Cook predicting that their company’s greatest contribution to mankind will be in healthcare.

[4] Shout-out to Richard Thaler, last year’s Nobel Laureate in Economics and a teacher at my dear alma mater!

[5] A lot of the momentum in this area was blunted during the push for the Affordable Care Act.  Patients confronted with “probabilities” were most often end-of-life patients and their families trying to understand treatment options and/or palliative care.  Reviews and explanations of evidence-based medicine protocols were labeled “death panels” and ended up politically DOA (no pun intended).  Now that we know that 25% of all Medicare spending occurs in the last year of life, the issue rears its ugly head again.

Entrepreneurship, Healthcare

Is Healthcare Innovation Different?

Capitalism without bankruptcy is like religion without sin. Bankruptcies and losses concentrate the mind on prudent behavior.

– Allan Meltzer (rephrasing of an old adage)

Last weekend, I binged through an incredible podcast (thanks Alexa!) called The Dropout about the saga of Elizabeth Holmes and her ill-fated biotech venture Theranos.  It made me look forward even more to when I get to read Carreyrou’s Bad Blood, based on all of the WSJ articles I had read before.  Her’s is a very compelling saga about our insatiable desire as Americans to be pioneers and frontiers(wo)men of the 21st century while simultaneously making billions.

Before I get into the meat of my latest thoughts, I want to be very clear on one thing: I am of the belief that Theranos was an unjustifiable criminal enterprise.  Putting millions of patients’ lives at risk through fraudulent behavior is not “flying the ship and building the ship”.  Real-world decisions have real-world consequences, and I think that this case seems more clearly a case of right and wrong as time goes on.

However, one of the questions that the podcast explicitly brings up is this: what role does Silicon Valley’s “win at all costs” and “fake it till you make it” have when it comes to disrupting healthcare? More broadly, what role does capitalism have in healthcare? Is it corrupting? Should we just listen to the 2020 Democratic candidates and accept that Medicare-for-All (single-payer or some safety-net alternative) is the right way forward and enough with healthcare as a money-making venture?

I’ve written before about how private markets are an incredible technology that help focus the whims of many to align to simple, achievable goals.  I’ve hinted at how complex our healthcare system is (largely driven by anachronisms in how we pay for and deliver it).  But now I want to answer the question directly: should innovation in healthcare be different than for existing industries Silicon Valley has disrupted?

Yes, but Tech can actually provide a model for how we have our cake and eat it too.

Healthcare approach to #Disruption

Let me explain this by way of analogy.  Let’s say you are about to buy a home.  Congratulations! You’ve signed some papers, found the perfect neighborhood, and lined up a lender.  The offer was accepted and you are about to close.  Just one small process: the inspection.  The inspector is walking through your soon-to-be-home and as he sees the outside of your house he says, “Hrmm, uh-oh.”  You wait for him to continue his walk-through, and just before he finishes he goes to your basement foundation wall and says, “Hrmm, uh-oh.”  Which of those worries you more? If you’re like me, probably the foundation wall.  The foundation of your house crumbling is a far costlier, scarier proposition than a small leak or missing piece of vinyl siding.

And that’s how we have to approach Silicon Valley disruption to healthcare.  There are varying degrees to which healthcare must continue to evolve.  Core phlebotomy and related lab work that is the basis for clinical diagnoses needs to be treated with infinitely more care than improved teeth-whitening products.  Some of the FDA’s guidelines on real-world evidence have been really illuminating on this topic and frankly, hearten me that our government agencies are being responsive in the Age of Tech.

However, these lines are going to get blurred very quickly.  For example, Amazon’s recent acquisition of PillPack shows that it is getting serious about disrupting healthcare logistics.  This is less concerning in cases of delivering vitamins.  A missed day of vitamins won’t have major adverse impacts.  But what if Amazon misses a shipment of at-home chemotherapy pills? How about if Amazon becomes the primary supplier for a hospital’s perioperative department and misses a day’s worth of disposable surgical instruments?[1]

In my opinion this is a solved problem.  At major tech companies, product capabilities are segmented into one of two major “buckets”:

  • Platform and Core: These are software solutions and services that should be very rarely modified and undergo extensive review/testing when they are
  • Applications and Non-Core: These are portions of the software stack where it will not cause undue burden to the business or to users if they are non-functional; they can be updated at a daily/weekly cadence with ease

This segmentation is the reason that you will see far fewer upgrade to the GMail core encryption protocol than you will to the “One-Click” integrations GMail has for airlines, car rentals, tickets, etc.

Prudent leaders of 21st century health systems are going to have to be clear in drawing these lines for their own organizations.  For example, modifications to core insurance eligibility checking systems should be performed far less frequently than updates to fitness monitoring apps.  With this in mind, innovation won’t die on the vine for core capabilities, but rather be entrusted to be as advanced as possible without sacrificing patient safety or operational stability.  Silicon Valley is more likely in this model to be successful improving healthcare by nibbling away at the edges of healthcare delivery than providing a grounds-up rethink.

[1] Supply chain risk in pharmaceuticals and medical devices is a huge concern for the modern healthcare organization, leading organizations like Intermountain to develop their own non-profit, named CivicaRx, for generic drug delivery.


I Live in the Future…

If it is now asked, “Do we presently live in an enlightened age?” the answer is, “No, but we do live in an age of enlightenment.”

– Immanuel Kant

The other day I had an odd experience.  As I was doing my normal checkout at Whole Foods (stocking up ahead of the madness from the upcoming price slashes), I double-tapped my Apple Watch, held it to the NFC card reader, and felt the “tap-tap” of a complete transaction.  It’s a Series 1, so I’ve done this dance hundreds of times, and to me now it feels routine.  But the cashier shot me a look and said, “Woah! I’ve never seen that one done”.  His surprise caught me by surprise.

Two things came to mind.  First, it is truly amazing how much we can do these days in a matter of seconds.  Apple Pay replaces something that takes 30 seconds to a minute, sure (fumbling with cash, writing a check, swiping a card), but there is so much more I can do from my devices in general that happen 10-100x faster and I have become completely inured to.  Get a late night email from the boss? No problem.  Open the OneDrive app on my phone, hit the share button, and instantly reply back with the document he needs (and permissions correctly configured).  When I told my grandfather that I do quite a bit of heavy-duty work from my phone, he was extremely surprised.  To have gone from radio broadcasts to connected-anywhere supercomputers in our pockets during his lifetimes blew his mind.

Secondly, I realized that I live in the future.  My guess is that, if you are reading this blog, you do too!  So many people are anywhere from a few years behind bleeding-edge technology (the cashier) to many many years (my grandpa).  Without carefully checking in with other people, it’s easy to become wrapped up in your routine and think your baseline is everyone else’s too.

Me Adopting New Technology

Rather than lament the fact that this new technology is causing a Loneliness Epidemic across the pond or draw out the litany of examples of how major tech companies don’t handle diverse customer bases well at all, I’d like to zero in on our current struggles in the Healthcare IT field.

This week, an influential piece called “Death by a Thousand Clicks” was published on the Kaiser Health Network, highlighting some of the very serious and very shocking struggles major Electronic Health Record (EHR) vendors have had since meaningful use’s launch.  It was an eye-opening article, forwarded to me several times by family members and clinician friends.

I applaud my employer’s timely response at HIMSS19, launching Virtual Scribe and Chart Assist to improve clinical documentation, lessen providers’ cognitive burden, and help solve the problem of physician burnout. It’s an important step in using the latest technologies to solve a real and pressing problem that is causing major unneeded pain in healthcare.

But I think there is a more basic solution that is needed for Healthcare IT companies to be successful: retrain on the clinician workflow.  In “Death by a Thousand Clicks”, the author likens the Meaningful Use legislation that came from the HITECH Act to “asking nine women to have a baby in a single month”.  In the rush to meet legislation and do the right thing, certain tradeoffs were made by HIT vendors so that healthcare could continue to function, providers could get paid, and patient safety would not be compromised.

Now is the time for all of us in Healthcare IT to regroup.  Let’s breathe a sigh of collective relief: the fight to digitize healthcare is over and we won. Today, more than 90% of hospitals across every category use an EHR and 85% of all office-based physicians use an EHR.  Now that the hard tasks of installation, configuration, deployment, change, and ultimately digitization have been done, we need to reflect and heed Kant’s words.  We are not yet fully enlightened, not fully realizing the promise of digital medicine, but we can see the path forward.  I am excited for the industry to make its long-awaited pivot and tackle the basic building blocks (user experience, stability, performance) that will restore joy to the patient-provider experience.  It is a many-sided problem with multiple required solutions, but the blocking and tackling is going to be just as (if not more) important than a lot of the futuristic AI buzzwords we see today.  Put another way, I will continue to use my Apple Watch for contactless payment, but we all have to make sure that “Cash and Credit” is a seamless, joyful option for everyone interacting at the Health IT checkout line.

Corporate Strategy, Entrepreneurship

Greed is (Not?) Good

Capitalism is a great technology and a mediocre philosophy.

– Reid Hoffman

This week I passed by an article in the Wall Street Journal about how pay regulations are back on the table for big banks.  Although the rule was mandated by Dodd-Frank, a decade later the pay restrictions and clawbacks are not in place (seriously?).   At the same time, I started reading Duff McDonald’s epic takedown of MBAs, The Golden Passport.

I haven’t read the full thing yet so don’t want to give a review, but it’s definitely getting my attention. Mainly I’m drawn in by McDonald’s provocative writing and crux-finding.  In the earliest chapters, he lays out the root of all MBA evil: profits.  Telling the story of Frederick Taylor, the founder of Taylorism and an early management science pioneer, McDonald throws down and calls out Taylor as a traitor to workers and glorified bean-counter.  When discussing the “original case study”[1], McDonald criticizes Taylor’s self-aggrandizement and attempts to science-ize management:

Frederick Taylor generalized a step too far.  In arguing that his methods revealed a universal science of management, Taylor engaged in metonymy–confusing just one part of management (that is, quantitative analysis) for the whole.  Efficiency–and its close relative, profitability–is just one possible goal of management.  Others include customer satisfaction, community relations, and quality.  In Taylorism, one could argue, lie the seeds of American industry’s eventual comeuppance at the hands of the Germans and the Japanese…[H]e was implicitly sanctioning the idea that a company can be judged by a single metric.  Today’s even more pernicious version of such: shareholder value.  Writes Stewart: “The modern-day CEOs who sacrifice the long-term viability of their corporations for the sake of short-term boosts in their quarterly earnings reports are direct descendants of the pig-iron managers who undermined their work team’s morale in order to achieve temporary productivity targets.”

McDonald is not subtle, to say the least.  But, ignoring European dissatisfaction with their more socialist system and Japan’s anemic growth over the last decade, McDonald also gets one crucial thing wrong in my opinion: that profits, shareholder value, efficiency, or whatever you want to call it, are the wrong metric.  In my opinion they are the right metric, but the markets that are developing in America are no longer fully free and fair.

Profits represent a very simple metric: revenues minus costs[2].  Revenues are also a very simple metric: the value to the person buying the good or service.  And cost, you guessed it, is a simple metric: the value that was expended in producing the good or service.  So, at its core profits represent the purest definition of value creation, the difference between what value was expended to produce a good or service and what the consumer values that good or service at.

My argument is that Friedman was right and there is no better way for a society to operate than to have corporations attempt to maximize profits.  By only taking into account value created (revenue) and value destroyed (cost), all of the hardest questions are boiled down into “value”.  It’s a nebulous term, but with a free and fair market, it forms the motive that self-interested humans need to participate without relying on political connections, committing fraud, or more.  In a free and fair market, you have to create value, or you go out of business.

But surely, there are problems.  In America today, there is income inequality, monopolization, fraud, Wall Street short-termism, and more.  These are real problems that are infecting our society and becoming more visible with each passing year.  So do they exist because MBAs have tricked the world into sacrificing the common good on the altar of profit-driven capitalism? No.  Increasingly, consumers lack the ability to take their dollars elsewhere.  In repeat transactions, consumers have no choice because America’s markets are getting less free and less fair. Some examples:

  • Transactional in Nature.  When corporations have a one-and-done interaction with you, why bother having good customer relationships, support, or quality?  Examples: car salesmen (who are not linked to service), realtors.
  • Private Equity Leveraged Buyouts.  If you’re definitely going to exit an investment in 7-10 years, does it make sense to plan for longer? Certainly a private equity firm that does will have a lower IRR, and therefore not look as good to future investors. Examples: RJR Nabisco, Toys R’ Us.
  • Monopoly.  When every repeat transaction is guaranteed to go to your platform, why bother doing anything right? Customers can’t switch, so they won’t. Examples: Cable companies, landline phones, employer health insurance.

    Meet customers where their tastes are

Compare that with some of the best examples of customer satisfaction, quality, and community relations.

  • Amazon.  Online retail is cut-throat, single-digit margin business with insanely low switching costs.  Bezos knew from the outset that good customer service could be a huge competitive advantage.  People value convenience and purchase consumer-packaged goods every few days, so by having the best customer service Amazon keeps its customers wanting more.
  • Rolex. When your good is a commodity, how can you stand out from the crowd? Make your watch impeccable quality, ornately adorned, and a status symbol.  The business model here makes sense from a profit perspective: don’t compromise on quality, and your customers will more than make up in the difference of your costs.
  • Mom-and-Pop Shops.  When your reputation is on display daily because all of your clients are neighbors, you often behave with community relations in mind.  According to a recent study[3], small businesses donate 250% more than larger businesses to non-profits and community causes.

So how to address the problems of our day if not by throwing out the concept of shareholder value?

  • Executive Compensation Periods.  Deferring the compensation for longer than the current 5-year standard and enabling clawbacks is absolutely crucial to ensuring that, say, 10 years into a toxic mortgage the executives are not retired and fully vested while the rest of the economy melts. The WSJ article is a salient reminder of the urgency of this.
  • Expansion of Small Business Loans and Incentives.  If Amazon can get billions of dollars in incentives for building HQ2, why can’t other businesses? To New York’s credit, the majority of what Amazon was leveraging were programs that already existed for other businesses.  For some municipalities though this is not the case.  We should be encouraging small upstarts to take on incumbents and build in the communities they serve.
  • Incorporation of Full Cost into the Production of Goods.  Coal-powered energy brought almost 1 billion people out of poverty in China at the turn of the 21st Century.  There is real evidence that the climate is changing, but at what benefit? Let’s assign a dollar value to carbon, modify it frequently, and levy it on large industrial companies.  This will help address externalities within the framework of the profit-seeking motive.
  • Aggressive Monopoly-Busting. I am firmly on the side of more vigorous antitrust enforcement.  Modern business has gotten basically a free pass to vertically integrate thanks to Bork’s precedents and a focus on an actually bad single metric (HHI).  Makan Delrahim took a step in the right direction, but the courts need to break precedent and change with the times.

Culture is important.  Greed is not always good.  But show me a better technology than profit-based incentives for capitalism before you say we should throw the baby out with the bathwater.

[1] The original case study was, not surprisingly, about steel and railroads.  In 1899, the Bethlehem steel company found themselves in possession of a surplus of two million pounds of pig-iron bars.  They needed to figure out the most efficient way to load them into railcars for transport, and Taylor stepped in.  Whether counting, efficiency, or science, McDonald considers this the original sin of HBS.

[2] What type of profits? Economic profits.  There are adjustments, tax considerations, etc. etc. in the real world I understand, but I am simply using the most basic definition of profit available.  This might even be part of McDonald’s argument: that such an analysis is too simplistic.  But I would argue there’s nothing wrong with establishing that gravity is 9.8 m/s^2 of acceleration, even if there’s always air resistance on Earth. As is often said, “the difference between theory and practice is, in theory small, but in practice much larger.”

[3] Seattle Good Business Network

Corporate Strategy, Healthcare

No Customization Without Differentiation

No one wants to hear Odysseus go to the corner store.

– Alex Blumberg

Recently, I was sent an interesting article about how “Cowboy(/girl)” doctors are driving up healthcare costs in medicine.  The authors cite a study that argues that, when it comes to dying, certain doctors “reject ‘evidence-based professional guidelines for appropriate care’ and… order invasive and costly procedures despite little chance their efforts would delay the inevitable”.  These “Cowboy” doctors, as they are labeled, contribute up to 35% of end-of-life fee-for-service Medicare expenditures, and up to 12% of overall Medicare expenditures.  To give you an eye-popping dollar figure, that would amount to $84.5 billion[1].

Beyond questions of morality and what constitutes “little chance” in the study, this raises another interesting question for patients and providers: should we drive toward standardization of care plans?

On the one hand, the word standardization itself implies, at the very least, a reduction in inequality for all.  But furthermore, recent studies of standardization of care across patient populations shows it cuts costs and raises quality, two front and center goals of the IHI’s Triple Aim.  In business school, we had a saying in strategy: “No customization without differentiation”.  Basically, I took this to mean that unless you could prove beyond a doubt that your special snowflake was far superior to the rest, you should not customize the product/company/service you were offering.  Bundled payments programs like CMS’s Comprehensive Care for Joint Replacement (CJR) aim to use standardization to drive improved outcomes and cost, perhaps implying that they believe current customizations between providers are not differentiated.

However, standardization of care (often through the specter of “socialized medicine”) is a common boogeyman evoking images of “death panels”, rationing, and the removal of physician judgment from the medical process[2].  Obviously, depending on how the problem is framed public opinion shifts, and there are different care delivery models that can make these problems better or worst.

As we enter HIMSS19 this week, and we start to see more intelligent offerings that aim to bring standardized, evidence-based practices to global healthcare delivery, I can’t help but hearken back to when the human genome was first sequenced.  The attitude back then, growing up in a family of physicians, was that from that day on every single treatment would be individualized and targeted.  No longer would your Advil bottle say “Adults over 12 take two pills per day”, and gone were the days of treating every infection with Amoxicillin.  But now, we have done a complete U-turn.  HIMSS vendors and attendees are focused on treating populations of thousands or millions of patients with reduced variation, reduced cost, and greater predictability.  Not greater customization.

In fact, I was in a conversation at Cerner last week where we began to touch on some of our advanced genomics offerings.  One business leader remarked that there were well-set standards in pharmacogenomics, but fewer in oncological genomic medicine.  This focus on standards led me to think that there may be a new two-tiered approach emerging in medicine.  First, advanced medical practices are studied and honed at leading specialty centers (for example, MD Anderson for cancer).  Then, they are formulated into practices that are proven to scale to thousands or millions of patients in a repeatable manner.

Dr. Bluth Adopting New Methodologies

It’s a far cry from the precision offered by gene sequencing and individualized treatment, and more akin to the University -> Industry pipeline that has existed in the tech industry for years (think Stanford PageRank -> Google Search).  I don’t know what to make of this yet, but I think there are implications that we need to think through:

  • Will the drive toward standardization compound the problem of ignoring rare illnesses, which the U.S. had to combat with special Orphan Drug regulations?
  • Will the rise in standardization cause a loss of provider autonomy and worsen the problems of burnout and disengagement U.S. clinicians face?
  • Is the human body and its millions of variations even “standardize-able” in such a way that allows this approach to work?

Either way, technology has a role to play.  But I always worry about pendulum swings, and my take is that competing approaches should be balanced to find an optimal path.

[1] See the HHS 2018 budget in brief for more details.

[2] I’m looking for a comprehensive article or journal paper discussing the systemic effects of rationing in single-payer, integrated delivery systems, and different competitive models but I can’t find anything good.  Let me know of any good links.

Corporate Strategy, Healthcare

Price Transparency – Healthcare’s Silver Bullet?

Trust is the coin of the realm.

– George Shultz

This week, most people are talking about all the news coming out of JP Morgan’s Annual Healthcare extravaganza, and rightfully so.  However, I don’t think there’s much I can add to the discussion, so I want to talk about another big event that happened in the past couple of weeks: CMS’s implementation of the much-anticipated Price Transparency rule for hospitals.

Unfortunately, over the break I was in a hospital for a family-related medical event for which I would be financially responsible.  Once I knew the issue would be resolved without any major harm or loss of life, my next question turned to: would I be able to afford this? Cerner starts its new plan year along with the calendar year, so being in the hospital in early January means incurring medical expenses without the added benefit of having time to fill your HRA/HSA.

Having knowledge of the new price transparency rule, I turned to Google and looked for the hospital’s chargemaster.  The first hiccup: it wasn’t there.  Being a determined consumer, I politely called the billing department to note that they had not released their prices and therefore were non-compliant with CMS’s new regulation.  To this organization’s great credit, they told me they were working on it and within a week got back to me with the link.

Next, once I downloaded the chargemaster as an Excel spreadsheet, I started to comb through it on my phone.  This was the second hiccup: although the pricing information was machine-readable, it was not human-readable.  Searching through abbrevations like INF, HOSP, etc. was time-consuming and not straightforward, especially as a non-medical professional.

So, lastly I decided to buzz my friend (who happens to be an RN at the hospital, convenient!) and asked her to explain to me what a typical set of codes/services might be for the stay that occurred.  Her response: no clue man.  And that is fair, because she is a healthcare provider and knows nothing about billing.

My Excitement Looking at a Chargemaster

Looking at Administrator Verma’s take on the new rule, I think she is absolutely right: this is a first step.  It is a great first step and I applaud it, but the major issue I take with the data is not inaccuracy for those with insurance.  Healthcare stakeholders need to understand that data is only as good as the tools that use them.  So, I would propose several next steps for those implementing and administrating price transparency rules:

  1. Campaign for Awareness – I was only aware of this new data source because I happen to work in Digital Health.  99.9% of Americans don’t even know this data exists.  Well-placed TV or radio dollars could help get the word out, increasing patient utilization.
  2. Encourage Sophisticated Tooling – By the time I got to the chargemaster it was in Excel format and highly complex medical jargon.  There are some great Price Transparency experiments that CMS is running to help modernize federally-run insurance programs, but private enterprise should be encouraged to build direct-to-consumer tools on top of the new information.
  3. Integrate Pricing with Workflows – The fact that my friend, who is an RN at the health system, could not tell me how specific clinical procedures mapped back to billing is troublesome.   Better integration between the EHR and revenue cycle solutions will help clinicians guide consumers as healthcare becomes more and more consumer-driven.
  4. Create Consumer-Friendly Price Hotlines –  Many major health systems are moving toward employing in-house billing and coding specialists to maximize revenues and improve cost efficiencies across their facilities and networks.  As this happens, health systems should also create “consumer helplines” that answer simple questions about pricing and services ahead of time.  Lots of startups like ZenDesk, LiveChat, and Intercom provide a front-door chat interface that integrates natively with websites and could solve this issue elegantly.

All-in-all, I was not able to get a sense of what the cost for my visit would be and had to wait for the bill to arrive.  This begs a question though: if I had been able to find out what the visit cost, would it have changed my behavior? The answer is almost certainly no.  My main concern was making sure that my family was healthy.  What amount of price savings would I trade off for that? That thinking alone is probably more likely to continue driving healthcare costs upward faster than any downward pressure this Price Transparency effort could provide.

New Year's, Personal

2018 Book List

Back at it again, with 5 books I read that totally changed my perspective on life, business, and coffee.  I would love to hear of any good books you’ve been reading, so DM me if you have them!

First, to commemorate the centennial of Armistice Day (the end of World War I), I picked up All Quiet on the Western Front, which (although I think I was supposed to read it in high school) I only saw the film for.  The book is far more gripping. In addition, I was recommended 1944 to discover more about the pivotal year in the second World War (the 75th anniversary of the end of that conflict is right around the corner too).

Second, I took a deep dive into business books as I started my next chapter in corporate strategy.  I’m making my way through Influence and The Basics of Hoshin Kanri to understand how decisions are made in large companies (or rather, how someone can make decisions “happen”).  This sort of plays on my theme last year of psychology books with true-to-life lessons (like Kahneman and Haidt), but from a more industrial/organizational lens.

Finally, I took the time to dive deep into what I say is a passion with some actual reading.  While a grad student, I found a wonderful local book entitled Craft Coffee that dives into the art and science behind coffee picking, brewing, and paraphernalia.  For any coffee-lovers, this is a great way to get quickly versed with what temperature to brew at, how to grind, and much more.

As with last year: rather than editorialize about each book individually, I’ve copied in the Amazon descriptions below (and included a link to Amazon Smile – go pick a charity of your choice!)  If you get some time this holiday season, these are definitely worth the read.


All Quiet on the Western Front, Erich Maria Remarque.  Paul Baumer enlisted with his classmates in the German army of World War I. Youthful, enthusiastic, they become soldiers. But despite what they have learned, they break into pieces under the first bombardment in the trenches. And as horrible war plods on year after year, Paul holds fast to a single vow: to fight against the principles of hate that meaninglessly pits young men of the same generation but different uniforms against each other–if only he can come out of the war alive.



1944: FDR and the Year that Changed HistoryJay Winik.  1944 witnessed a series of titanic events… But millions of lives were at stake as President Roosevelt learned about Hitler’s Final Solution. Just as the Allies were landing in Normandy, the Nazis were accelerating the killing of millions of European Jews. Winik shows how escalating pressures fell on an infirm Roosevelt, who faced a momentous decision. Was winning the war the best way to rescue the Jews? Or would it get in the way of defeating Hitler? In [1944] one challenge—saving Europe’s Jews—seemed to remain beyond Roosevelt’s grasp.


Influence: Science and PracticeRobert Cialdini. Written in a narrative style combined with scholarly research, Cialdini combines evidence from experimental work with the techniques and strategies he gathered while working as a salesperson, fundraiser, advertiser, and in other positions inside organizations that commonly use compliance tactics to get us to say “yes.”…  Cialdini organizes compliance techniques into six categories based on psychological principles that direct human behavior: reciprocation, consistency, social proof, liking, authority, and scarcity.

51h-tqyvVzL._SX331_BO1204203200_The Health Care Handbook: A Clear and Concise Guide to the United States Health Care SystemElizabeth Askin, Nathan Moore, Vikram Shankar, William Peck. The Handbook is the one-stop guide to the people, organizations and industries that make up the U.S. health care system and major issues the system faces today. It is rigorously researched and scrupulously unbiased yet written in a conversational and humorous tone that’s a pleasure to read and illuminates the convoluted health care system and its many components.


Craft Coffee: A ManualJessica Easto and Andreas Willhoff.  Written by a coffee enthusiast for coffee enthusiasts, [this] is a comprehensive guide to improving your brew at home. The book provides all the information readers need to discover what they like in a cup of specialty coffee—and how to replicate the perfect cup day after day. From the science of extraction and brewing techniques to choosing equipment and deciphering coffee bags, Craft Coffee focuses on the issues—cost, time, taste, and accessibility—that home coffee brewers negotiate.