On October 1 and 2 IBM held its second global Smarter Cities conference in New York City. The first such conference was held in Berlin this past June, and the third will be held in Shanghai next year.
As was the case with Berlin, the New York Smarter Cities event had a very impressive agenda. It included talks by IBM Chairman and CEO Sam Palmisano, New York City mayor Michael Bloomberg, and Melody Barnes, Director of the White House Domestic Policy Council. The agenda also included panels with governors, mayors, and leaders of cultural institutions.
In addition, there were break-out discussions to enable participants to share their experiences on what it takes to build a smarter city in six key areas: transportation, education, public safety, energy and utilities, government services and healthcare. I helped organize and moderated the healthcare session. Our panel included Denis Cortese - CEO and President of the Mayo Clinic; Ronald Paulus - Chief Technology and Innovation Officer at the Geisinger Health System; Chris Coburn - Executive Director of Innovations at the Cleveland Clinic; and Armando Ahued Ortega - Health Secretary of Mexico City.
Healthcare, in my opinion, is one of the the grandest of challenges the US faces. The problems are enormous, as has been evident in the highly emotional debates and town meetings over the past few months. But, we also have more technologies, innovations and ideas than ever at our disposal to do something about the problems. What this grand challenge is crying out for, more than anything else, is the leadership to finally take action and do something positive.
That leadership was abundantly evident in the succinct and eloquent talk, Great Expectations for US Healthcare, given by Dr. Denis Cortese to the whole conference prior to the break-out panel. I would like to now summarize the key points made by Dr. Cortese in his talk, and I will then write about our subsequent panel discussions in a later entry.
Dr. Cortese started out by telling us that he was not going to talk about actual healthcare, but rather, about systems and systems thinking as it applies to healthcare. Why do you need to approach healthcare as a system?
Healthcare involves lots and lots of people - patients, insurers, device manufactures, pharmaceuticals, advocacy groups, biotech, research institutions, IT companies, governments of all sorts, state licensing, state insurance commissioners, and on and on and on. And this is before you get to the providers side, which involves doctors, nurses, hospitals, pharmacies, non-traditional providers, medical schools, and others.
“How are we going to deal with that level of complexity when there are so many interrelationships?,” he asked and then proceeded to answer his own question:
“The only way I can think of dealing with it is taking the approach from a systems viewpoint and to state a vision of a future state that you want: where do we want to be? Let’s start with the vision. Then you need leadership to get to that vision, and you have to have system thinking to try to solve the problem.”
He went on to say that many think that in the US we have a broken health care system, which we can now proceed to fix. “The fact is we don’t have a system. If we do, I want to know who designed it. Point me to the person. Where are the system engineers? What academic center thought this up? Nobody actually consciously formed the system.”
So, rather than focusing on fixing a non-existent health care system, we need to take a step back, take a breath, reset, reboot, and begin to design the system of the future. What are the key goals for such a future healthcare system?
Making his point in rather dramatic fashion, he then proceeded to ask the audience three simple questions:
“Number one, who in the audience would like to be admitted to the hospital tomorrow even if it's the best hospital in the world? Did any hands go up? Why are hospitals viewed as the center of the universe for healthcare delivery in the United States?”
“Number two. Who in this audience would like to be sick tomorrow? Anybody raised your hand for that? We have a sick-care system, by the way. Everybody's geared up to take care of you and get paid if and only if you are sick.”
“Number three, who would like to be a patient tomorrow? Patient is defined as somebody who long suffers or long endures. Anybody who wants to do that?”
“You have just stated the goals . . . You don't want to go into a hospital. You'd prefer not to be sick if you can help it, and you'd prefer not to be a patient if you can help it.”
“I would agree with every one of those. We're all going to be sick. We're all going to end up in a hospital. We're all going to die at some time. But you'd prefer to put it off as long as you can or to avoid it as much as possible.”Dr. Cortese then proceeded to lay out the framework for designing an effective healthcare system, which he illustrated with this slide. First of all, a well designed healthcare system must be focused on the patient. It is composed of three key domains, which work with and interact with each other to deliver the best possible care for each such patient.
First is the knowledge domain - the world of medical research centers, research institutes, biotech companies, pharmaceutical companies, device manufactures and others doing research and developing all kinds of new ideas and inventions. Next is the patient care domain, - the world of doctors, group practices, hospitals and academic medical centers where patients are treated. Finally, you have the payer domain - which pays for the delivery of healthcare, and includes employers, private insurance, individual patients, Medicare, Medicaid, the VA system, the military system and so on.
The knowledge domain is the best organized. The patient care domain is quite fragmented, except for a few institutions like the Mayo Clinic, Kaiser and Geisinger that do their best to integrate and coordinate their care for the patient. The payer domain is “total chaos, you can make no sense out of who pays for what.”
In addition to designing each of these three domains, you need to also design the interfaces among the domains so they interact with each other effectively. There are two major such interfaces.
The first is the translation from the knowledge domain of medical research to the patient care delivery domain, to ensure that the innovations coming out of the research and discovery side are put to work for the benefit of patients. On average, it takes about 17 years for new medical products to trickle into the delivery system. And when they do, the products get used appropriately about 50 percent of the time. Breast cancer has the best record - women get the right advice on what product to use 85 percent of the time.The second major interfaces concern the interactions between the payer and the patient care domains. A number of good ideas for improving the delivery of healthcare do not make it across this interface because payers will not support them, such as taking care of people at home electronically instead of in physician’s offices or hospitals, or treating kids with diabetes in the school. For inexplicable reasons, the payer system generally rejects paying for such effective and innovative ways of delivering care.
Even harder to understand is how different patient procedures are reimbursed. “Some are overpaid, most are underpaid. And it's unpredictable, because one insurance company will over-pay you, the other insurance company under-pays you, and we play the game to figure out where we put our business. It's crazy. It's certainly not patient oriented.”
Dr. Cortese then discussed some of the most important new concepts that should be part of any future healthcare system. The first is personalized medicine. How can you translate new discoveries into incremental value for each individual patient? This involves not just major research advances such as genomics medicine, but also the ability to reach everyone in cases like the H1N1 virus, where untreated people can compromise the health of the whole community.
The second major concept involves the science and engineering of healthcare delivery. Our country invests a lot in medical research, a great portion of which is funded by the National Institute of Health. However, there are no major academic programs focusing on healthcare delivery, the very core of any healthcare system.
We have been trying to build such programs at MIT, and so have other institutions like Georgia Tech and Arizona State University. There is great interest on the part of faculty and students but little funding so far to help organize the efforts. The funding available from the Department of Health and Human Services for such programs is miniscule compared to the funds available for medical research.
We also have to figure out how to measure the value created by the healthcare system we are designing. Value for each patient must be defined in terms of better outcomes, better quality and better service divided by the cost of providing care for that patient. It must be concrete and measurable, otherwise you don’t know how well your system is performing and whether you are getting adequate returns for the money you are spending.Dr. Cortese concluded his remarks by unequivocally stating that in order to have an effective healthcare system, we need to get to the point where everyone is insured. Our present fee-for-service approach encourage lots of unnecessary treatments while leaving over forty million people with no insurance and little care. Universal insurance would help keep everyone as healthy as possible, as well as offer them adequate treatment when they need it. Everyone should get basic insurance, which they can then add on to and supplement. Individuals should be free to choose from among competing programs offered by competing insurance companies and providers.
In roughly fifteen minutes, Denis Cortese laid out the basic principles underlying an effective healthcare system. I am confident that if we design a system along the lines he outlined, we will evolve, over time, into the kind of high value healthcare system our nation badly needs.
It is time to finally take on this grand challenge.