Systemness (sĭs’tə-m nes) adj.

1. Arrange according to a system or reduce to a system
2. The degree to which something shares the attributes of a system

Last week I attended the World Health Care Congress Consumer Connectivity conference in San Diego. The Twitter stream was at near flood capacity, and several excellent speakers were present to share their ideas. Conference attendance was affected by the economic climate but I believe the course of dialogue, the information shared, and value of the networking still proved worthwhile.

I shared a panel with Jordan Shlain, MD the founder and Medical Director of Current Health. I served as an advisor to the company through the late summer / fall and participated in their launch in December at World Health Information Technology Conference in Washington DC. Our presentation was intended to focus on “Millennial Technologies for the Medical Home” but given the light attendance, we essentially abandoned our traditional presentation given the intimate setting. After a brief introduction from me regarding the notion of Millennial Patients demanding Millennial Care, Dr. Shlain spent the balance of the session sharing some of the reasoning, thought, and opportunity behind the “direct practice” concept of Current Health.

During the presentation, several examples of “fortress medicine” were shared, including some which highlighted some individual failures and market perceptions with Kaiser and other large providers. The conversation took a couple of pointed turns as several Kaiser employees were in attendance (including an excellent Twitter follow in @janoldenburg). As Dr. Shlain would highlight individual cases which created opportunity for Current, they were countered by persuasive examples and initiatives from the Kaiser team. Abstracting out the tone, the content of the conversation was instructive in terms of alternative models of care.

Integrated health delivery systems deliver better results, period. The evidence is overwhelming as identified by the Dartmouth Atlas and countless other studies. We need to move our country to more “systemness”, which implies coordination, teamwork, shared learning, shared responsibility, and a long term perspective with aligned financial incentives. This is why I love the vision and the promise of true “health systems” like Kaiser, Intermountain Health Care, Group Health, Geisinger, and others.

However, Kaiser and all of these systems, are not perfect (nor claim to be) and despite systemic results that are superior there are individual failings (which seem to find their way into the sensational or anectdotal) that creat opportunities for viable delivery method alternatives. The notion of the medical home, or its complementary concept of Concierge Medicine, is also a “system” of care wherein a single physicians assumes the role of integration and patient experience. Assuming accountability to deliver this “virtualization layer“ enables these physicians to approximate the degree of integration that leads to better outcomes. These organizational delivery concepts have been created to remove the clinical and financial friction and frustration inherent in our current system and deliver personalized care that is safe, effective, patient-centered, timely, efficient, and equitable. We are also starting to see the positive results from these early studies.

The bottom line, we can no longer tolerate our uncoordinated, fragmented, silo’d delivery mechanisms. We must create “systemness” through all the appropriate means as any production organization has had to do as well. The culture of quality and outcomes must be built into the health care processes themselves and their must be rigorous, ongoing improvements with shared learning as the results are captured. This systemness, by any means necessary, will be good for our nations health.

Levee (lĕv’ē) n.

1. An embankment raised to prevent a river from overflowing.
2. A small ridge or raised area bordering an irrigated field.

The medical home concept is going mainstream. Not only is it a significant part of the Obama teams reform agenda, but it has hitting the front pages much more frequently.  Of interest, Seattle continues to be the hotbed of innovation around this concept (interesting, they are one of the few states that have changed their laws to accomodate “direct practice” medicine), with commercial innovators like Qliance and academic institutions creating new types of practice models.

This article from the Seattle area highlights some early successes working with insurance companies to pay a monthly fee for (a new form of capitation?) services that are increasingly showing a major impact on health (increased communication, care coordination, population/preventative health, etc) but have never traditionally been compensated.

You will recognize this model, “fee for service with a capitated medical home fee” or “compensation for enhanced practice capabilities” (I will actually peel back the onion on what these “enhancements” really are), as the model advocated by Alan Goroll and his associates in Boston. Their model envisions the smoothest path to fundamental reform as being one that works within the current insurance paradigm but with several key improvements over Capitation 1.0. These would include compensation for the enhanced practice capabilites already noted, adjustments according to patient complexity, (they have a fairly elegant patient modifier algorthm), and tying a significant dollar figure to patient satisfaction and ultimately patient outcomes (when they become available). This is a workable approach as long as the payers come to the table which apparently is beginning to happen in Seattle (with at least 50 other “pilots” nationwide).

However, at the same time we are witnessing the above success, we are also seeing Primary Care Clinics being overrun, patients locked out, and system impassibly constipated in terms of new patients moving through.  Increasing access in Massachusetts did nothing to increase capacity. I fear the current economy will only accelerate this based on this report from the California Healthline. This will in turn hurt the most structural at risk part of our health care system – the community  health clinic. These often under-funded, under-staffed, overcrowded, and overburdened facilities are home to some of the most noble of the entire profession who day in and day out slug it out in some very difficult trenches. But they are also some of brightest, most resourceful, and talented clinicians and healers we have in medicine. They represent the levees of our American Health Care system.

But their limited surge capacity will most certainly be overwhelmed in the coming flood of patients being sent their way by the prevailing financial storms. When the flood waters break, I believe Katrina will look like an afternoon shower compared to the vicious cycle of care that will ensue (no primary care, crash in the ER, most expensive place to treat, kicked to the street, no followup, and back to the ER. Rinse. Repeat. Ad Nauseam and Ad Infinitum). Ouch.

Louise McCarthy, vice president of governmental affairs for the Community Clinic Association of Los Angeles, said, “There’s not a very large infrastructure in place to handle the increasing need, even though providers will do everything they can to treat as many people as they can.” Sounds reassuring.

Given that the Community Clinic is the “medical home” of the indigent – what low cost, effective, and useful technology sandbags can be put cobbled together to hold back the waters? I like David Kibbe’s recommendations to Obama as examples of the simple, but far reaching processes that can be implemented to complete the growing support for ubiquitous EHR deployments (about time!).

What other sandbags, or better yet, what infrastructure needs to be put in place to service the Community Health Clinics as a fundamental component of our primary care system?

Treadmill  (trĕd’mĭl‘) n.

1. An exercise device consisting of a continuous moving belt on which a person can walk or jog while remaining in one place.
2. A similar device operated by an animal treading a continuous sloping belt.

Today, Dr. Jordan Shlain and I opened the morning session of the 2009 WHIT Conference by introducing the notion of Direct Practice as a model for enhancing access, reducing costs, and improving quality. For this particular audience and presentation, I set the stage by introducing three themes:

1. Health Care in Crisis
2. Patients as Consumers
3. Direct Practice as a Response

This then set the table for Dr. Shlain to share his 10 year experience as a pioneer in this field. He described very intimate stories of the deep relationships, the personalized service, and the exceptional outcomes achieved. It was a truly powerful way to introduce what we believe will be the next wave of innovation in health care delivery. He closed by publicly unveiling for the first time Current Health (which I profiled yesterday) as the first branded primary care experience coming to a west coast location near you.

Given the time constraints, we were not able to take all the audience questions. I will post responses to these on shortly:

1. What application are you using to send data to your iPhone?
2. How do we get Americans to take care of themselves?
3. You are speaking about General Practitioner from 80 years ago?
4. You seem to be talking about non-universal healthcare?
5. If more primary care docs see fewer patients with your model, how will we meet the burgeoning primary care needs of America?
6. How many patients do you see at any one time?
7. How does your model handle emergencies?

Current Health (kûr‘ənt helth) n.

1. Membership based, comprehensive primary care practice based in San Francisco area with plans to spread branded clinics throughout the West.
2. Millennial version of the classic vision of a trusted physician who makes house calls.

As I have mentioned previously, I have been involved in some really cool projects recently that I believe are at the forefront of the wave of change that will soon wash over the health care industry as the “time for change” appears to be now.

Current Health - Guardians of Your Health

With that preamble, I am thrilled to introduce you to Current Health (formerly San Francisco On Call) – The Primary Care Specialists. I have had the privilege to work with Dr. Jordan Shlain, David McKie, Vy Le, and the excellent team of physicians over the last six months to help transition the practice from a house call / urgent care focus to a membership-based, comprehensive primary care “medical home” for individuals and families who value their health as an asset.

The macroeconomic reasons for this transition at this time are well known. The American health care systems is in shambles. The United States currently spend 17% of Gross Domestic Produce on health care, a number which is anticipated to balloon to 25% over the next 15 years. Despite leading the world in terms of absolute and relative spending in the health care sector, the United States ranks ~35th in health metrics tracked by the World Health Organization. Serious questions have also been appropriately raised regarding the quality, efficiency, safety, and outcomes achieved by the US health system: 100,000 preventable deaths due to medical errors annually, approximately $700 billion spent in ineffective/unnecessary treatment, and consistent estimates of 30% waste associated with administrative inefficiencies.

These systemic challenges are compounded by a employment-based insurance model that has continued to fray as companies have been forced to reduce their health care offerings in order to remain competitive in the new global economy. This has resulted in real wage decreases, increased numbers of uninsured individuals, spikes in medical bankruptcies, increased costs due to delayed care, and misallocation of limited health resources. These challenges have directly affected health care providers who have experienced decreases in wages, job satisfaction, and control over the way they deliver care. Primary Care physicians have been particularly hard hit, and their former role as guardians of health has been minimized, displaced, or eliminated. This has lead to current and predicted severe primary care physician shortages at the same time that primary care has been identified as a necessary pre-requisite to low cost, high quality, and best outcome health care systems. Even if this shortage began to be addressed today, it will take approximately a decade to close this primary care gap.

Current Health is a response to the health system crisis in general and impending break down of the primary care speciality specifically. Our business focuses on elevating the nature of the patient physician relationship by creating a practice design whereby the patient, the provider, and optimal health outcomes are aligned. Current Health is a membership-based, direct-practice, comprehensive primary care delivery model. Our direct financial, administrative, and clinical relationship with the patient provides both the freedom and the flexibility to deliver optimal health care.  In its most basic form, it is a fresh perspective on the classic vision of a trusted physician who makes house calls.

Members pay an affordable membership for access to our practice and our physicians and are rewarded with a single point of health care accountability for all aspects of care. Members are assigned a care coordinator who oversees followups and proactive health maintenance. Members are invited to participate in their care through several engagement techniques as well as access to their personal health record which serves as the medium of communication with Current Health. Given our intense focus on delivering an unrivaled customer service experience, we ensure that our Members are informed, empowered, and connected to their physicians and the practice at all times.

Current Health plans to become a leading primary care brand that delivers on the promise of high touch service paired with unprecedented access to physicians. Our direct practice model, including centralized support of all health stores and effective use of technology, enables Current Health to democratize the concierge medicine experience for an entirely new generation of patients. Current Health creates an environment where clinical excellence, administrative efficiencies, and financial alignment can lead to best outcome care.

We look forward to documenting our journey in the coming months in this blog and other places. There will be alot of interesting things to discuss – providing conceirge experience for the masses, fee for service model, direct practice model, patient care coordination – and I look forward to helping each of you become Current.

Tweet (twēt) n.

1. A weak chirping sound, as of a young or small bird.
2. A “Tweet” is an individual message (or “update”) posted from Twitter.

Twitter is an interesting application with a very simple premise – your friends and associates are actually interested in knowing “What are you doing”. These “tweets” are constrained to 140 characters and for a wide variety of reasons people are actually interested to follow these micro-updates. As with most technologies, the original somewhat superfluous reason for which it was created has begun to find new uses, in new settings, and to be adopted by an ever expanding base. Interesting to watch and follow.

The premise of Twitter – What Are You Doing – has stuck with me during the last several months that I have been using this new tool. The reason for the reverie is the unsettled feeling I have had for the last two and half years since an acrimonious departure from my former cause. When you pour your heart and soul into something, only to have the dream denied for completely preposterous reasons, it takes some “gathering time” to reinvent yourself, or more appropriately realign yourself with a cause worthy of passion to which you can devote.

There is a recent precedent for this. While I do not support his politics, you cannot help but acknowledge former presidential candidate Al Gore for creating the template for this type of career recharging. After losing the highly contested election in 2000, in the most bitter way possible (won the popular vote, miscounting hanging chad’s, and judges determining the outcome), he had to gather himself. As the bitterness began to eat away at him, he realized that he needed a new cause, to redeploy his focus, and redirect his passion. The election had caused him to “fall out of love with politics”, and so he took up his other passion, the environment. His prodigious effort was captured in the award winning film an Inconvenient Truth which ultimately led to his winning of a Nobel prize. Impressive.

This past October, Steve and I quietly celebrated the one year anniversary of our own career freedom. After being handcuffed for 18 months in litigation, I have taken the last 12 months to re-engage in the broad and emerging Health Consumer space (is Health 2.0 a better term?). I started blogging about two years ago, and was immediately awakened to the possibilities of this new communication medium. I started connected with fellow sojourners, interested in reforming health care to create a true health care system based on the principles of quality, access, and value. I had wonderful opportunities to engage as a consultant with MyMedLab, HealthEquity, Lemhi Ventures, and most recently San Francisco On Call. My efforts have been focused on health care information technology, finance and delivery innovations, and open collaboration.

So what am I doing now?

Essentially, I have been focused on bringing in a new era of health care, enabled by technology, enhanced by open collaboration and shared learning, and tailored to each person who is accountable for their own health care decisions. Essentially, I want to “tear down the walls” that have prevented the free flow of information, failed to deliver outcomes consistent with the price we pay, and hindered the creation of true health care “system” that we as Americans demand. One patient, one process, and one system at a time.

I am still currently working as a consultant to innovative organizations seeking business acceleration in the consumer health space. I am currently engaged in an awesome project that will be unveiled before the year is out – great concept, great team, and great opportunity. I have also been contacted by Ingenix, Walmart, and other larger players about potential collaboration opportunities. Even while consulting, I have continued to evaluate, design, and test out some new concepts which tie all my interests and consulting work together back into a new concept that Crossover Health will be introducing. It will serve as an extension of my consulting services, but may very well evolve into something much more.

Just in case you were wondering. Stay tuned.

Retail (rē’tāl) n.

1. Of, relating to, or engaged in the sale of goods or commodities
2. To sell in small quantities directly to consumers

The “retailization” of health care continues to advance in fits and starts. There are multiple fronts of attack in this movement – everything from general transparency issues such as pricing to physician ratings, to new services and delivery models accentuating convenience and access, and ultimately to new payment models involving risk sharing and financing hybrids.

Somewhere in the middle is the evolving concept of the medical home – which at its heart is a old concept resurfacing as a new innovation trying to solve the timeless conundrum of access, quality, and cost. As I mentioned previously, the notion of the medical home is gaining speed, but it is neither a retail play (access/cost) nor an elite consumer experience (quality/cost). It is designed to be the “homey hearth”, right in the middle of these two spectral ends. In fact, I would suggest that the application of the medical home concept lends itself to the creation of suite spot right within the big bell curve of health care delivery.

Description of the Health Care Continuum delineating a sweet spot for the Medical Home

The Medical Home should resonate with that large middling population that actually is employed, has insurance (typically through said employer), and lives in the suburbs with the wife, the 2.2 children, and the family dog in Average Town, USA. It is the typical middle class person who is worried about the financial meltdown, what it portends for the interest rate on his ARM, gas prices at the pump, and food costs that are starting to hit his bottom line. It is also the center of the bell curve where uniquely American trends of obesity, inactivity, and the burden of an aging population with a growing chronic disease burden looms like an innocent iceberg to the approaching health care Titanic.

Interestingly enough, it is also the exact place where the age old concept of a primary care physician – now equipped with modern tools of communication, electronic health records, and population analytics – can have a dramatic impact on the health and well being of patients before future tragedies strike. In theory, this muddling middle is exactly where the level of care described in the medical home concept could very effectively be applied for best return on investment.  Hence, the reason for what I perceive is now a widespread interest, to the implementation of the medical home as the “new new” single point of health care accountability (gatekeepers was never a good analogy anyway!).

To tie this together, it appears to me that the round mound of the bell curve is ripe for a medical home brand to stake a beach head along a specific (price?) point along the curve to deliver on the promise of primary care. In fact, there are multiple potential points along the curve where varying access/quality/cost variations could be offered to appeal to specific segments. For example, a “Target” equivalent offering exceptional consumer value, or a “Nordstroms” equivalent offering higher service levels, as well as every model, price point, and health value equation in between.

A primary care “brand” is destined to emerge, probably several, with each delivering on a specific value promise to health consumers along the wide continuum of the health care delivery bell curve. Looking forward to seeing / helping this become a reality.

Membership (mĕm’bər-shĭp)

1. The state of being a member
2. The total number of members in a group

I have watched the meteoric rise of popular term “Medical Home”. While I personally dislike this phrase, it has caught on in the popular vernacular and looks like it is here to stay. In conjunction with the rise of the term is the growing popularity of a practice model that includes a higher level of service on a membership basis. It is essentially, next generation concierge medicine, but now being promoted under the more politically correct banner of “Direct Practice”. Multiple variations of the model exist, from an all-inclusive single fee to a membership structure that retains a fee for service financial arrangement.

So the discerning patient evaluating these practices is left with determining the relative value of this new Direct Practice concept, and having passed that test, determining which type of practice model actually makes sense to them (All inclusive or Fee for Service). Lets look at these questions in order using a traditional 4 person family with an annual all-in health care spend of $15,000 (consistent with Milliman’s 2008 numbers).

First, the value of a direct practice to a regular insured person receiving a very rich high premium, low-deductible benefit package from their employer. In this arrangement, the worker typically pays about 20% of the cost of care, and so the resulting split is employer paying $12,000 (premium) and the employee coming “out of pocket” $3,000 (co-pay, co-insurances, etc). In this setting the insurance options are set, and the employee chooses from the menu. Within this menu, there is typically a PPO option which is often selected because it provides significant flexibility in choosing a provider/specialist. However, you are stuck with selecting a provider from the directory, stuck in the current 2 hour wait room, 10-12 minute physician visit, and getting the same old no value added consumer health experience. This heavily subsidized model (paying $3,000 for a $15,000 benefit) of health care is going away rapidly, and Americans will continue to feel the pinch as the cost shifting pendulum continues to swing toward consumers.

Contrast this with the individual who views their health as an asset that needs to be invested in over the long haul. This individual will have already transitioned to a low-premium, high-deductible health plan so that the same $15,000 can be spent much differently: $3,500 for the premium, $7,500 for the deductible, and the remaining balance of $4,000 being made available to purchase additional health services. Even if fully maxing out the insurance benefit (remember that any part of your deductible that you don’t use can be saved in your tax advantaged health savings account), this $4,000 is available to optimize care for the family. What is the most effective way that it could be spent?

While every individual will have different priorities, I would suggest that these extra dollars could create significant value by enrolling in a direct practice relationship with a primary care physician. In this arrangement, the member would have 24×7 access to the physician, see the physician in an office/home/virtual setting, have care coordinated across medical conditions and across care environments, proactive preventive measures being actively undertaken, medical advocacy support, and someone whom you absolutely trust who can help you navigate your health. Essentially, a personal medical director, working with your personal medical staff, to ensure that your personal health objectives are met. An unbelieveable value (outcome/price) to help you manage your most valuable asset.

Is this really possible? Do these numbers really jive? Is this type of individual consumer experience really available? It absolutely is. They absolutely do. It is absolutely coming. Membership based practices really do have their privileges and those privileges are going to rapidly be extended to the masses.

Will discuss the All-Inclusive vs. Fee for Service next . . .