Thursday, March 25, 2010

Medical Encounters of the Third Kind


The practice of Medicine is designed around the physician-patient encounter, one in which the patient sits across the table from the physician or lies in a hospital bed or an operating table. That was the only type of medical encounter possible until not long ago. That´s how physicians have been trained to think and work, that´s the scenario implicit in medical textbooks and early clinical protocols.

Medical encounters of a different kind are already possible today. Among them:

-         Real-time “virtual” consultations (online, 3G)
-         Asynchronous consultations (email, formularies…)
-         Encounters with  non-physician providers (where the de-skilling of certain procedures or interventions  makes it possible)
-         Access to (or proactive delivery of) customized, relevant information on prevention, risk, wellbeing… without the direct involvement of any provider
-         Point of care diagnostic tools that allow the self-monitoring of chronic diseases by patients

Medicine has indeed incorporated great advancements in diagnostic and therapeutic technologies in the past few decades. But their translation into significant improvements in efficacy and efficiency (plus in other relevant parameters such as accessibility, convenience, etc) is constrained by the lack of innovation in delivery formats. In some sense, new technologies are funnelled through old structures and mindsets and thus are not fully exploited.

In a not too distant future, a large share of medical care could actually be delivered without the patient and physician having to be in the same room. In the process, healthcare will be transformed. An opportunity to do things differently… but also an opportunity to do entirely new things. Healthcare will no longer be a strictly local business (which will have great competitive implications). It will no longer be episodic, but rather continuous or at least far more frequent. That diabetic patient will no longer be “seen” only every 6 to 12 months…

This is not a futuristic tale, the technology is here. The most important barrier to the growth of these alternative encounters (to their gaining an increasing share of healthcare services) is not one of technical or “medical” viability but rather an issue of commercial viability (reimbursement schemes are anchored in the old world).

For all this to become mainstream, we need to rewrite Medicine. Its textbooks and protocols. We need innovative health insurance products and new delivery models that capitalize on the many opportunities to provide non-presential medical services.

Tuesday, February 16, 2010

Health 2.0? Not there yet

A quick, sobering look at Alexa´s rankings for “Health” (Alexa combines average daily visitors with pageviews to derive website traffic rankings) yields:

1) Facts:

-         A top 20 list dominated by .gov (nih, cdc), pharmacies and “old”, web 1.0  companies with no health 2.0 pure-plays.
-         Just one health site (NIH, rank 448) in the Alexa overall top 500
-         Selected rankings: Vitals (rank 12,000), RateMDs (33,000), OrganizedWisdom (25,000), PatientsLikeMe (65,000), Sermo (195,000).
-         An obviety: there´s no health equivalent of Facebook-Twitter-Wikipedia (all three in the top 15), not even a equivalent to IMDb or AllRecipes.
-         Most health-related content on the Internet still flows top-down, from established institutions or dedicated encyclopedia-type sites.
-         Google and other general, rather than vertical, search engines are the main portals to health information.

2) Hypotheses:
  
-         Health social networks populated by peers (“other patients”, “other doctors”) have a low ceiling. The appeal and real value of user generated content –and other community features- decrease outside the very narrow niches in which they play.
-         Some of these communities may still be very profitable if, and only if, pharma buys into them seeking targeted communication channels. Sponsorship / ad revenue from pharma seems to be the only viable business model.
-         User ratings of physicians and hospitals (as of today, only for peripheral service attributes) are gaining some traction. If they are ever coupled with hard, risk-adjusted comparative data on outcomes… the implications for the healthcare industry (providers and insurers alike) would be significant.
-         Open, interoperable and accessible electronic health records platforms (such as Google Health, MS HealthVault) may be the killer application this industry badly needs, opening the door to the emergence of:
o       Transactional services (i.e. online medical consultations)
o       Communities that include both patients and physicians among other healthcare participants

Monday, November 23, 2009

American Well, a new model for virtual online visits

Fray Luis de Leon so began his first lecture at the University of Salamanca after a long period of incarceration by the Spanish Inquisition: "as we were saying yesterday...".

That will be the spirit behind the continuation of this blog after a long period in which it has been dormant. A time in which the term "Health2.0" has taken a new, more precise, even proprietary meaning, referring to health social media, user-generated content, etc.

Healthcare 2.0 remains loyal to its initial scope of highlighting new ways of organizing and delivering healthcare services. There is a significant area of intersection between these two definitions, because most innovation today occurs with the use of web technologies. But offline, brick-only innovations (such as retail clinics, concierge medicine, etc) will still be portrayed here.

American Well had been on our radar for quite some time, ever since they began operations in Hawaii (thus bypassing potential regulatory hurdles while gaining experience). The have moved to the mainland and are in the process of launching nationally. Finally, a company that makes a serious attempt at making online medical visits become a mainstream feature.

Healthcare, this is no secret, lags behind other industries in its use of the web and of information technologies in general. So far, internet had only scratched the surface of the industry. Early entrants in the eHealth space were focused on providing consumer access to medical information that previously was the exclusive terrain of physicians. But few dared to offer transactional services.

American Well (building upon Relay Health but going far beyond it) aims to the core of healthcare, the very provision of medical services, by creating a platform that allows for online patient-physician visits.

Non-presential encounters were always possible if only via telephone (and later through email). And they are, and always were, valuable. A significant share of  "visits" (for acute minor ailments or for the monitoring of chronic conditions) could potentially be performed without actually having the patient sit across the table. Testing is needed to prove their efficacy and quality. Security and privacy issues also need to be addressed. But the single most important issue behind the reluctancy of insurers to reimburse for these visits is probably one of control of what might happen in these virtual patient-physician interactions and its potential impact on utilization. AW´s early successes thus probably have more to do with their business model than with its technology.

AW has decided (at least for the time being) not to make its move a pure consumer play, but rather to piggy-back on insurers, connecting their physicians with their patients. They become an intermediary, the platform where visits take place plus the algorithm that ensures a smooth matching of physicians with patients. In doing so they avoid the costs of piecemeal customer and physician acquisition, and they are able to grow their network through new big chunks, at a much faster rate than any B2C move could achieve.

And as in any (virtual) marketplace, there is a significant network effect that rewards those who aim high and grow fast.

Very savvy early moves by AW.


Friday, April 20, 2007

Retail Clinics Industry Coming of Age

Retail health clinics cannot be seen as an exotic phenomenon anymore. What was originally just a new business concept, pioneered by Minuteclinic, has become a new category, a new channel for delivering healthcare services.

Media coverage of this new model has trascended the blogosphere and the occasional note in the general press. In the past few weeks we have seen The Economist ("McClinics"), The New England Journal of Medicine ("The rise of in-store clinics...") and Strategy & Business ("Health care´s retail solution") running very positive articles on this emerging industry. It seems that the idea has finally landed in these higher grounds. Retail clinics are now in the spotlight of academics and consultants, who will surely dig into the business fundamentals of the model.

Young as it is, this industry segment is entering a new phase of development. Life cycles in today´s fast paced economy are compressed. Gone are the placid days of just "testing the waters" that were valid in the introductory stage. Each player needs to have a sound, differentiated strategy in order to navigate the rapid growth of today and the transition to a more mature market. So far, we have seen a homegeneity of business models. The collective action of all industry players has contributed to drive primary demand stimulation: the "enemies" were (and still will be for some time) the traditional channels (emergency services, primary care practices). In the near future, we will see more divergence in business models and competitive strategies. Other retail clinics groups will become actual "competitors".

The current business model has indeed proven itself. The economics are compelling:

- Lower labor costs, lower overhead (from limiting the scope of services) and potentially lower unit costs (from learning economies) than traditional channels (i.e. emergency departments).

- Furthermore, a chain of clinics beats the stand-alone physician practice: greater bargaining power vis a vis insurers, efficiencies from economies of scale (spreading fixed costs of IT, advertising, product development) and economies of density (several clinics in the same area achieve advantages from pooling labor and from capitalizing word of mouth). The implications for primary care physicians are significant. Contrary to what some medical associations are proposing, they just cannot compete with retail clinics for minor ailments just by extending their hours of operation or improving their scheduling methods. It would be a lost war, like bank branches trying to compete with ATMs for the cash withdrawal business.

As of today, the leading retail clinic operators are focused on geographical growth, entering new markets and perhaps consolidating those in which they already have a presence. However, in a more competitive environment, they will probably be forced to explore new avenues for growth and value creation (expanding the scope of services, entering new client segments). Growing up, a fact of nature, has these "side effects".

Thursday, March 22, 2007

Concierge Medicine: back to basics

Concierge ("boutique", "VIP") medicine has received much criticism, mainly on the grounds of its questionable (for some) ethics. While its business model is not all that sophisticated, it is nonetheless an attempt to break with the homogeneity in private practice models.

For physicians, CM changes the economics of their practice but also the very nature of the service they provide. Through a retainer model (as it used to be the norm in the past, by the way), the physician becomes again an agent for the patient. For patients, CM is an alternative model, one in which the physician is not subject to any restriction by a third party in terms of accessibility or utilization of resources. A doctor that also doubles as a counselor that helps them navigate an increasingly complex healthcare system.

CM changes the incentives inherent to the prevailing practice model. The current reimbursement methods are skewed towards the attention of the acutely sick, resulting in episodic, disconnected care. Two major segments are neglected in this scenario:

- The "healthy", who face difficulties in accessing relevant preventive and wellness services, screening programs and counseling.

- Those with chronic diseases, who would benefit from more frequent encounters with their doctors and a higher accesibility through non-presential communication (telephone, web ... channels that are not adequately exploited because they are not reimbursed). The life of diabetics, asthmatics, etc., would be far easier if they were able to consult with their physician the many doubts that arise on a day-to-day basis (should I adjust my medication?, should I worry about this funny new symptom I am having?). Not to mention the fact that this model is likely to be more effective and efficient (even small improvements in the control of chronic diseases yield huge benefits: fewer complications, fewer ER visits).

CM may prove to be a very appealing proposition for some physicians and some consumer segments. It will probably continue to evolve and even permeate beyond its current boundaries of primary care.

Saturday, February 10, 2007

Revolution Health: ambitious, as it should be

Revolution Health has finally launched its preview version. And it looks good. It is one the first serious attempts at building "the" healthcare 2.0 site, offering much needed, still missing features in healthcare such as consumer ratings of providers (which ideally should be coupled with hard data on outcomes) and social networking tools.

They are making a lot of noise, too. Steve Case is everywhere and so are many of RH employees, actively commenting on every blog that mentions their company. There seems to be a strategy behind this. Like all things web 2.0, RH´s play is subject to a significant network effect. They are in a race to build a large base of installed users before competitors-to-be make their moves. They also need to manage consumer expectations. And they are playing it by the book: using penetration pricing (free memberships and other inducements to participate), leveraging Case´s reputation (as someone who built something so big as AOL), making product preannouncements. They are ambitious and very active in communicating and praising their company - the right way to play this game.

Among the many challenges they face, two stand out. First, how to engage consumers of healthcare services and have them coming back regularly in a matter that is not recreational. Second, how to create synergies among the different service lines they offer (a must in order to compete with pure plays that might attack each of its components).

And of course, there´s also always the tricky issue of how to make money, with a business model that appears to be based on ad revenue, with subscription services as a much smaller complement. If they do succeed in becoming the market leader, though, this model is not only viable but also potentially very profitable, by providing access to very targeted audiences of highly valuable and motivated consumers.

Strong retaliation from WebMD is coming. Google Health (as of today!) is still in the works ...

Alea iacta est ...

Friday, December 22, 2006

The case for Focused Factories in Healthcare

Focus is a major competitive weapon. This fact, well known in manufacturing and service industries alike, is still underexploited in healthcare.

A key insight comes from framing the problem not as how to increase productivity but rather as "how to compete", as Skinner put it in his seminal article (W Skinner. "The focused factory". Harvard Business Review. 1974; May-Jun:113-122): "... a factory [hospital] that focuses on a narrow product mix for a particular market niche will outperform the conventional plant [general hospital] which attempts to be everything for everybody. Because its equipment, supporting systems and procedures can concentrate on a limited task for one set of customers, its costs and especially its overhead are likely to be lower than those of the conventional plant. But, more important, such a focused plant can become a competitive weapon because its entire apparatus is focused to accomplish the particular manufacturing task demanded by the company´s overall strategy and marketing objective" (the brackets are mine, not Skinner´s).

Regina Herzlinger is the mind behind the Consumer-Driven Healthcare concept as the way to achieve system reform (as opposed to top-down initiatives proposed by others in the 90´s and still held by many). Her ideas may be consulted in the numerous books and articles she has published on the subject (and in a not-to-be-missed recent presentation). She believes that true change will only be achieved through an organic, bottom-up process in which each person takes charge as a consumer of health care and entrepreneurial forces will create delivery models and insurance products aimed at better meeting the needs and preferences of consumers (rather than those of providers as it is currently the case). It is in this scenario that focused healthcare factories (a central topic in Herzlinger´s writings) will flourish. Not everyone agrees, though, that this outcome is likely or even desirable.

The competitive advantange of focused factories derives from embracing a specific, differentiated positioning and from gearing operations to exploit it. The focus could be on an illness, on a procedure or on a defined population target with unique needs. Focused providers outperform generalists, both in terms of quality and costs. The well-known volume-outcome relationship helps make the case for focused provider models, regardless of the direction of causality in this relationship ("practice makes perfect" vs. "selective referral patterns"). Costs are also lower, both overhead (due to a lower complexity and variability in operations) and unit costs (that go down with cumulative experience in similar cases through learning economies).

Healthcare´s supply-driven nature is reflected in the homogeneity of provision models and their inertia to change (the organization of hospitals today, for instance, is not too different from what it was decades ago) despite the great advancements in medical and information technology and changes in the relative prevalence of diseases and in the needs and preferences of consumers. Hospitals are very complex organizations designed to treat acute, serious conditions, and whose structure mirrors the division of Medicine in specialties. This self-centered approach is not only anachronic but also a limitation to innovation in itself (ie, by setting barriers to the creation of cross-functional services). Further complicating these matters, in this insurance-mediated market, what doesn´t have a "code" is not reimbursed, thus raising additional barriers to innovation. Email or telephone consultations, patient-provider communication through web applications and many other alternatives, more convenient and potentially more cost-effective, to presential encounters, are not offered because they are not reimbursed.

The specialty hospitals (with a focus in cardiology, oncology, orthopedics) that have emerged in the past few years represent a step in the right direction, if only still just a baby step in terms of what can be achieved. The fierce criticism they face , though, gives us a taste of what may lie ahead: going against the tide in healthcare comes expensive. Specialty hospitals, many of them physician-owned, are in the midst of an angry policy debate over their supposedly cream-skimming tactics (that is, carving out a niche of higher-margin services at the expense of general hospitals). Although there are many other angles to this debate, it is noteworthy that what in almost any other industry would be called "beating the competition" through a more appealing value proposition for consumers is, in healthcare, a questionable strategy.

The future reserves only a marginal role for general hospitals as we know them. Even it they persist in their positioning as generalists, they would do well to incorporate the focused factory approach, creating "plants within a plant" (separating organizationally and even physically the different service units). Also, the hospital of the future will probably not be a "place", as it is today, but rather a collection of diverse focused inpatient and outpatient services (including electronic delivery models) in different locations, networked through a shared information infrastructure.

The most innovative focused factories, though, will be outside of the hospital business. Regulation permitting, we will probably see a rebirth of disease management through a variety of products aimed at managing chronic diseases, new delivery outlets and a marked increase in the offering of preventive services (the healthy are the most neglected segment in the current system). Even more targeted delivery models, focusing on a very specific target population, condition or procedure, will emerge with time.

Focus is a powerful concept that, along with a shift of decision power towards consumers, will result in a much needed redefinition of healthcare services. It will bring greater diversity in provider business models and a broader range of medical services. A new system, more responsive to the evolving consumer needs.