“Come on dowwwwwn!”; fateful words that all anxiously await.  Having pinned their hopes on being plucked from the live audience for “Contestant Row.” The first step from which they might win a treasure trove of goodies, based on their uncanny ability (or luck) in guessing prices – prices of products that can range from a can of mushroom soup to a new car or a dream vacation.

“The Price is Right” game show has set countless records.  It is the longest-running network television program in history (currently in its 46th year).  And even today it remains the #1 watched USA daytime television program.  Although it has tweaked its games and products slightly (adding items like VR goggles alongside the soup) to remain relevant across the decades, the vast majority of its fast-paced format remain wholly unchanged over all these years.

Game experts suggest that it is the “high win-per-minute ratio” along with the “use of life skills” (i.e. accumulated knowledge derived from purchasing) that are the key ingredients in the game’s attraction.  But when asked why, Bob Barker the host of the program for 35 years, made it clear, “The reason it was so popular originally and why it is still popular is because of the powerful basic premise of the show… everyone identifies with prices. The minute we put something up for bid and a contestant offers a price, all of us are deeply involved.”

Books are written and websites filled with stories of, and tactics for, winning (with all the resulting statistics).  Some of “The Price is Right” gurus will push for product pricing memorization drills and card counting-like training.  Others will drive you toward a game theory-based approach which focuses more on the optimal counter bids than it does on knowing the price per se.  For example, from Contestants Row, if you are last, then bidding either $1 above the lower bidder or $1 above the higher bidder, depending on the spread between the other bids, results in a 54% winning outcome as compared to 34% for all other strategies.  And for the other ~75 sub-games, similar tactics abound.

But the apex moment of the show is the “Final Showcase”; here is where the big-ticket items await and only two contestants make it to this stage. The showcase offerings are presented as bundled packages.  Often with a theme, but in each instance, each contestant will need to put a total price on one or the other package.   And as with all The Price is Right sub-games, it is critical to get as close to the actual price as possible, but to NEVER OVERPAY; for being even $1 over is an automatic losing bid.

Interwoven with the psychology and success of The Price is Right are keen insights into human behavior and motivation.  As highlighted by Barker, we all care deeply about price.  And although we may differ in what we believe is an appropriate or “fair” price, we have visceral reactions when we believe we may have overpaid. The positive aspects of getting a good deal are important and motivational too.  We will drive a great distance, sit in a cold pre-dawn Black Friday queue or perhaps even endure the tedium of cutting coupons to save just a little money. But as rewarding as it feels to save some, we have significantly more potent emotions attached to losing money.  And The Price is Right wonderfully highlights this with its overbid elimination rule.  We always feel, if/when we have overpaid, that we have lost – we feel cheated, or worse, we feel stupid.

For the vast majority of our transactional lives, we have agency, experience and expertise in buying stuff – in all but one. When it comes to buying the products and services on which we will all eventually seek and need–namely healthcare–we must all blissfully proclaim utter ignorance.  For when it comes to these matters, we’ve been trained to presume that “price” cannot matter.  Yet matter it must – any illusion to the contrary is truly a fool’s folly.

But what price is right?  Who should decide? What value has been received? How can we know?  These are but a few of the thorns in the briar patch of health economics.  And depending on who you ask, the answers vary wildly.   Ask the parent of a critically ill child and even the mention of price can evoke condemnation – “how could you?!!”.  A similar query to a physician will often result in questions regarding the “how could we know;” medical outcomes come in variation, often wax and wane and each are steeped in long-term uncertainty; “this is more of an art than a science.”  Ask an Rx R&D executive and they quickly retort, “be careful, if the incentive to invest in the remarkably risky business of drug development is compromised, then medical innovation itself will die a swift death.”  Or speak to a payor and the conversation quickly turns to prevalence and value.  In the setting of a single payor system, the conversation hinges less on time-to-efficacy and more on population coverage cost; a calculus of can they, the actuarial pool, truly afford it.  In the US, in which coverage responsibility jumps fleetingly with each change of employment, any conversation of long-term savings/value with payors generally falls on deaf ears.  Their businesses are living in the moment; what claims will we have to pay this year.

But regardless of these complexities and headwinds, we must pave new ways.  Develop new systems in which the vagaries of treatment effect can be more effectively classified, if not truly quantified. Build new business models and relationships with those who seek treatment, allowing them to actively capture the data on which their benefits can be more clearly understood. This real-world data must be entirely owned by them, used per (and only with) their agreement and their participation should be economically (and attractively) rewarded.

To move toward a world in which costs (i.e. prices) are clearly understood by both the recipient (and really the buyer) and those that provide care, the real cost/price must enter into the picture. In this new landscape, deeper patient engagement becomes expected and incented.  It requires an utter commitment to personal privacy; underwritten by sound policy/data security and is as focused on the long-term as it is on near-term outcomes.

We have a long and difficult way to go.  Today, we see steady annual increases in Rx prices, without any commensurate proof of increased cost or utility.   While global sales of branded drugs rose from $720 B to just under $800 B between 2011 and 2017, the volume of prescriptions filled concurrently drop from ~998K to 584K. Over the same time window the average of branded Rx prices increased between 6.5-14.0%.  For the top 45 already approved branded drugs, annual price increases drove >60% of the 28% US sales growth between 2014-2017.   Innovation is remarkably expensive, particularly in the setting of new Rx treatments. Further, it is certainly true that of every healthcare dollar spent, less than 25 cents of it is spent on drugs.   But that said, when buying “stuff” as opposed to “services,” per unit prices are particularly sensitive and increasing prices well above the rate of inflation is even more so.

Just imagine a day on which informed patients, rather than hyperbolic contestants, were invited to “come on dowwwwwn” and take a seat at the table of “The Price is Right for Healthcare” – we would begin to see a new dawn.   A day in which prices in healthcare are set exactly like they are in all other markets.  The right price based on the value thought to be received, by those who paid.  Some will be willing to pay more and others less.   Some will expect brand and others will look for savings, but all will be dramatically engaged in the process.  Prices will be dynamic, reflecting market-driven decisions and patients will have much more and tailored information to help support their purchasing choices.  Outcomes, or least prices, will come with guarantees.

Until patients help set prices and personally determine value, all too often they will feel cheated.  And the new tools on which this paradigm rests must be the responsibility of those who seek to enter this market.  If one cannot provide a means by which outcomes can be assessed, by the patient themselves, then they too will soon prove to be relics – the history of medicine is filled with them.   As the industry walks down the plank of year-over-year price increases, an abrupt end awaits and the waters below are not friendly.  Building robust evidence platforms to validate utility (value) and ensuring consumer-driven advocacy is the only “pricing lifeboat.”  We all want and will need, medical innovation, but the Price (must be) Right.

Image Source.  CBS.com


Birth Right or Right Birth?

October 29, 2018

From the hand of fate, we are all dealt our cards. To each, 23 chromosomal pairs – each one a blended representation of the genetic precedents that have preceded us. Outside of identical twins, no two chromosomes are ever the same and their sequence similarity to our forbearers diminishes rapidly with each iteration; i.e. next generational birth. By the time you have gotten to 10 generations back, there is only a 50:50 chance that you share any of a given ancestor’s DNA. This is to say, that our genes are not our genealogy. Yet we are still related, regardless of our germline.

Our human need for kinship runs deep. With those that we believe to share bloodline or tradition, we have banded for millennium. Together, we have suffered and shared in life’s hardships and spoils. When separated, we swiftly re-partition into the groups that we feel we belong. As humans, we deeply seek and need to be members of “our tribe”.

In cultures spread across time, “banishment” has been put above “death” as the-ultimate-punishment. If you broke with accepted traditions or appeared to reflect something too far afield from the “norm”, ex-communication was the group’s response.

First impressions are critical. Extraordinary effort is placed on distinctive dress to ensure one’s quick recognition amongst the tribe. Perhaps a specific type of feathers, jewelry, garment or graphic design. To belong was to be safe; as true then as it remains today. As time has passed, our history has ridden alongside us. Visual triggers remain a key way to reinforce our tribal clustering. Whether it is skin color, gender or any other physical feature that could be used to filter, identify and sort. Our legacy biological systems are built on these visual tools.

Yet we’ve begun the long journey “to see past what we see.” To notice the extraordinary similarity we share with those who may appear to look just a little different.  To realize that we so often share more in common with those whom we have shared aspirations but perhaps a different external wrapper. And to acknowledge that even with those that we seem to share little, we all share the same responsibilities. To respect (and harness) our differences, to expect shared resources and to demand just treatment and equal opportunity.

On the long journey we have seen many moments of remarkable advancement. Milestones in which freedom and equal rights have been extended to those for whom they had long been denied – providing more integration, then more evidence of our remarkable similarities and synergies. We find ourselves becoming increasingly comfortable with the expanded safety and productivity of our new empowered tribe.

Yet, habit is stubborn. New ways seldom run free from the past. When tired, worried or repressed, we cling to the old. Revert to reflex. Cower from the new.  Our slow advances on gender and race, get hip-checked as revelations on sexual exploitation (#metoo), or police brutality (#blacklivesmatter), starkly remind us of today’s residual societal asymmetries.

Similarly, our remarkable global progress on gay, same-sex marriage and gender rights become clouded by anti-scientific policy recommendations proposing that natal birth designation provide an irrevocable definition of gender. If enacted, this line of thinking would seriously reverse the rights for those in the transgender community – critical and current ballot box issues that would reverse the path of inclusion and return us to our dark history of narrow-minded banishment.

To be born is a miracle. For some a work of the divine and for all a demonstration of the pristine – to be human. Every birth a never before (or again) blend of history. A forward-looking statement derived from the trials and tribulations of every forbearer that precedes us. In some, we will seek to claim direct kinship or a shared bloodline. But with all, we have shared upside and obligation.

We each fulfill a space on a spectrum.  How we think, in whom and how we love will all be completely unique. The veneer of our surface belittles the richness of our core.  As individuals we can become exceptional but only as communities can we be unstoppable. This is our true birth-right, as is our right-to-vote; squander neither.

Humans often proclaim that “intelligence” is what sets our species apart – the ability to analyze, to imagine, to organize, to then cooperate and execute. A unique gift that enables us to be remarkable.

Monuments to humanity’s capability are sprinkled all across the world — early works are colossal demonstrations of ingenuity coupled with brute strength. Consider the statues of Easter Island, Rome’s Colosseum, Egyptian, and early American pyramids, or the Great Wall of China as examples, each demonstrating a singularly human ability (and need) to reshape our world and leave evidence of our presence.

And as time and talent has unfolded, the complexities of our contributions have advanced as well.

Just imagine Michelangelo toiling day after day, for three years, on a suspended ceiling scaffold to complete his Sistine Chapel masterpiece in fresco (an arduous painting technique that uses freshly mixed wet mortar). In his mind, he had assembled the nine-paneled piece that retells the book of Genesis. Then to return again 25 years later, to the same sacred chapel, the actual room from which all future Popes would be selected, to toil for another seven tireless years painting the massive Last Judgement. What drove him? Was it intelligence, or something more?

Or consider the four stoic faces of Mount Rushmore. Originally intended to feature celebrities of “the wild, wild west,” sculptor and principle engineer Gutzon Borglum would have no part of that ill-considered idea. His vision was to record “leadership greatness,” in massive stone. With congressional funding and President Calvin Coolidge’s personal endorsement in hand, Borglum and four hundred fearless souls dutifully chiseled 60-meter granite renderings of Presidents Washington, Jefferson, Lincoln, and Roosevelt as a timeless (and today yet again timely) reminder of how “great character” is core to “true greatness.” Mount Rushmore is an engineering and artistic marvel, but here, too, something more was required.

These, and countless other examples, are certainly demonstrations of human intelligence.

But intelligence relies on something else unique to humans. Excellence in analysis, imagination, organization, cooperation, and execution all have a shared co-dependent variable. They each deeply inter-depend on us — the actor, the agent, the painter, the human — to truly and deeply care. Each is pulled forward by a personal purpose. By our durable (and uniquely human) interest in the consequence. For when we care, remarkable things can happen, and when we don’t, they won’t.

Sadly, for one of the most consequential and economically critical topics in our lives, “healthcare,” it seems we don’t actually care. Or, we don’t care soon enough.

Why is that?

There are many, many reasons for this, but the major contributor has been the fact that caring about our health early just hasn’t mattered much. For most of us, it has not felt as though caring before we need to would have much consequence.

What could we have actually cared about?

Well, we could keep an eye on our weight and/or what we consume. Perhaps we could “count our steps” and try to be more active. We could make certain that our children were vaccinated in a timely and complete way. Or we might regularly get our annual check-up and our gender/age-appropriate recurring tests. With some attention, perhaps we could try to get enough sleep.

If you generally took good (enough) care of yourself, you would have nearly the same risk of getting a disease, as say, your neighbor. If either you or your neighbor were eventually (and inevitably) unlucky and converted from being “complacent” to becoming “a patient,” the doctors and insurance companies stood ready to jump into action.

This general maintenance is about as much “caring” as we do, and it has mostly worked — until now.

In the near future, the way we care for ourselves should change.

The first actionable item we must work on is reversing healthcare passivity. As it turns out, most diseases have long incubation periods. And for most of these diseases, when detected early, our ability to curatively treat them is much higher than when treatment begins after symptoms entrench – cancer perhaps being one of the best examples. Even many infections are more effectively treated when caught early.

At the individual level, “caring” about healthcare in the future is to participate in the collection (and pooling) of the data needed to understand and eventually detect diseases at their earliest stages. The types of data involved will be highly diverse and increasingly captured by lower and lower cost in-home systems. These will soon move beyond today’s conventional medical tests (e.g. genetics, blood test, imaging, and so on) to capture a larger swath of our real-time exposures and biological responses (e.g. consumption, voice, eyes, gait).

And for patients undergoing any active medical intervention, their ubiquitous participation will provide the dynamic real-world data sets required to continuously optimize care delivery and generate the evidence needed to confirm the economic efficacy within the lives of every customer.

Advances in collection technology will minimize the personal effort required to participate, but the healthcare data itself must be owned by the individual who will be compensated for its use.

The greatest of humanity’s achievements have been made possible not only by intelligence but by a collective resolve — a societal push to reshape our world.

Our shared need to travel, to power, to transact has enabled the extraordinary infrastructure of our roads, airports, electric grids, sewers, banking systems, weather forecasting, space exploration, the internet, all of which were made possible by our pooled resources, rigorous covenants of compliance, and defined economics for their use.

As humanity’s knowledge base accrued past what shared stories and local apprenticeships could teach, mandatory (and free) education for all children was swept across the world. Again, a human achievement made possible and underwritten by the collective.

Healthcare must escape the constraints and shared stories of our past.

The secrets that distinguish between health and disease are written within the daily biological transcripts of every human life. These crucial bits of information are largely lost today, but they await our capture, assimilation, integration, pooled use, and returned reward.

But first, we must “care” enough to enable and empower their collection. Second, we must robustly underwrite their security, ownership, and privacy. And lastly, we must fairly value and transact upon their pooled use.

Death and disease will not overlook us. But in a preemptive healthcare system of the near future in which the biology and experiences of all individuals are pooled, analyzed, and used to optimize the outcome of everyone, we can remove “the hand of fate from our shoulders” for a much longer fraction of our lives.

It all depends on us “caring” enough to share, and being intelligent enough to look past the past.

As Elie Wiesel teaches, “the opposite of love is not hate. It’s indifference”.


Societies come and go. Yet central to them all is sustained, and shared subsistence followed by (hopefully) increasingly competent organizational leadership – what we have come over time to call “government.” Diverse living examples are spread across the world today and often built directly on top of those have preceded them. Each demonstrating the innovations by which humans have tackled the paired challenge of feeding and leading scaled-societies. And how collective creativity can foster increased productivity. Tucked into the mountain folds of the Peruvian Andes, the remarkably productive and stunningly short (only 300 years) Inca civilization or “Tawantinsuyu” as it was called then is a telling exemplar. Just before its precipitous collapse, it was 12 million citizens strong.

The Inca civilization is perhaps more famous for how in 1533, at the hands and treachery of the Spanish Conquistador Francisco Pizarro and his 180 horsemen, it was swiftly conquered. But the far more fascinating chapters of the Inca 300-year story are those of the Inca’s rise. For as breathtaking as the Andes are in beauty, their imposition on transportation, climate, and agriculture remain formidable to this very day.

In the year just before Pizarro’s expedition had made their way deep into Inca Andean territories. Being tragically preceded with their deadly gift of smallpox, the (what was to become the last) Inca Emperor Atahualpa had just completed quelling a revolt and consolidating his rule. Upon arriving in the Inca capital of Cusco, Pizarro invited the ascendant Emperor to attend a feast organized in his honor. Atahualpa accepted and joined with what is estimated to be several thousand but unarmed Inca soldiers. At dinner, Atahualpa was asked to abdicate his rule to the Spanish Emperor Charles Vth and accept the sovereignty of Christianity as the only and one true religion. After refusing both, Pizarro had his hidden cannons open fire; and his soldiers simultaneously launched a deadly horse-mounted attack. In the chaos that ensued (Incas had never seen guns nor cavalry) thousands were slaughtered and Atahualpa captured.

In exchange for his release, Atahualpa promised and then delivered over 24 tons of Inca gold, in what was then the largest ransom ever paid. But Pizarro reneged. He put Atahualpa on trial for treason against Spain for the murder (of his half-brother) for which he was convicted by a Spanish puppet tribunal on all counts – then handed a swift sentence of “death by fire or strangulation.” He chose the latter and the last breath of their Inca leader and a remarkable Tawantinsuyu sovereign society vanished together – Spain claimed its newest conquest and the so-called “Peru” was etched onto all maps that followed. Although so much had been lost, as the Incas did not have a formal writing system and so much of what had been painstakingly built has since been plundered, what remains provides telling and timeless lessons.


Millions visit Peru every year; and all marvel over the Inca’s architectural prowess and stone craft. Though many historic sites are just remnants of their original scale, examples such as mountain-perched Machu Picchu dramatically illustrate the Inca’s inspiring architectural vision coupled with highly detailed engineering and execution skills.

But what can easily go comparatively unnoticed are the Inca terraces – cascades of countless plateaus carved into the sheer mountainside. Each one is topped in imported and carefully enriched soil, often vividly green with growing food crop and all interconnected with vast aqueducts and water flow control systems that feed from mountain aquafers built hundreds of years ago and still working wonderfully even today.

To provide shelter is one thing, but to sustainably feed a rapidly growing population is wholly another. In food production, the Inca were particularly sophisticated with their agricultural terraces being the key enabling innovation. To feed a society of 12 million citizens in the high and arid Andean climate requires extraordinary sophistication and planning. This chapter of Incan history remains vivid in the Peruvian markets and products of today – a region that presently produces over 6,000 distinct varieties of potatoes, as just one of countless examples.

But how, in such extreme climates and topology did the Incas create such extraordinary agriculture diversity and productivity? As you might expect, they focused on scientific methods and attention to detail. One of the more telling examples is Moray, their elegant agricultural laboratory.

Moray is a set of cascading circular terraces that begin at an elevation of 11,500 feet and drop down ~100 feet in precise increments. Although stunning to witness and ponder their construction (by hand and shovel!), the effectiveness of this ancient laboratory is even more telling. Each resulting terrace results in a distinct micro-climate (27 degrees Fahrenheit differential from top terrace to bottom). Each terrace level then being indicative of a specific temperature range that one can expect to extrapolate to the countless other terraces spread across the empire. On the terrace arrays of Moray, each variety of agriculture product could be tested for fitness for a specific micro-climate and the specific planting and harvesting schedules could be precisely optimized. This, coupled to a steady and reliable source of water, enabled the early Incan agricultural experts to shift from experimentation to mass food production.

As we prepare for a climate-changed world where the availability of water is rapidly changing, and mean temperatures shift upward, the prescient planning of the Incas is a wonderful reminder of how creativity can enable productivity, even in the most trying of environments. Clearly, it is (was) hard work and takes long-term planning. But the “mouths of the masses” will always be eagerly waiting.

All About Transitions

February 19, 2018

Olympic Games bring out the best in all of us.  Athletes from across the world set aside national differences and reconvene to honor the pursuit of excellence.  To stand shoulder-to-shoulder as the world’s best, each hoping to take center stage of behalf of their nation – fourteen days during which anthems and admirations stream across the world.

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February 7, 2018

“The Red Apple” was the elusive prize of medieval conquest for an uninterrupted 800 years.  Secured behind what had proven to be the most formidable combination of building ingenuity and natural defenses was the fortress city of Constantinople.  Dedicated in 330 AD by its namesake Emperor Constantine the Great, it quickly became the center of wealth and commerce of the Middle Ages.

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JPM at 15

January 4, 2018

To “skip a stone” takes more than just practice.  It requires discriminating selection, as only a tiny subset of stones will do.  The perfect stones for this are those that have been polished by time – rounded of rough edges and protected from too much mid-body girth. 

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Thrilling Three for 2017

December 22, 2017

2017 will be recorded as the year of “resilience” – a year that illustrated more than any in recent memory our human capacity to endure. To survive the unexpected, to adapt and to rebuild after recurring setbacks. A year where the world began to search for new sources of leadership. A world where iconic institutions that were seemingly unshakable began to prove disruptable.

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Power Struggle

November 9, 2017

Power takes many forms. In physics class, we might think of it as what it takes to move a mass of X from point A to point B. Or in politics, perhaps it is the influence an individual or institution leverages to achieve its objectives.  But when it comes to biology, the “seat-of-power” resides along membrane leaflets within ancient microbially-derived organelles, and for those of us within the animal kingdom we call them “mitochondria.”

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To Nurture Our Nature

September 20, 2017

The quantification and forecasts of productivity are the gristmill of economics.  Typically, a ratio of inputs (labor and capital) over outputs (products and services) are often used to measure how effectively or efficiently a given economy is performing.   The range of creative variations of these ratios and measures are staggering. 

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