Archives For Patient

“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.

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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”.


Hard to Fathom

June 14, 2017

In the mere moments required to utter and comprehend a “we are so sorry to have to tell you” diagnosis, we are transformed from an individual, a customer, a voter, a parent, son or daughter into a patient.

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