Patient Centric Healthcare
My daughter went to see a doctor a month or so ago. She thought she had strep throat. The doctor checked her out and said that she did not think she had strep. My daughter wanted a strep test but the doctor talked her out of it. A week later, my daughter was back at the doctor with a massive case of strep throat. I told her the lesson of that experience was the the doctor works for her, not the other way around.
I was reminded of that story when I read my partner Andy’s long and wonderful post on USV’s approach to investing in healthcare.
In that post, Andy quotes Jay Parkinson:
People are the CEO of their health, and doctors are just consultants.
And that is what I was explaining to my daughter last month.
The good news is that technology is changing all of this.
My daughter’s iPhone can’t deliver a strep test to her, yet. But it can deliver an eye exam and a hearing test. So I am confident strep will come to a phone someday. And in the process our phones are becoming our electronic medical records. But we own them. That’s a big deal.
Andy gets into it more in his post which I re-tweeted with this observation:
User centricity may be the megatrend of our time https://t.co/x2GqPeJ090
— Fred Wilson (@fredwilson) June 14, 2016
Comments (Archived):
Yes, relates to every industry. One fear, bureaucracies like Obamacare/Dodd/Frank etc get in the way. Someone needs to disrupt and get rid of the fourth estate.
Many people even now now revert to doctor google before wasting waiting room time live on estates, Good on ObamaCARE.
Meh. I think they are getting more comfortable with the internet. Obamacare is a disaster. To be fair the fifth estate stands more strongly in the way of innovation
The thing about Dr J and Sherpaa is you still talk to a doctor (virtualist). There is still an expert involved making a decision and directing you. That’s the critical component. Not the device in your hand. That’s just the vehicle.Without that expert you just end up with a mobile version of WebMD where every set of symptoms returns, “Oh my god I’m dying of cancer”.
Also, I’ll add, the bigger disruption (at least here in NYC) is the proliferation of quick, well staffed, affordable, and super responsive Urgent Care facilities that have sprung up. They have been a remarkable improvement for general care.
faster, better, more efficient than people going to the ER for non-urgent healthcare needs on weekends, before 9, after 5, and any time. Drugstore chains are building them in suburban stores, and hospital chains are building them in strip malls. i’ve used them for my daughter for a sprained ankle after a weekend bouncy house playdate, etc.
Totally agreed. See comment above.
That’s where the doctor refused to give Emily a step test. She went to her regular doctor later and got one. But the next week I went to an urgent care facility and got my ear unplugged because I could not wait another five days for my ENT appointment and it was one of the best medical experiences of my life. I have no point to make here. Just some anecdotes
I hit my temple on the sink, bled everywhere, and needed 7 stitches. At urgent care they did such a great job stitching you can barely see it. My friend in EM was impressed as I was.
ouch ouch ouch
Honestly you should join one of those concierge medicine practices for your entire family. Worth the cost just in lessening anxiety alone.
My PCP in NYC moved to a concierge model last year. Began limiting his practice to 700 patients. Charged a $4K annual fee for an individual, $6K for couples, on top of the $650/month I was paying for my policy w/ Empire BCBS. Could finance the fee at 2.5-5% depending on payment sched. Good doctor, but had to drop him. He was overburdened w/ patients before Obamacare and no doubt his patient load increased w/ enactment of the law.
Are you sure about the number of patients ? That brings in 2.8m of revenue even with office staff and rent that is out of whack for a PCP (obviously). Are there multiple docs in this office servicing the 700 patients (who whatever number he signed up)?
Huge practice. Ridiculous. Multiple doctors, his name first on the door. He’s living large, no doubt. One other physician practicing w/ concierge model.Edit: 700 patients was his stated cap, no idea if he achieved that.
To be kinda blunt, the doctor did the right thing. Overuse of antibiotics is a problem. As an adult she’s more likely to get something viral than bacterial, so unless she gets a culture back positive with strep bacteria, there is more harm than good giving her antibiotics.
But she wanted a strep test, not antibiotics.I am really surprised that the doctor resisted administering this. Our kids’ pediatric group is hyper-vigilant about checking for strep.BTW, got your email. Good question. Will respond but may be slow.
It’s unclear why your daughter’s MD refused the strep test. Without knowing specifics of the case, these are possible scenarios that I’ve used when seeing patients.(1) classic case of strep – no strep test needed. Classically strep has sore throat, fever, white exudate on the tonsils, and swollen lymph glands. There is no hoarseness, runny nose, or cough. Scoring system here – http://www.aafp.org/afp/200….(2) symptoms are not classic for strep and more likely are viral. Aside from a bad sore throat, other symptoms including having cough, runny nose, hoarseness. In fact getting a strep test here can be confusing to patients because some patients are carriers of strep. This means had we swabbed their throats for strep when they were perfectly well we would have discovered strep. The only time one treats a carrier of strep throat is when someone in the household (like a child) repeatedly gets strep and the source of that is due to a carrier. Because they are a carrier of strep – they have no symptoms and there is no harm to the carrier patient.(3) uncertainty – sore throat. perhaps a little fever, no cough, runny nose, hoarseness that mean it isn’t more likely a virus. This would be a reasonable time to do a strep test.Just to clarify for patients in situation (2) I discuss with patients everything as noted above. If they want a strep test, happy to do so. Even if the result is positive and we treat with antibiotics, if they see no improvement in 2 days it isn’t because the antibiotic isn’t working, but because they had a virus! Antibiotics kill bacteria, not viruses. The majority understand and don’t want a strep test. Those who do, majority have a negative result.Now doctors get sick as well and I’ve had very bad sore throat (3) plenty of times (occupational hazard!) I know it’s highly unlikely it’s strep but I hope it might be so I can treat it with antibiotics. Nurses swab my throat every time. Result? Negative. Negative. Negative.I hope if such a strep test becomes available to the public that the they will be educated on the above.
And, the massive increase in people with insurance but no primary care physician (Obamacare) is what is driving the adoption and rollout of these new urgent care facilities
The device / vehicle will be combined knowledge of a thousand oncologists or would you rather your local GP ?
Can’t my local GP tap into that knowledge and I get the best of both worlds?
My virtual GP Q&A will disseminate the information you will have an early prognosis, you are still in control, your GP will also be made aware if the data throws out problems / early warning signs. My generation would not trouble the doctor and then it was tooo late, for now I am empowered by Dr Google : )
our portfolio company HumanDX is trying to teach machines to diagnosehttps://www.humandx.org/
All amazing stuff that supplements and serves, not replaces. That’s just my opinion of course.
Yes at our level. But what about the poor person in India who has no doctor but has a phone.
Valid point.Though personally (though maybe not practically) I’d like to see improved health services in those areas, not improved cell signals.
they are better off using the internet to find a doctor elsewhere who can offer a professional opinion.most doctors suck, but machine learning healthcare, while probably inevitable, is going to run into the same problems that machine learning finance does. it’s going to have a tough time understanding psychology. ultimately, at scale, a hybrid man/machine solution is needed.
most doctors suckOh really why do you feel that way? And how do you define “suck”? You mean in the same way that every politician sucks, or every government worker sucks?What about people who suck and abuse their bodies with the wrong food, drug abuse, alcohol abuse and risky behaviors. They suck as well. So I guess in the same sense that we could say “people suck”.
only agree in some symptoms and medical issues clearly an automated machine solution will be appropriate and in others having a physician whose skills are augmented and leveraged with technology will be best.
Great. So they find out they have something but don’t have the resources or local expertise to fix it. What good does that do?
Thats a fairly big assumption about medical care in India Fred.
I wasnt really making a point about India per se
Yes, understand..
you discredited the indians in general, poor indians specifically. don’t forget the physicians are 80% indians worldwide
How into mental health are HumanDX?
Not very, they specialize in edge cases across medicine
Seriously correct. Lot’s of things come down to judgement which a Dr. gains over time combined with protocols they follow and is based on things that can’t be diagnosed with an algorithm.Ever wonder how people even survived 200 or 2000 years ago? I am not talking about diseases that we have cured that they died from and improvements like that. I mean the anxiety level must have, in a sense, been much less because until you had something (excluding suffering) that actually made you close to death you probably weren’t to concerned about it. Just a guess.
There is a value to medical training, to the years spent in the training and to the quality. Followed by years spent in practice.Somewhat related – This is slowly becoming a pet peeve of mine watching whats happening in the fitness – wellness ( & wearables) space.
This is slowly becoming a pet peeve of mine watching whats happening in the fitness – wellness ( & wearables) space.My pet peeve with that is people thinking that some device is magic as opposed to just hard work over time and being sensible.
The fitness and wellness space I know pretty well.In neither of them oddly to i think that wearables is a lead indicator of much.There but certainly in the wellness space way way down the list.Your view is different I’m presuming….
Not different from yours re wearables. They seem quite useful for some people, and thats fine….to each their own.
Had to Google Sherpaa for Dr. J reference. As a Philly boy I thought for sure you were referencing Julius, the only Dr. J in my book. As a small kid I grew up watching Julius and the Nets (ABA pre-merger) at the Nassau Coliseum. Team couldn’t draw for shit. The team was marketed as “Dr. J and Mr. K,” the latter for Larry Kenon a talented forward out of Memphis State. Julius had the best fro in the game, sans Darnell Hillman (see attached image).Let me digress just a tad more. My all-time fav ABA story: James “Fly” Williams, a head case who lead the nation in scoring in college, actually went up in the stands for a hot dog during a time out while playing for the ABA’s St. Louis Spirit. Bob Costas called the game.
Didn’t The Fly go to Austin Peay, which then created the iconic chant:”The Fly is Open! Let’s Go Peay!!!’
Yes, that’s the one and only “Fly” Williams. I’m impressed 🙂 I read somewhere that when Leonard Hamilton (current FSU coach) recruited “Fly” at Austin Peay he showed up for a scheduled visit at his home in Brooklyn. Hamilton literally waited for him all day and through the night (Fly’s mom kept him company) until Fly finally walked in at 7 a.m. the next morning after a night on the town.
Medical expertise is important, but it does not have to be and should not be the beginning of the journey.There’s value to having a better experience than WebMD with online diagnostic tools that can get a user/patient closer to understanding their condition and triangulating which doctors to see at the lower cost to the user. Discrete services are popping up to do this already (some that you mention) but they’ll become smarter and more automated over time.
I guess that wearables have the best opportunity to evolve into health devices. In a very modest way I have had the experience with Apple Watch activity app which tells me when i have been seating for too long or not achieving the daily burnt calories goal. Wearables may become great preliminary diagnostic tools once they get the chemical and molecular sensor technology.
Not strictly medical but very relevant to healthcare, awareness. In a decade we may be able to continuously check several health parameters.
I think it also speaks to humans poor job at prognostication. In the Heath brothers book “Decisive” they state that- “There are studies of doctors that say that when a doctor expresses complete certainty that a diagnosis is correct, they could be wrong up to 40% of the time”. AI and ML take out all sorts of biases like confirmation, recency bias etc.. AI will help doctors and people in all jobs make better decisions.
it’s always about the user …
If only that were always true in practice 🙂
ROI of UX http://www.usability.gov/wh…
Docs offices will have to be in on this too. In May, I had surgery on my leg and the second part was done in a plastic surgery unit. It was like checking into a hotel instead of a hospital, But most reg doc offices are overwhelmed with just trying to stay even
Cost of regulation and to deal with insurance
Not really. The Docs don’t do any of that part but still overwhelmed. Some Docs go with a retainer for the year to limit their patient load and give more time to wellness.
Totally. We will soon have more medical data about ourselves than our doctors do via tests they order or exam they perform. It will become a partnership of data and data interpretation in order to arrive at the best diagnosis.The best doctors now will respect the data that the patient brings with them.This is a key pivot statement “the doctor works for her, not the other way around.” I would add to that point that, we are the ultimate decision-makers on our health. Doctors should describe all possible alternatives with pros/cons, and it is up to us to decide.Remember this question when talking to a doctor about something you have. Ask “Are you sure?”
My first thought was that there’s a giant leap between delivering an eye and hearing exam with a phone, versus delivering a strep throat exam with a phone. But maybe not. If there’s an attachment you plug into your phone that you swab the inside of your mouth with and the sample gets examined by the phone. Does that technology exist yet? I guess the phone would have to have microscope capabilities to look at the cells…
Imagine the same thing to see if you can get pregnant right now. That would be a game changer for women who want to and women who don’t
Yes, totally, and then to take that a step further, to see how fertile you are.
You can kind of get that already. They sell ovulation kits at the drug store (along with paternity tests!!)
Even given all the chemical data, still tough to know due to two pieces of data, both so far tough to know: The lifetime of the male sperm in the female’s body, and the lifetime of the female’s ova in her body and after ovulation.
Such as your portfolio company Clue?
The base technology exists, it is a matter of miniaturisation and getting the sensors price low enough and with good quality results for consumer devices.https://www.youtube.com/wat…https://en.wikipedia.org/wi…
Wow that was great, thanks.
My pleasure. People will be very soon licking their phones while walking and texting.. and driving. Your swab-attachment is more elegant but you know, most people are lazy. 🙂
Gross
It’s getting there
There has been lots of progress in using biomarkers in saliva as a risk assessment tool but I haven’t seen anything that works without being first sent out to a lab. That kind of takes the fun out of it.
Lab on a chip for streptococcus Dna?
I can see something like this.One of my clients (now called Nima Sensor) has a pocket-sized device that you carry around and put food in the disposable cup to detect gluten. Other allergens in the works. I wonder… could something like this be developed to detect certain diseases, viruses, etc.?
Contributors:Two Healthcare notes…Walmarts in Arizona have sever their business relationship with Theranos mainly based upon unreliable testing. But Theranos has stated the company will do a stand alone model. (Good luck with that) There is something to say about remaining in college all four years. Attempting to emulate Bill Gates or Mark Zuckerberg which is the exception and not the rule. (Reflecting on a post Fred submitted a while ago regarding knowing when to quit)The other out take is Healthcare providers are increasing their rates for the ACA or pulling out of markets. Wasn’t this negotiated with the Healthcare companies not to do what they are now doing?
Theres a few books out there on this subject. One of them has the greatest title: “The Patient will See You Now”. What a turn of the tables.
Dr. Topol is a legend on that topic. Also, his previous book that started this:”The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care”
It would be so great to see that revolution in our lifetime.
It is happening. no doubt.
Do you see limitations w/ a patient centric approach in a socialized med system? From what I know about CA healthcare it’s heavily driven by prioritization and statistics.
Not really actually. In Canada (as in most other countries), the relationship between the doctor and the patient is the same as in a totally private system.I think there’s a big misconception about the Canadian healthcare system by US citizens. It is not entirely correct to call it “socialized”. It is universal healthcare, and it’s a right all residents have. The government doesn’t run these hospitals. They just fund them. They are run like an entity in the business of providing healthcare, and not for the single purpose of making extra profits. Doctors are self-employed individuals like in the US, and they can bill to their heart’s content. As a matter of fact, more than 500 doctors in Ontario billed over $1M/year, and the top doctor billed $6.6M last year. There is nothing “socialistic” about that type of system.The key difference is like having a single insurance player, and without the red tape and administrative hurdles and extra costs of a US system for example. So, the level and quality of healthcare is very similar to the US, without the hassles of convoluted health care administrative costs.
Thanks for the detailed explanation, William. informative and appreciated.
I agree that it will happen but there must be some significant structural changes before the consumer is really in the driver’s seat.
It will be cool for the patient to aggregate his own data across providers, be able to share them selectively, and control how it is shared beyond.But… it will need the ecosystem (healthcare providers, pharmacies, insurance companies, etc.) to play ball and optimize for the customer than for themselves. Forward thinking government regulation mandating data sharing and API access may be necessary to bring this to fruition.
This is more a general problem with health professionals that can be solved with simple checklists: Clinical review: Checklists – translating evidence into practice. Another issue is trying to find only one cause instead of thinking about problems with multiple variables.
That is a great reference! “Despite the corpus of evidence regarding the benefits of checklists, medicine remains slow in broadly adopting them into practice” which was the realization of my favorite physician writers Atul Gawande, author of the Checklist Manifesto (2009), discovered a few years later that checklists alone won’t get the job done. It will take leadership, and in health care arguably physician leadership, that will get wider adoption of checklist use every time. http://www.davisliumd.com/w…Interestingly from the article you highlighted, the authors wrote that physicians should not blindly follow checklists and use judgement much like Miracle on the Hudson pilot Chesley Sullenburger did, which makes perfect sense. What the article failed to mention was that his co-pilot Jeffrey Skiles was going through his checklist on engine restart (he attempted at least 5 times in a little less than 5 minutes). This freed up Sullenburger to focus his cognitive expertise on solving the problem at hand, which clearly did not have a checklist.
I am sorry for your daughter experience. It sucks to be medically “dismissed” only to be dx after time has passed. Medicine, like every industry has a spectrum of practitioners. And all of you here on USV know there is also a CEO spectrum. There is always a relationship that is established between patient and physican. There is not doubt tx becomes more efficient when the patient is aware and cognizant of their baseline and there is a respect/trust that goes both ways. In our “on demand” economy it is important to recognize that quick answers/algorithms/pop up medicine comes at a relational cost. Data and tests require the consideration and thoughtfulness of both pt. and dr. – otherwise they are soulless. This shouldn’t be an adversarial relationship on either side but one of accountability and advocacy
DX? TX?Guesses: diagnosed, treatment
Yes
And what is Rx? Guesses: Prescription, and all 3 abbrevs come from Latin? Almost sure Rx does.
There are probably numerous systemic/economic feedback loops that push doctors into playing the role of cost containment police.Even here in Canada with a single payer system doctors seem to get subtlety pushed to play that cost containment role.If my doctor is tempted to skimp on ordering a test I just politely say “well the only thing we know for sure here is that we don’t really know so I’d feel more comfortable with a definitive test result”.One or two go-arounds with that response and you’ve put your GP on notice that you expect testing not guessing.It is probably a little easier to insist in a single-payer system as the only personal cost is the effort it takes to insist 🙂
Overtime, I’ve noticed that the reverse is happening. I have to ask patients to find the money to pay for definitive testing. It’s getting a lot harder when patients have a $500 or higher deductible for an MRI and a recent article in the Atlantic found that nearly half of Americans don’t have $400 for an emergency…In addition, not every test can provide definite results. For example, MRIs are over sensitive and ordering MRIs on all patients with no back pain, it turns out about 1/3 of patients have herniated discs on MRI. When they studied this cohort over time, the patients that ended up having sciatica or a lumbar radiculopathy were not the original 1/3 of patients! It was another cohort.In other words, anyone can ask for and order an MRI. It takes some understanding, judgement, and experience to figure out whether that MRI result is the “truth” and the right “signal” versus a red herring or “noise”.
When it come to dx and tx, for ambulatory medicine like Emily’s case, it’s all about the patient pitch. Like pitching a VC, You have 3 minutes to pitch. Pitch incorrectly and you may not get the outcome you desired.
Sure, but don’t doctors have a responsibility to ask patients the right questions to get to the right diagnosis? For most patients, seeing doctors is more the exception rather than the rule. Practicing a symptom pitch, though makes a lot of sense so one can safeguard against doctors who don’t listen. Yet in my experience and that of other doctors, people who practicing their symptom pitch and advocate others who do the same are those who have been hurt by the health care system.
Access to tests are less critical than access to expert diagnostics of the tests.That access is not democratic and therein lies the most challenging and important change.A bunch of years ago something scary was diagnosed for me, very very early.My physician noticed it, picked up his cell phone, got me into to see the world’s best, no waiting. All ended well.Wasn’t a case of economics as every piece was covered by insurance.It was expertise and caring that made this story end well.
Our portfolio company HumanDX could make it so that our phones can do that toohttps://www.humandx.orgI said could not will but the thought it tantalizing because it would democratize access to high quality diagnosis
This is a topic I could be involved in as it is personal, real and targetable.Also will not be solved 100% by tech but I think tech can drive the human connection possibly through community in a more efficient way.Appreciate this post. Been awhile since I re-realized the importance of this community for surfacing issues like this. This is the real stuff of life.
Diagnosis as a case of personalization is relatively doable because the human biological systems under consideration are quite standard and very, very similar across 6 billion humans and significantly similar across a lot of mammals and even more. That is, whatever the current patient had, likely they are not the first. That is, for that patient, the medical profession has been there, done that, maybe thousands of times just in that hospital or clinic. Right, Zika, but such new causes are very rare.But for personalization based on likes, emotions, tastes, and the rest that is unique between a person’s ears, from their life experiences, etc., that is in principle much more challenging.
Great story, and it makes you wonder to what extent certain patients get better / faster care because of who they are or who they know.
A story with a good ending.Not economic because it is no longer true that the very best don’t take insurance. Use to be so need to give some credit to the insurance companies for breaking this down and to caregivers to understanding why they became doctors.Networks are made of people. Platforming their knowledge is one thing. Platforming human connections is and has always been a function of community.Critical topic.
Yup, if my startup is successful, then there will be some gifts I should make to some hospitals and clinics.
In many hospitals certain patients are marked as VIP’s which has a wide range of definitions. Could just be someone related to a person who is another doctor at the hospital for example. The short answer to your question is “yes” with faster, and “maybe” with better.In Arnold’s case the Doctor did what any Doctor would do which is contact a top doctor (who he might send patients to) and get his patient squeezed into a slot. Nothing unusual about that actually. And even if he had not ever referred to this Doctor before, by personally pleading the case an exception to the scheduling rule was made. Nothing unusual about that either.I had a radiology study years ago that needed a 2nd opinion and my sister (who worked for a pretty big doctor at the time doing research) got him to call his buddy and literally take it over that day. That “faster service” just resulted in less anxiety time for me. Outcome was the same “everything is ok”. Once again w/o adding more cost to our healthcare nothing wrong happened here. No different than Fred taking your referral more seriously than someone writing to him for the first time.
yup. i had that priority service given to me as well in Canada.my father is a doctor; and as a son/kids of a doctor, we used to receive royal treatment when seeing other doctors who were his buddies or colleagues, when we were growing up. it did feel privileged.but as a doctor, he was very generous with patients that weren’t on full insurance or were less privileged, and he routinely waived his fee.
No doubt it can make a difference.We have figured out that having daughters around asking articulate questions makes a huge difference in the treatment my mother receives when hospitalized (she has several health issues that have required hospitalization over the years).And knowing the head of surgery at a local hospital got my son into a specialist whose staff had previously told us he couldn’t be seen.And so forth…
Sadly that is true in health care because it is still a cottage industry unchanged from the 19th century. We don’t have large integrated health care systems, except perhaps like a Kaiser, like we do other aspects of our lives (aviation, hospitality, 3rd spaces – Starbucks), where consistency of experience, quality, and safety can be reliably delivered every time. Until that happens, then who you know or what you know can make the difference between getting so so care and the right care.
I agree with your assessment, and was thinking too that integration is a real issue that hasn’t been solved yet. Do you mind emailing me if you’re interested in continuing this conversation? [email protected]
i, like most Brits, experience the NHS healthcare system. are you describing a *private* US healthcare experience here?on phones and healthcare, the new One Plus Three phone has 6 GB of RAM. doctors may need to up their game.
They must be. See @susanrubinsky:disqus comment about wanting the know the price of a yearly check up. I suspect you, like me, already know the price: $0
Patient centricity is something I’m increasingly interested in. Tech is enabling timely access to healthcare for so many people. Combine that with development of AI and soon we will have the expert, personalized recommendations instantly available in our devices. The future is bright!
I can’t decide how to respond. Pending a hearing outcome, I might be contacting the aclu in part over this issue to see if there is a nationwide class action to be filed.I also tend to think hipaa as it stands doesn’t work, and the guy who created health records is an idiot for creating a data model around billing codes instead of health.Going to go scream and giggle in my corner now
the other side of the customer-centric approach, and not just in health care, is the superb customer service. i was in PartyCity in NYC, a few days ago buying balloons for my kids bd and it was just an awful experience all around: unpleasant unhappy people behind the counter, doing a bad job blowing up balloons.this happens so much lately – bad customer service. was thinking that its only good on the outskirts, i.e. either an occasional shop that does a good job, or the startups that are all data/customer driven and take particular cares to figure out how to please the user.
100% agree that whatever you call it — user centricity, patient centered care, consumerism — it’s inevitable and happening. That said, working in health again after years in consumer tech, I’m reminded how many still undermine and underestimate patients. It’s nearly offensive. Take a recent Health Affair op-ed: “for consumers and patients the quality aspect of health care should be removed from their calculus.” healthaffairs.org/blog/2016…Patients can and will demand, understand, and act on information – cost, quality, value. The problem is not in patient intelligence, it’s in the current solutions available. That’s all changing.
There’s no doubt patient-centered healthcare is happening and the patient is becoming more and more powerful and direct to consumer apps are slicing off revenue from large provider groups. But let’s not get ahead of ourselves. It’s not clear that, given current payment models, patients are all that sensitive to cost and quality just yet. And the vast majority of healthcare spend is still driven by provider to provider referral patterns. Healthcare is unique in that sense. In the short/medium term, you’re still better off prioritizing the provider over the patient.
true but this too is changing rapidly, see for example Lemonaid and Nurx which change the whole economics of care
There is from Lemonaid’s home page:I discovered this app while searching for the simplest way to fill my prescription and it’s simply the best! No embarrassing doctors visit! No waiting room! No fuss! I can’t believe how simple and easy this is! Anyone who needs a basic consultation for a basic prescription should use this app.But in the long run, this is like treating body odor with perfume. Build a relationship with a primary care Doctor. Get your physical each year with him or her, Give them a a few softballs, like a one minute office visit and the the need for a script. Make the dr feel like a dr, so when you “need” a dr you will have one. The time to look for a dr is NOT when you needs dr.People forget that dr’s need a little love too.
Hmm. Really interesting. Curious to see if a Lemonaid will handle a referral into the healthcare system for more serious conditions; e.g. if the prescription isn’t working do I come back to them for a referral to a specialist? This directly competes with hospitals’ community-based primary care strategy and this is where the money is. Community-based PCPs are a loss leader for big healthcare providers as a way of generating referrals. In a fee-for-service world, direct-to-consumer apps like this could replace that entry point into the system. In a value-based world they could be a great way to provide the same quality of care with the same number of patients but fewer docs.
Two thoughts. For Lemonaid, we follow-up all of our patients who have been treated by us for an uncomplicated urinary tract infection to ensure they have improved. For the very small percentage who do not (which can happen even to patients who see a doctor face to face) we recommend they see a doctor in person.The second, regardless of whether fee for service world or value-based world, one can envision using a model like Lemonaid as an inexpensive way of extending a health care system’s brand. Use technology in an inexpensive way to treat simple uncomplicated medical problems and those who need additional care see your health care system’s doctors. In the former you increase your reach more easily because you don’t need as many doctors or offices to expand. For the latter you already are capitated on how much you can spend on bricks and mortar and doctors, so you want to use those as effectively as possible by moving problems that can be treated more simply in less expensive venues.
Two Responses:On Strep ThroatWhen I was in my 20s, occasionally, and for no apparent reason, I got a sore throat. At one of the early episodes, a physician did test for strep and got a positive. From then on, when I got an episode, I rushed to a physician and asked for the usual knock’m dead cure — penicillin. Yes, we don’t want overuse of any anti-biotic, especially penicillin. But strep is darned dangerous. Sometimes I had to insist on the penicillin prescription, but I was never turned down, and none of the episodes ever got serious.It was just a 20s thing — haven’t had another episode in decades.I interject, an age thing? From age 6, I was the world’s favorite hangout for any and all cold viruses. My nose would run; I’d blow my nose; the end of my nose would get chapped; and sometimes finally the sinuses would bleed (at which time usually the cold would soon end). Well, I haven’t had a cold in decades! So, somehow it’s possible to outgrow some of these vulnerabilities.On PersonalizationYup, generally darned important and in particular is in my startup. Of course, the biggie problems are (A) how to get sufficiently good data and (B) how to manipulate that data to get good results on personalization.For (A), getting bad data is easy, but the problem with bad data is that, if only by definition, it doesn’t provide much help in doing well in personalization.In my work, about the only way I could think to get good data was from the business model and the user interface (UI) and user experience. All three of those turned out to be strikingly different, original, novel. Thus, my guess is, getting good data is not easy and may need a lot of help all the way up to the business model itself and, then, all the way down to the UI, etc. That is, getting good data can be difficult.For (B), maybe in practice that about has to be from some good applied math. And maybe the math won’t be elementary; instead it might be in part original and have some advanced prerequisites — that’s the case in my startup. Yes, we’re talking proprietary intellectual property, trade secrets, technological advantage and barrier to entry, etc. — all things we’re supposed to do in high technology, innovative information technology, promising startups, etc.Yesterday I saw a headline that Netflix thinks that their movie recommendation system is worth $1 billion a year to them. Good for them. Netflix did try to have a good recommendation system, e.g., ran their Netflix Challenge contest.My view of their contest is that they did a poor job formulating the problem, especially on the point of personalization, which was the main goal of their contest and system. So, maybe their contest got them a good solution to a poorly formulated problem, that is, a relatively good answer to a poorly posed question.I believe that in my startup the formulation of the question of how to do well with personalization is much better than what Netflix has, with some irony, including for personalized movie recommendations (discovery, curation, etc.). Right: Watch the movie at Netflix, but get the discovery, recommendation, curation, etc. of the movie at my startup (for the basic plumbing, just a Web site).Part of the difference is the data (A) — for my startup, that data is, again, strikingly different from what Netflix has and is assuming, using, etc. In particular, for the data Netflix is assuming, my view is, for a lot that is important in movie recommendation, just can’t do that at all well with just that data.Then, for how to manipulate the data, it did appear that they were looking at a mix of some manipulations currently popular in what is called computer science and otherwise at some fairly elementary techniques from classic multi-variate statistics.In my startup, well rested, in a quiet room, I put my feet up, popped open a cold can of Diet soda, reviewed some of the best pure math I’ve studied in grad school and both before and since, had some ideas, got out some clean sheets of paper, and wrote out some math, right, with theorems and proofs (e.g., so that I could believe in the results).I especially thank H. Lebesgue, A. Kolmogorov, and J. von Neumann! Nope, I wouldn’t have thought of all that on my own!For multi-variate statistics? Early in my career, I consulted and/or read stacks of such books, but for my startup I didn’t consult or consider those!Consider computer science? Not a chance!Ah, correction! Sure, at one point my code needs to go through maybe 10 million numbers and end up with the 20 largest. So, how to program that efficiently? Sure, borrow the heap data structure from the famous heap sort, right, the one that meets the Gleason bound. Darned clever algorithm. And Gleason’s math is also clever. That was A. Gleason, long at Harvard, and the guy who, before they could get him his Ph.D., knocked off one of D. Hilbert’s problems. Gleason was made a Harvard Fellow and never bothered with his Ph.D.! Once I was in a summer math program with one of Gleason’s students — bright guy.Yup, doing well with personalization can be important but not easy.
Learned this lesson a little over 15 years ago when our daughter was born 72 days early. We quickly learned to be her “advocate” and that word does not come close to capturing it. Parkinson gets closer with people needing to be the “CEO of their health.” It is still not aggressive enough.
For most patients, however, until they have a serious or bad outcome do they became true advocates for their health. Otherwise, patients judge health care qualities on things they can measure – did my doctor listen to me, was it easy to get an appointment, was it when I wanted the appointment? What really should matter is how accurate was the diagnosis, how effective is the treatment, how experienced is the doctor (particularly in procedural based specialties), how good is the doctor in making judgement calls. Of course all of these latter aspects are harder to quantify…
The doctor checked her out and said that she did not think she had strep. My daughter wanted a strep test but the doctor talked her out of it. A week later, my daughter was back at the doctor with a massive case of strep throat.It’s entirely possible that the Dr. screwed up here. But based upon the doctors judgement and experience your daughter didn’t have strep. We don’t have enough data to make a determination based on one “miss”. How many times did the dr. say the exact same thing and the results were different?People want healthcare to be affordable but then they wants tests for anything and everything. And they want no errors and no mistakes. A typical Dr. can see between 20 and 60 patients in a day and they don’t get an hour to check, think and double check on every situation.This is one of the things that has led to over prescribing of antibiotics as only one example.We can’t have a system where we pay someone for their experience and judgement and then have someone with no experience whatsoever in medicine using someone else’s money (all of ours) to pay for a test which statistically and protocol wise is not deemed necessary.
Better question for first doctor was how do you treat early state strep?He may have said without antibiotics.http://www.ncbi.nlm.nih.gov…Then Emily could have said, I understand the risks of taking antibiotics but id like to take the test anyway and if positive be treated with antibiotics.The doctor would have written the scriptAlso, every person should know what specificity and sensitivity are when it comes and how they apply to medical tests
Great points in that article – things are rarely as simple as we hope them to be.”Symptoms caused by a bacterial sore throat fail to clear much faster when treated with antibiotics than they would if left alone.”If the evidence truly shows that antibiotics are mostly ineffective for Strep, then there is a case to be made that you don’t prescribe antibiotics for every case of Strep you see. It’s quite possible that antibiotics are effective in reducing symptoms for severe cases of Strep (your daughter’s case) but blanket prescribing of antibiotics for every presumed case leads to the bacterial tolerance we’re seeing around the world. There’s been a significant correlation between the prescription of antibiotics and the recurrence of Strep in individuals also.http://www.pediatricweb.com…I find the issue in health care is that sometimes MDs fail to explain the logic and rationale and protocols for their decisions, leading us to assume they are incompetent or negligent.In this case the doctor’s line of thinking may have been:1. Antibiotics don’t really help, except in severe cases, which she doesn’t have.2. Getting a test will only tell us she has Strep, and I still won’t prescribe antibiotics for the reasons discussed above.Great discussion. I’d love more input from the MD community.
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i’m as confused as you are, this was edited
I’m a little confused. If someone tests positive for strep, it’s ok NOT to treat?
But she wanted a TEST! Not antibiotics. A simple swab. So simple.
Well from what I read that requires both a rapid antigen test (in the office) and then a culture (sent out to a lab). The dx for strep (according to link below) takes into account various symptoms.Like I said it’s entirely possible that this Dr. screwed up. But it’s also possible that given the same symptoms as Emily came in with, they didn’t think a rapid antigen test (assuming they had one) was even necessary.There is a definite move in medicine to draw the line on tests (no matter how ‘simple’ they are) so I don’t think you can just say if the patient says “give me this test I want it” the Dr. just caves in.Plus it sets a precedent. In this case maybe it’s no big deal. But in another case a patient may demand (and demand they do from what I hear) an invasive test. Can’t have medicine work that way, make sense?Lastly, even a simple test gets billed for and somebody pays for it.http://www.mayoclinic.org/d…http://www.webmd.com/oral-h…
I could see the cost factor entering in. But not for this particular patient. 🙂
Doctors not wanting to give strep tests is commonplace for some reason. We used to keep a strep testing kit in the house. All you do is swab and put it in some chemicals. Easy to do.
Medicine has become far more consultative between patient and physician. Knowledge is power. The Internet has empowered patients w/ knowledge. Experience is power too. Physicians have the benefit of a formal education and real-world experiences (e.g., data points). Medicine is hardly an exact science. Statistically there’s likely far more danger when a patient is empowered than when a doctor is empowered. Let’s face it, medicine is nuanced and hardly linear. Good medical practitioners recognize the importance of creating balance and the need for a different, modern-day type of interaction w/ their patients. Today’s patients no longer are 100% deferential.
If that is the case, I can’t wait until doctors publish their rate cards. Or, at least be capable of submitting a proposal/quote for more complex services. I have been asking every single health care provider that I interact with for these things for years with zero results.
If you give the office manager a billing code, most will provide you with a cash price.
How is that consumer-friendly? You should be able to call up and say, “I’d like to schedule my annual exam. How much will that cost?Obviously, there will be standard exams and tests which they should easily have on hand on a rate card to tell you. I have no problem if they use a disclaimer to say that the price may change if the doctor and I consult on other exams or tests that are a result of the initial exam.Imagine if a client called me up (I’m a consultant) and said they needed to meet with me about a project but I could not give them any information about how much it would cost and then billed them whatever I wanted later.
Do you really want to choose a healthcare provider by the price that they charge? To a low bidder? Specifically and in your case how will knowing the price guide your decision? And are you paying cash out of pocket for your exam without health insurance?
Information is powerful; it isn’t about choosing the lowest bidder, it is about the pressure placed on all providers to be more efficient and more open about costs for everyone.
You’ve got a bunch of providers that are essentially small businesses. I wouldn’t assume they give a shit about what other docs are charging if their waiting room is full. There is price competition in some fields now, some dentists and others advertise prices (where allowed) and the incumbents don’t appear to be bothered by that. At the hospital scale there is room for improvement but that wasn’t what Susan’s comment was targeted towards.
No, I don’t want to chose by price. However, I need to know costs for planning purposes. For most of the years since the recession, I had no healthcare insurance so I needed to plan ahead for the costs associated with doctor visits. After I did get a healthcare plan, I still needed to plan for costs because of how high my deductible was. This is how most Americans live. It is insane that you cannot call a doctor, hospital or healthcare facility and get an estimate of cost.
Closer than you think with Medibid. Whether people will trust this? Any thoughts? I couldn’t have foreseen Uber or Airbnb. Medibid anyone? https://www.washingtonpost….
Classy move by ESPN: Hired Craig Sager, a 34 year employee of Turner Sports and leukemia patient, to work his first NBA finals as ESPN sideline reporter. Shows big biz can still have heart.
Interestingly I was meeting with a new client yesterday–Heal– that sends doctors to your home, office, etc. The value to the patient is obvious and really inspires me. I asked what the value proposition was for the doctor and part of the response was that they are a good solution for those doctors who want to provide the personalized care that is not always available through larger medical groups.Not sure what the reasoning was for your daughter’s doctor. That’s crazy. Our pediatrician always wants to rule out strep as a first step.It was AVC that sparked my interest in Healthcare tech. HC was one of those industries that never much interested me for probably the same reasons that healthcare is ripe for disruption. But companies disrupting Healthcare– very exciting!Heal will be huge!
Here’s the other side of that coin.A patient arrives at a doctor’s office and requests an antibiotic for some minor infection. An antibiotic isn’t necessary but the patient insists. The doctor, you might say, ‘works for’ the patient. So the patient gets the antibiotic. But here’s the problem. Rampant over prescribing of antibiotics is giving rise to multi drug resistant bugs which are becoming a serious problem. And this is just one example. The number of unnecessary surgeries conducted in the US, because the patient has been marketed some miracle procedure is frightening.So we have to be very careful that we hit a better balance on the doctor patient relationship than framing it as the doctor ‘working for’ the patient.
In a world where doctors often order unnecessary tests, I find it strange that Emily’s urgent care doctor didn’t think that it was necessary. It doesn’t take long to swab someone’s throat for a strep culture. When I go into the doctor with a sore throat, they swab me every time, even if I know that it doesn’t hurt enough to be strep. You’re paying for the test, obviously, so why wouldn’t they do it? It takes minutes. So strange.Anyways, patient-centric healthcare used to be my job and my focus. As patient satisfaction becomes increasingly important, we’re watching a shift in hospitals where patients become part of the care team, which is really exciting. Facilitating that shift was really fun. I used to work for a major EMR company.
I guess that’s why doctors call it a medical practice. Tech applies more science and less cognitive reasoning, so I translate that to mean specialist vs. generalist.
This is exactly what I love with entrepreneurship vision.In countries where the medical bills are managed by the state, problems like the one mentionned here should not occurs.But in the US, instead of waiting for a healthcare system to be put in place, entrepreneurs find ways around to fix the issue. And the new services like having an eye/hearing test is the true proof of that situation.Except from advanced test like DNA analysis, I believe those “basic” tests services will be created mainly in the US to serve the missing purpose of a free national healthcare that other countries already have. In those other countries, developing such service is not relevant since the state already takes care of it for “free” (included in taxes).(again, I’m talking about simple tests, not advanced one).(sorry if I made some english mistakes)
Fred, I’m working with start-up and early stage companies here at the Texas Medical Center which brings me in close touch with every dimension: providers, payers, government, and the mega trends that are moving this industry at a rapid pace.What your daughter likely experienced was an attempt to cost-reduce care by avoiding “unnecessary procedures”, i.e., a strep test in this case.Who is driving this strategy? Insurance companies of course. New payment plans that award providers for NOT performing services, and payment system that give bonuses to physicians for meeting cost targets are two examples. Capitation is a payment system where insurers assign a bulk number of insured to a provider network (something called accountable care organizations), for a flat rate per patient, with the ground rules being, in essence, “keep these patients healthy, and whatever money you don’t spend, you keep”.The stuff that is going on in this area that patients aren’t privy to is astounding. The healthcare system we so dearly love to say is the “best in the world”, is becoming the most perverted in the world.So, the advice here is this: NO ONE is watching out for your health but YOU!
The danger of this is that you have people demanding antibiotics for viral infections or the see some medicine on the TV and think they need it. It’s fine to say the docs work for us and it’s true in some cases. But when there’s highly specialized knowledge involved in some diagnoses it’s foolish for the patient to pretend that they know better than the doctor.Yes, in her case the doc was wrong. But this winter I ended up with a nasty throat infection… that wasn’t strep. It was viral. Insisting on a test or on antibiotics would have just been futile and a waste.Challenge, insist on explanations…but if you really think you’re a better doctor that your doc… you need a new doc.
The fact that the patient isn’t actually paying for the services makes this a really difficult topic. If patients could order all of the tests they want, the insurance rates would double. Also, many tests have high false positive rates (see mammography) that can end up having a net negative impact on patient outcomes.
This may have been said in comments below, I only skimmed them. But, I think there is a not unpredictable but unfortunate sentiment that physicians are the bungling gatekeepers of tests and medicines that the public should have a right too.I blame physicians for our bad PR and our under-socialized communication skills with the public. But, there is a large amount of research on something like “Strep Throat” and this doctor likely did the very right thing in first doing no harm. Her job is not to relieve any chance of suffering a patient may have but instead to do the right thing. Sometimes the right thing is to wait and see how a disease, or lack of, progresses.Antibiotics do not reduce the small risk of serious after-effects from a strep infection. Antibiotics can cause mild to life threatening reactions in folks and almost certainly negative effects on your GI tract, notice them or not, and cause zombie-apocalypse bacteria to develop when used unnecessarily. In other words, antibiotics are not benign. And, strep throat is not “dangerous” although very unpleasant unless you get a rare complication (which, again, is not reduced by antibiotic treatment).Finally, the “test” referred to here is not 100% accurate, and studies show the clinical clues a doctor uses are just as accurate. So, the test costs money, is not always accurate, is no more accurate than a typical doctor’s guess, and the treatment of a “false positive” test can cause the patient harm. Waiting a couple of days and treating the infection that presents itself more obviously is not a mistake, but often a nuanced and subtle smart decision. One that is not immediately obvious.I often suspect it’s doctors’ personalities and lack of social skills or massive patient volumes and little time that tempt people to think of themselves as knowing more than the doctor knows about how to dx and tx a disease. But, just statistically, that’s probably unlikely. Doctors are far from perfect, and the system is terrible. But we should all be careful not to go too far in thinking we know more than someone who has dedicated their lives to understanding very subtle human health and statistics.As humans, we hate and try to deny that there may not be a perfect test or treatment for anything that ails us. We want answers and solutions. We’ll even pay huge amounts of money out of pocket to find someone who will tell us what we want to hear, that our problem is fixable. But, again, there are so many things that are not fixable yet and sometimes, after a good college try, it might be better just to learn to be OK in that reality.This us vs. them doctor/patient thing is one of the saddest things I’ve watched in medicine. If you like your doctor, go hug them. You’d be surprised how much he or she is dedicated to helping (and not hurting) you.
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