The Unbundling Of Health Care

Naomi Shah, one of our analysts at USV, has been doing a deep dive on health care since she joined us this past spring.

She has started to publish a series of blog posts on what she has learned and what she thinks is investable at the intersection of healthcare and consumer tech.

Kind of like putting our playbook on display before we have even implemented it.

But that is how we roll at USV.

At least this way, we get feedback and input on these sector theses which ultimately make them even better.

And we get a lot of incoming pitches from entrepreneurs working in our target areas as a result of making our playbooks public.

She starts off her series with a post on the unbundling of health care and compares it to what has happened in financial services.

Naomi ends this post with this observation:

these observations seem to indicate some unbundling of the existing large, monolithic systems in healthcare towards a more open, local, independent and transparent model, with control residing with individual users. And ultimately, this could change the way healthcare is delivered to consumers.

“A more open, local, independent and transparent model, with control residing with the individual users” sounds exactly what we like to invest in at USV so expect to see more investing in health care from us and more posts from Naomi. You can find her posts on and/or follow Naomi here.
#hacking healthcare

Comments (Archived):

  1. jason wright

    as a starting point (there are others), is a hospital the expression of economies of scale?the human body is a unified system. there is no ‘stack’. how then can healthcare be unbundled?

    1. Naomi

      The trend we’re seeing is the unbundling of healthcare services. Agreed – the body is a unified system but each individual has different needs and a bundled, opaque high-deductible plan is causing more people to pay out of pocket for specific services they need that are priced too high. The idea with unbundling is that healthcare services will be unbundled so individual apps or clinics can service one part of healthcare (e.g. imaging, birth control, surgery, UTIs) really well and at a low price point. The idea is that, then, various market-specific verticals in healthcare can scale to more people who need it.

  2. William Mougayar

    Rooting for this.But some of the current stakeholders need to come on board (especially the care givers). This unbundling can’t totally bulldoze them. We want them the change their allegiances, some of which are legally enforced.

    1. DJL

      With all due respect – it is not the caregivers – but the government/regulatory/insurance/legal complex that needs to change. Why should it cost hundreds of millions to bring a new drug to market?

      1. ShanaC

        Most of that cost is marketing costsJust to give you an idea of how important marketing costs are:There is a new class of chemotherapy drugs called PARP inhibitors. It directly closes off the pathway controlled by BRCA. The first major drug in this category is something called Olaparib (it is marketed as Lynparza ). it approximately $3, 391 at list for one month at 50 mg. It is $7,256.80 for one month at the 150 mg doseObviously, if you personally are BRCA positive and then get breast, ovarian, prostate, pancreatic or brain cancer, this is an ideal drug class for you. Just so we understand the medicine behind this: you personally is known as a germline mutation.But what if you personally aren’t a carrier but your tumor is a carrier (aka an acquired mutation)?So this question actually just came up for my mother (via me). Apparently it is unnecessary (as of right now more data coming soon). Her doctor refused to perscribe it because he turns down most to doctor marketing materials, citing the lack of evidence it would help her (she isn’t a carrier), its side effect profile, and the cost. Not every doctor is like that: there are plenty of oncologists working with drug companies that would have given her the drug, because they get “paid” by drug companies.I can tell you personally it isn’t in their marketing materials, because the way I found out about Olaparib was through their patient advocacy programs, because they know patients (and their families) want to live. The costs associated with these sorts of programs is huge, and that’s on top of marketing to doctors directly. So there are definitely patients out there, taking an currently unnecessary drug, because of huge budgets just to get this drug in discussion with doctors.

        1. DJL

          I understand. That is an entirely different set of problems – matching drugs to patients for proper outcomes. The government has lots of this data via the VA but it never sees the light of day.Sorry she is going through that! We live in Houston so many cancer patients end up down here. I have two Oncologists in our family.

          1. ShanaC

            She’s doing extraordinarily well, though reconstruction has been a b*tch. She got REALLY lucky and isn’t going to need chemo outside of a hormone supressor for the next 10 years, nor radiation.Just so you know, the center for medicare and medicaid also has similar data. The VA, centers for medicare and medicaid, can only tell you about what is prescribed and drug company payments, not necessarily outcome research. That’s the NIH’s responsibility.So it isn’t just a drug to patient issue. The price would come down for PARP inhibitors (and a lot of other drugs) if marketing costs came down.The reason for this is that way more is spent on marketing than on R & D. In fact, if you are a Merck, you outsource R & D to tiny startups and then buy them if you think what they are doing is viable so you can market the new drug.Merck by the numbersFull-year 2017 marketing and administrative expenses were $9.8 billionR&D expenses were $10.0 billion for the full year of 2017, a 1 percent decrease compared to the full year of 2016.Why are marketing costs the same as r&d? if you cut them in half you probably could get the same reach and lower the drug cost, making everyone happier…

          2. DJL

            I always wonder about this when I am watching a show on the History channel and see an ad for drug that seems to treat something I have never even heard of. Certainly some scatter-shot marketing is going on.

          3. ShanaC

            It isn’t. There is something about the audience of people who watch the history channel that implies they would be part of the targeted market for a drug and helps them reach core marketing saturation points to move the needle

      2. William Mougayar

        Agreed, but they have the caregivers hostage to them.

    2. SubstrateUndertow

      And how do you deal with your healthcare cost assessments 🙂

    3. Naomi

      I agree with you. The direct care movement is a bottoms-up movement where physicians are generally leading the change because they are more interested in treating patients at lower costs and providing better health outcomes. This could be independent physicians operating their own primary care practice, a physician as a telemedicine doctor on a market-focused app like Nurx, or even specialty medical professionals that operate individual imaging/surgery centers to name a few. It basically takes healthcare back to what it looked like when the medical services provider has a direct relationship with the patient. From what we’re seeing – because both parties are incentivized to lower costs – technology is generally a key factor in decreasing friction and creating a more affordable price point.

  3. John Revay

    just still very amazed when having a procedure …or even simple office visit – & when I ask – what will this cost me – I never get a straight answer – always we will see …even some times if you call insurance company – you get the same answer…Really waiting for a time when someone like Amazon delivers these services

    1. PhilipSugar

      I could not agree more John. The only thing I would add is the look you get when you ask.I could understand if maybe you were worried could I pay it. But you know my insurance and who I am.They take it as an insult. What do you think I am a plumber?! Frankly, I have more respect for my plumber. He will at least tell me, Phil, I don’t know exactly what we are going to find, but if it goes perfect, it is this price, if we find that, add this much.And the way they are so certain, when frankly you should know you don’t know. If you ask well what are the side effects of Lipitor, you get a look like you have three heads. Look up the written warning….muscle wasting, impotence, loss of cognitive function. Ok, but it prevents a heart attack……no it does not claim that. It reduces cholesterol.I am not debating whether medical professionals are super important, and valuable. Just that nobody would accept if anybody else could operate like this.

      1. John Revay

        I generally ask any one – what will this cost me

      2. LE

        I don’t think you can compare a plumber who is used to being asked the cost and is not having the cost covered by insurance to a doctors office or medical care.For example we have a ‘home warranty’ which we have been paying for for years since buying our current house. (Through HSA). We pay a set rate for a visit by a repairman. $79 iirc. The main reason I have the policy is actually not to save money. It’s to be able to call one phone number and have them take care of someone showing up. It actually works pretty well. Anyway when the person comes to the house I don’t care about the costs because it’s covered by insurance. As such I don’t have to ask the repairman the costs. But the costs are still contained in some way by HSA who makes sure the plumber or Hvac person isn’t ripping them off.Yesterday I sent a handyman to fix some tenant repairs. I didn’t ask the cost. And honestly with anyone I work with I don’t ask the cost. Quite frankly I am just glad to get someone to show up and fix the problems. Kitchen renovation? Sure of course that’s major. Major operation on your body? Sure that’s major. Typical doctor office visit? Not the same.Anyway the one handyman told me to send him $75 for replacing two leaky water supply cables. I actually sent him $100 (I thought of you when doing so btw). Another handyman replaced fluorescent bulbs in about 10 to 15 light fixtures (4 bulbs to a fixture you know the ones that are hard to take out). I bought the bulbs and he charged me for labor. ‘His guy’ (a former alcoholic) was at the place all day changing the bulbs and picking up a few transformers. He billed me $450 for the labor (was $30 per hour) and I paid it. I never asked ‘how much will it cost’. I just figured I was glad someone could do what I needed and that the price would be fine in the end. And it was.So that is part of my point. When you are going to a doctor the main thing you are thinking is ‘I want my problem fixed’. Not “I hope I am getting a fair deal”. At least that is the way I am. I honestly want someone who is good not someone who is cheap.I would imagine many people are like this also. They trust and they care about results more than cost. Especially if someone else is paying.

      3. Richard

        I read the nonsense of your post all the time. Shop around for medical care BEFORE you need it. Read the phase 3 results of a pharma study BEFORE you need the drug. People need to stop whining, stop wasting time on FOX, CNBC, ESPN (there are essentially the same distractions) and learn about things that are important to you and your family.This isn’t plumbing.When you go to a lawyer and sue you your neighbor for building a deck that’s abuts your property. Do you get a fixed price? No. If you want a will and you have no assets, can you get a fixed price, yes.

    2. Susan Rubinsky

      I’ve been asking that for years and get the same run-around. However, Planned Parenhood is transparent about their rate sheet. You call, they ask your income bracket, they tell you what it will cost. Very pleasing.

      1. DJL

        Pleasing? What is the cost of ending a human life?

        1. Pete Griffiths


          1. DJL

            Please what? Are you saying that Planned Parenthood does not end human lives?

          2. ShanaC

            Statisitically, they’ve saved more lives just due to the sheer volume of patients they’ve seen(also, on a personal level, If you want to get into the abortion discussion, I’m perfectly willing to get into the theological aspect and the personal aspect going into this. I credit the legality of abortions as the primary reason I was a healthy birth, since pretty much all data indicates that it was the reason I was born ok)

          3. DJL

            Statisitically, they’ve saved more lives just due to the sheer volume of patients they’ve seenSeriously? How can you back that up. They have aborted millions of babies over the years. I understand that abortion is a loaded topic. But let’s please not pretend that abortion is not their (PP) primary mission. Can we at least agree on that?

          4. ShanaC

            But let’s please not pretend that abortion is not their (PP) primary mission. Can we at least agree on that?No we can’t. Their primary healthcare mission is to advance reproductive health, of which offering abortions is a small fraction of what they do.Last year, they offered 270,000 pap smears, most of which are at or below cost. Outside of getting an HPV vaccine, this is the number 1 thing you need to do if you plan on not dying from cervical cancer, because your pap smear is necessary if you want to cut out pre-cancerous tissues in a colospcopy.About 3-8% of all pap smears will come back abnormal. Of total pap smears, slightly less than 1% will show medium or high risk/automatic referall to an oncologist.…So, ~2700 women were referred to an oncologist by Planned Parenthood last year.of the 3-8% group, most will end up being treated via cryotherapy so that Planned Parenthood does not have to refer these women to an Oncologist later. let’s pretend the real rate is 5%, and that 70% of this 5% were treated with cryotherapy.That’s 9450 women treated.None of these numbers include the free mammograms, breast screening, testicular screening, or HIV tests. None of these numbers include discounted/free PrEP drug regimes for people at high risk for hiv.They have aborted millions of babies over the years.Unless you want to get into a theological discussion of ensoulment, back away from this point. As someone who thinks ensoulment is unfounded and can’t be proven logically and therefore the bright line test that most theologically conservative revealed religions prefer is therefore illogical, the contention that abortion is equivalent to killing a full human being doesn’t hold up.I’m a terrible person to talk to about abortion with if you fundamentally believe ensoulment occurs at conception. I find it personally offensive, because at the end of the day the science behind it is weak and all it does is make babies similar to me difficult to be born. I’m perfectly willing to ask you if you feel comfortable killing me or my mother the day I was born[1][1] My mother was born with massive uterine malformations. Before the advance of modern medicine and the legalization of abortion, there was an extremely high probably that biologically my mother would not have been able to carry to term. My mother and brother were very sick, nearly dying as my dad would say, when my brother was born for this very reason.

          5. JLM

            .You’re getting a little obnoxious, Shana. It seems like you’re itching for a fight to defend the millions of abortions that PP has performed. You are an agent provocateur. Please stop it.There are people of good faith who believe that life begins at conception and have a religious foundation for believing that.You have no exclusive franchise on whatever is your justification for abortion.Amongst the almost 60MM abortions committed in the US since 1973 Roe v Wade, I am convinced there were a few who would have been as lovely a creature as you.I mourn for them.One day we will look back on abortion as we do on slavery, women’s suffrage, and civil rights as a time when we failed to live up to the goodness of life and America.JLMwww.themusingsofthebigredca…

          6. Richard

            Whether life begins at conception is a philosophical debate, whether life ends for a pregnant teen, college student is a fact. Keep your penis in your pants or stick to the facts. And if you are a religous person, remember not even the holiest who believe in abstinence seem to do a good job with it.

          7. JLM

            .Ignorant comment, Richard.The issue of conception has more to do with the initial cell mitosis in which the first DNA markers are transferred and replicated true to a unique creation. This DNA is unique to that life and always will be.This creation unimpeded will become a lovely baby, but for the interference of people who do not wish that to happen for a myriad of bad reasons.Persons may cloak bad reasons under some guise of “philosophy” but that is some pretty thin gruel.In keeping with your fixation on my penis, a college student would be better served by studying from whence a baby is produced and focus on contraception.My penis, which at times can be a real dick, is offended by your comment.JLMwww.themusingsofthebigredca…

          8. Richard

            Common JLM you are better than this. When a sperm and egg combine they produce a single cell which is programmed for mitosis. When these cells become human and posesss inalienable rights is subject to 3000 years of debate. There is nothing ignorant (lack of understanding) of what I said. It’s all very factual.

          9. ShanaC

            I think we shouldn’t talk about the theological issue, and therefore take abortion out of the planned parenthood discussion. I think we should talk about 270,000 pap smears provided at or below cost instead, because for the sake of on topic discussions, it explains about bundling or unbundling

          10. DJL

            I am not sure I understand your argument. Are you saying that without abortion and Planned Parenthood you would not have been born?That is what is sounds like. I must not be getting it.

          11. ShanaC

            Yes. There is a known statistical linkage between legalization of abortions and likelyhood of survival of a high risk birth for both the mother and child.… <- very recent look at data across the US, places with easy access to abortion have a roughly 15% lower infant mortality rateMaternal mortality is even more dramatic.Observationally, in the TRAP law passed but before Whole Women’s Health decided by the supreme court, the rate of maternal mortality in Texas. There were no other major health care policy changes or major other health care changes in texas at the time that would have dramatically impacted the maternal mortality rate (no major hospital closures, no changes in delivery policies in hospitals and birthing centers across the state). The only major change to ob/gyn healthcare in Texas was a bunch of laws that created limits on abortion clinics in an effort to stop their existence (and therefore, abortions) in the state of texas.It happens to be that I’m one of the people affected by the legalization of abortion. I think it is terrifying to know that today there is a child being born to a mother with a similar condition as my mother’s and that depending where in the US that child is born, the mother and/or child will not make it purely because some people dislike abortion on personal, primarily religious grounds. While some people may consider indepdent human life as beginning at conception, that doesn’t change the fact that other people don’t, and that other independent humans;’ lives are at stake. If they want to have a fair discussion about babies being killed, then why don’t these women and children dying matter?

          12. Pete Griffiths

            Yes.Planned Parenthood provides a huge range of services most of which have nothing to do with anything that could be related to what might be described as “ending human lives” in even the most fevered imagination.As for those services which could be so characterized, it is perhaps worth remembering that this is not settled fact. It is the passionately held opinion of many most certainly but it is scientifically controversial for most cases and is most definitely not something on which there is a social consensus.I respect your right to believe whatever you do about Planned Parenthood. But please don’t present your controversial opinion as fact.

          13. DJL

            I would ask the same of you. I never said my opinion was “fact” here or anywhere else.

          14. Pete Griffiths

            I’m sorry. I thought you had said that abortion was ending lives.

          15. DJL

            Yes I did. But I realize there are people who do not share this view.

          16. Pete Griffiths

            I understand. But to state it as you did is to present it as fact. You see my point?

        2. Susan Rubinsky

          I have been utilizing Planned Parenthood as my healthcare provider on and off for many years, starting in my late teens. I was living on my own while still a high school student and Planned Parenthood was my best resource for all my medical needs. They provide excellent healthcare. When I lost my job after the dot com crash, it was too expensive for me to maintain my cobra plan so I went back to Planned Parenthood — I was in my mid-30’s at that time. And I go there now for my healthcare needs as well. I opted out of ACA because I could not afford it.I think your comment is oddly uninformed.

          1. Josh Jackson

            Most are uninformed about Planned Parenthood. In addition, many criticize what they don’t understand. When I found out that a relative had testicular cancer, I decided I wanted to be screened for cancer as well. I could use Planned Parenthood for an appointment that met my schedule in a couple of day or I had to wait 5-weeks to see my primary care provider. Directly from Planned Parenthood’s website shows other valuable services that they provide: “Breast, gynecological, and testicular cancers affect millions of people in the U.S. every year. Early cancer screening saves lives. Learn about your risks and the testing and treatments available with us.” The information is there but most are lazy and would rather be uninformed – not entirely their fault.

          2. DJL

            I can respect your position. I was talking specific about abortion.I don’t want to derail my primary messages: I think that private enterprise has a LOT to contribute to healthcare and better outcomes. I think USV agrees hence the post.

      2. PhilipSugar

        That is good to know. I have never been to one, but we do have one on Campus.Political statement from a conservative: I find it completely reprehensible and repugnant that people protest them and shame women going in there.They made that a no protesting zone. I am all for freedom of speech and loved Brad Feld’s posts about illiberals which I find on Campus, but that is not the time or the place.

        1. DJL

          I agree. I just wish the Liberals on campus would show conservatives the same respect. It is okay for them to throw rocks and scream and riot when Ann Coulter comes on campus to exercise free speech. But let’s make it a “no protest zone” when conservatives want to defend their views..

          1. JLM

            .Campuses today are multi-layered with both a view projected from the faculty and a view held by the students.Faculties are, generally, wildly liberal and this bleeds over onto the students, who are also liberal.In this manner, a conservative student or thought has to deal with and overcome both levels of opposition.What is particularly troublesome is the simple ignorance of campuses with thoughts which do not conform to their widely held liberal ideas thereby creating an echo chamber.JLMwww.themusingsofthebigredca…

          2. SubstrateUndertow

            I guess I fall into some vague category of liberal.I don’t really buy into the usefulness of those old 19th century left/right categories. They have been pushed to far into an age of organic social/economic complexity and are no longer useful analytic tools but over simplified impediments to social framing.It pains me to say so but I must agree with you that many new student liberals are over sensitive snowflake sensors.

          3. JLM

            .I apologize for inflicting pain on you. Luckily, there are a great number of new emergency care facilities and you can get quick treatment for that. Cheers.Exactly my point, characterizing a person rather than an idea as being conservative or liberal or progressive is a waste of time. We are all too complex.JLMwww.themusingsofthebigredca…

          4. LE

            The funniest are those that deride non-liberals but then want to be able to use their shore places with a great beach view bought by thinking that was not liberal. (My inlaws..)

          5. LE

            Also if you are not liberal and among people that are liberal you have to be concerned with being an outcast or made fun of as a result of your views and your thinking. In other words once the makeup and balance is such that most people run, hide and don’t present an opposing view, others will simply not be willing (for survival) to voice what they think. Because it appears they have no support. So the large group ends up controlling most of the thought and has the most influence.This is happening now with freedom of speech. Where many things that someone might say are taken to be either racist or sexist. Even if said as comedy or expressed in a artistic way.

          6. PhilipSugar

            What is really troublesome is that they take government funding. One thing I do not understand is why the government would not just say if you take one dime, one scholarship, one grant, one loan, then you abide by our rules which start with the first amendment. If you don’t no issue, you get not a dime.You’d choke off the oxygen so fast it would make heads spin.

          7. SubstrateUndertow

            There is free speech and then there is:Disingenuous “epistemological terrorism” as practiced by political ideologies like Ann Coulter who can’t possible believe the non-sense she peddles.

          8. DJL

            So only the free speech you approve of qualifies as “real” free speech?I rest my case.

          9. JLM

            .When ideas wrestle, the result is stronger, better reasoned ideas. One can only refine one’s ideas by exposing them to critique and what better critique than an opponent? Somebody who holds an alternative view?This is why debates are so worthwhile – each side exposes their ideas simultaneously to an audience to consider and evaluate.Some may say your response is typical of what liberals do today, they demonize the messenger rather than evaluating the ideas, pointing out the flaws in those ideas, or proposing alternative ideas.Calling someone a disingenuous epistemological terrorist is a bit overdone.First, I think Ann Coulter is perfectly sincere. She is certainly not lacking in either frankness or candor. I don’t doubt for a second she believes what she says.The notion of being epistemological is off the mark. Epistemology deals with the origins, nature, methods, and limits of human knowledge. Bad word choice.She is not a terrorist, though apparently, she frightens some with her quick witted intellect.Why not take issue with her ideas. I find her to be very thoughtful though there are some ideas I don’t agree with.JLMwww.themusingsofthebigredca…

          10. LE

            what liberals do today, they demonize the messenger rather than evaluating the ideasAlso use big words to rope a dope others and make them think the writer is smart and others (who might not understand) are stupid. They do this a great deal in opinion pieces. And other displays of (what they think and claim is) a well written essay.Hence what you are saying:Bad word choice.Will note that not even the NYT gets away with this type of word usage in reporting. If they did (not ‘8th grade level’) they would never have been able to sell that high priced advertising. They do it in other places of course (the magazine or in opinion pieces).

          11. PhilipSugar

            Rope a Dope??? I never knew you loved boxing…….I would go to the Blue Horizon. Joe Fraiser was a great guy, and Bernard Hopkins is a friend.

          12. LE

            I don’t love boxing. I don’t watch it. I honestly actually don’t like to see fighting. Even web videos.(Just remember that phrase from Frazier vs. Ali.)I did have a really good hanging bag in my basement which I used for both kicking and punching. And hitting the bag is really great exercise. I also had a speed bag and I was really really good at hitting that with rhythm.

          13. LE

            What does this actually mean:Disingenuous “epistemological terrorism” as practiced by political ideologiesIsn’t there a simpler way for you to express your point?

          14. PhilipSugar

            You need to look up: SesquipedalianI’ll challenge you to post your SAT verbal vocabulary scores. Mine were perfect.What you are really saying is I hate that B… Ann Coulter and I don’t want to afford her the right to free speech because I fear that people I deem “stupider” than me will believe her.No free speech in your house or company….ok.Take one single dime of government money or are on public property or airways? It is not free speech for me, not thee.The Red Hen’s actions and the subsequent reporting will give Trump and people he supports literally millions of votes.I know you will say it also energizes “our side”. Guess what??? You are voting against him no matter what.The people that got Trump elected were those that voted for Obama last time or didn’t vote. They weren’t racist deplorables then, and they aren’t now.But your core belief is that Ann Coulter/Russians/Facebook can convince these stupid people to do things you deem non-sense.Your lack of respect for the constitution in their mind shows no common-sense, and on that I would agree.

          15. PhilipSugar

            I agree completely.

        2. LE

          Political statement from a conservativeIt actually bothers me that people put themselves into buckets to begin with. As if it’s not possible to be aligned with things that either a conservative or liberal would do because you identify as one or the other.So since you are a conservative (and your sentence shows this) it would be expected that you are against Planned Parenthood. And further you need to apologize for your position to the contrary (or explain). This is similar to someone agreeing with something the President does but having to preface it by indicating what they otherwise think of him. As if (once again) you are either ‘all for’ or ‘all against’.

          1. JLM

            .A huge intellectual failing is to allow ourselves in our own person to be labelled. We are entitled to hold diverse views and to have those views evaluated on their own merits.JLMwww.thmusingsofthebigredcar…

          2. LE

            Social media has made this worse than it ever was. And the traditional news taking what is on social media has made it even more powerful an impact.When they say ‘and some people are questioning’ it really just means ‘someone on twitter or facebook reacted to the event’. You can always find an opposite reaction if you look long and hard enough.

      3. ShanaC

        They are probably the best gynecological and ob providers in the US. quality of care is directly correlated with the amount of patients seen. Since Planned Parenthood sees a ridiculous amount of ob/gyn cases because of the price sheet/discounted care as part of their mission, the likelihood of them catching something bad early is extremely high.(Btw, this holds true for all doctors)

      4. LE

        You can’t compare an operation like Planned Parenthood with a defined mission and list of services to a hospital unfortunately.Also Planned Parenthood works also on donations and funding. I used to be able to get ‘vaginal condoms’ from them and generally not pay. Sometimes they would give me a bunch (giving me stares as in ‘why are you getting these’) and other times I think they would charge me $2 each or whatever. Plus one other thing is they have labor and overhead that is vastly different from a hospital (or even your dentist office) and I am sure the pay reflects that.

        1. Susan Rubinsky

          There are no apples to apples comparisons in healthcare. That’s part of the problem. But it would be wise to competitively assess an organization like Planned Parenthood to understand some positives regarding transparency and the customer experience.

          1. JLM

            .Before entering into a full discussion of PP, it is important to recognize and acknowledge they receive a massive gov’t subsidy. They are not full fledged members of the healthcare economy nor are they a free market enterprise.JLMwww.themusingsofthebigredca…

          2. LE

            Exactly. I don’t understand comparing PP to a hospital that has to take all sorts of problem patients and deal with families etc and importantly ‘end of life’ care.And hospitals are containing costs. I was involved in several contract negotiations over the years with different hospitals for providers (doctors salaries) and I can assure everyone that at least the ones that I dealt with did not roll over and just increase pay and not give when someone wants higher pay. The last one tried to lock in a minor pay increase and wanted a four year contract for that small increase. Apparently some doctors actually went for that.

    3. DJL

      That is because these providers do not have to be price competitive because of insurance. In fact, the SAME procedure is roughly 20% cheaper when you self-pay versus using insurance.I once started building an app like this with Doctor friend. Amazed that nobody has done this.

      1. ShanaC

        that isn’t true for drugs (MSKCC actually has a pdf about this… ). There’s no particular reason why insulin’s (human analogue) price has gone up outside of market manipulation. and there are other issues with procedures/lab tests, such as a lack of quality control vs cost of complications

    4. Pete Griffiths

      I was in a well known hospital in LA recently and before the receptionist was a sign – ‘Customers please line up here,’. I would have felt more comfortable with ‘Patients.’

      1. ShanaC

        I agree. The reason is everyone, including your doctor is a patient of someone!

    5. Richard

      What people do not realize is the complexity of the billing is saving them money and not costing them money. It’s saves them money because there are many many insurers who are all negotiating on your behalf to get the payment as low as possible. Naturally, the negotiated rate is different for each insurance company. Most doctors who do not accept insurance charge 2x-3x of customary rate.That said single payer is a terrible idea. Single anything is a terrible idea. If we as a couunty haven’t learned this by now, we are doomed.

      1. Salt Shaker

        You honestly think insurers have our best interests at heart? They are money making machines and a huge part of the problem. Unseemly deductibles has likely lead to more people taking a flyer w/ their health needs rather than go out-of-pocket on top of their ridiculous monthly premiums. Patient reluctance will only translate to even greater profitability for insurers. The plan I have now would be categorized as “catastrophic” only a few years ago, now it’s pretty much the norm.

        1. Richard

          You are terribly misinformed. There is no evidencd what so ever that insurers cause medical inflation.Have you looked at the salaries of healthcare providers. In California, a hospital stock person makes $30/hr, most physicians make 400k-800k. Don’t believe the hype that the average physician salary is 130k or what ever number they put out. While in training physicians make 50k a year and this goes on for 3 to 7 years.Drug costs are super high and are justified by their input costs as well.You can’t have it all folks. For those who want to ration healthcare and it’s options, start by not paying $400-$3000 to see the knicks play basketball. Start by selling your beach front house and your 100k car.

          1. Salt Shaker

            Lots written on this. Below is just one example. On a personal note, my healthcare provider (Kaiser Permanente) is a so called “non profit.” My premiums went up 40% in 1 year, with roughly a commensurate increase in my deductible. They’re not public so I had to request their financials. The amount of employees in their org (non-physicians) earning hundreds of thousands of dollars a year was eye opening. It’s a ruse, as is the term non profit. The system is broke wrt pricing, transparency and accountability.

          2. Richard

            kaiser is a healthcare provider (who self-insures). Henry Kaiser’s the founder Kaiser Permanente did so to provide heathcare for his Cement Plant Employees on Black Mountain in Cupertino, California.

          3. Richard

            As to employees earnings 100,000 of dollars in nonprofits, Salaries and Nonprofit status have nothing to do with one another in practice. Just ask any Division 1 football coach.

          4. Salt Shaker

            Actually, successful D-1 coaches bring in millions of dollars for universities. Their pay is outlandish, but there is a quantifiable financial benefit to their existence. Comparing the economics of sports to healthcare isn’t relevant in any way.

      2. ShanaC

        The complexity of billing isn’t designed to save anyone money. My mother designed the first one of these systems for Macdonald Douglas Healthcare Systems (RIP). The basic premise of her design is still in use today in pretty much every computerized EHR and billing system.Her design is optimized to maximize revenue based off the list price and negotiated price levels. If tylenol has three potential prices due to negotiations with your insurance company of uses of tylenol, your ehr will code for the highest value use and pass it on to the billing system (it is a huge problem that we do this, because if we were to take everyone’s data to study it for preventative care, the risk and type of usecases are ALL mislabled.)

        1. Richard

          you are conflating two issues. Insurance companies have some but little incentive to drive up healthcare cost today. Hospitals and physicians of course too often bill for what take what they can get. Go visit the DOJ website and you will see thousands of doctors convicted for healthcare billing fraud. 20% of the GDP is spent of healthcare, about 10K per person. Why do you think companies spend billions of dollars developing life improving drugs on breakthroughs like immunotherapy for breast cancer. Where are the marches of folks wanting less advancements in healthcare and waiving their end of life care? You wont find in here or anywhere. There is very little FREE lunch in healthcare.

          1. ShanaC

            1) There are tons of doctors in the system. The absolute rate of healthcare billing fraud is between 5-20% with private insurers reporting more total fraud than the center of medicaid and medicare. Even if we reduced the fraud rate to 1% total, you’d still have thousands of doctors because the US is huge and has a huge healthcare system2) I participate in medical trials because I am in an extremely rare category of patient within the familial breast cancer/HBOC community. True story that I mentioned above. I wanted to get into a trial around breast tomography (otherwise known as 3d mammograms) versus a standard mammogram for high risk women who are monitoring, because lowering the scan false positive rate while improving test sensitivity is a HUGE deal among high risk women. The trial ended up being done in Great Britain through their NHS. Most manufacturers (and therefore, sponsors) of these trials are US based device manufactures, like GE. There are WAY more high risk patients in the US than in Great Britian, but the overhead to do this kind of study is WAY higher here because of a mixture of how insurance works, how these patients find doctors (most are NOT in high risk groups in cancer clinics, wereas in GB, their cases are centralized, moving data has to be done manually in the US (they ship cds of images between doctors if you aren’t being treated in a centralized clinic). Basically, there are a lot of STUPID overhead costs that occur because of the way the US healthcare system is set up that made it more feasible to do this in the UK3)As an ultra-rare patient. I’m ashkenazi jewish and the most immediate genetic pass through for risk to me, my mother, is negative for all known cancer genes. This occurs in less than 1% of ashkenazi jewish familial breast cancer cases. Ashkenazim are among the most studied ethnic group vis a vis genetic diseases, including breast cancer, because we’re basically all the equivalent of 4th cousins to each other, live very similar lives, have similar socio-economic statuses, eat similar foods, and tend to live near research centers. A family in the less than 1% set of cases within that kind of already existing knowledge base is a HUGE deal for researchers because we can give a great baseline about what to look for.I’ve actually been on the phone with Dr. Mary-Claire King about this (I wanted a second opinion about a specific aspect of genetic testing and if it was worth skipping the normal procedures to enter genetic databases). Dr. Mary-Claire King is the researcher who discovered BRCA. She’s a world class geneticist. She’s in the middle of doing more expansive research on other oncogenes, and she’s semi-actively recruiting patients. One of the things that came up in conversation was the extremely low likelihood of them finding anything in the next 10 years. I cried after that callThe reason is it is hard to recruit women and their families, it is hard to move documents around, it is expensive because the way trials versus insurance work means multiple rounds of genetic testing (as opposed to full genome sequencing for just everyone) and hipaa.Change the healthcare system to start centralizing data and patients, you change research.I really want a one payer system because I don’t want to cry anymore about how research priorities are dictated by insurance company and private bureaucracy nonsense. I want to know why my mother got cancer 2x and if I will too, and what I can do about it. And at the rate we’re going, that’s not going to happen, for absolutely no reason outside of certain people (namely insurance companies and certain parts of the drug development world) to make a buck.

  4. awaldstein

    All in on this as a necessity.But–need to say that at the end of the day, the handful of doctors who are dedicated are what we need to find a way to support better.The idea is to strip the crap out at the same time, support these doctors who by definition are in a system that is broken.They literally save our lives. Mine has for me.

    1. Naomi

      Totally agree with you on this

  5. DJL

    Notice how her conclusion ““A more open, local, independent and transparent model, with control residing with the individual users” is the exact opposite of what Obamacare was all about. That is why it was rejected by both consumers and providers alike.We need to get the government out of healthcare – which means private companies – and there will be better results across the board. I am looking forward to this new wave when it hits!

    1. Pete Griffiths

      Do you want to dismantle medicare?

      1. DJL

        I am not going to fall into this trap. But – Do I think it could be more efficiently implemented in the private sector? Absolutely. The government destroys everything it touches with waste and fraud.

        1. ShanaC

          The amount of fraud at best is about the samehttps://www.insurancefraud…. ,,-private fraud ranges between 5-20%. Not billing mistakes, just fraudMedicare improper patients (screwed up billing for whatever the reason including fraud) is 11%, of which only a small percentage is actually fraud…So best guess is both iare about 5-8%. in both cases bureaucracy sucks, and the only difference is who is paying. I’m not really sure why a private bureaucracy is better than a public one, since both have the same problems associated with them

        2. Pete Griffiths

          “The government destroys everything it touches with waste and fraud.””The government” “everything” Very general assertions those.You don’t think a position so extreme is perhaps driven more by ideology than evidence? You think markets are universally efficient and that companies always outperform government bodies. You imagine that the military and public infrastructure would be better outsourced? Or perhaps you only think that your criticisms of government apply only to some sectors? What’s the coherence in that? Why should government be so efficient in national defense? Are government military contractors really that efficient? Perhaps their profiteering and inefficiencies are just a function of terrible government oversight? That must be it. 🙂

  6. Pete Griffiths

    The US healthcare system is at a crossroads. Presently it is incredibly expensive and outcomes are not great for a huge number of people.There appear to be two putative solutions. They are diametrically opposed and engender fanatical rhetoric with precious little fact to be seen.The first is single payer. This has several proven benefits. Much cheaper than our current system. (At least 50% less as a percentage of GNP), covers everyone with decent level of service, can coexist with a private sector (eg as in UK). I say these benefits are proven because they are. Practically every advanced industrial society other than the US has some form of single payer.The second is a radical extension of market forces. Abolish all controls impacting the market and all sub sectors that do not play by free market rules ( eg medicare, Medicaid) and let health products find their own pricing. It should be understood that this is a huge leap of faith. The US has not had such a marketplace and neither has any other major industrial economy. It may work but it may not. It is perhaps worth observing today as single payer will likely (on the basis of real evidence) half costs as a percentage of GNP this option must provide good reason to believe it will do still better. Otherwise we would be taking a hugely disruptive risk for what reason?The stakes are so high here for countless millions of real people that I am very uncomfortable with making a choice either way on ideological grounds. Arguments to the effect that single payer is more egalitarian it that markets are good cut no ice with me. If single payer is a real improvement in the basis of real data I’m for it. If free market can improve on that option I’m for it. But let the data rule not ideology.

    1. DJL

      This type of “binary” thinking is the problem. Either “total control” or “total market chaos”. Why not take local government and private sector initiatives that work at the State level and then expand them?Seriously, this is not that hard. Take out the politics and you can find solutions.

      1. Pete Griffiths

        I don’t think it is binary thinking. It is just pointing out that there are very different extremes. You can of course try to square the circle and combing them.As for:”Seriously, this is not that hard. Take out the politics and you can find solutions.”Good luck with that. Anything that involves billions of dollars is going to involve politics. There may be no solutions but there certainly aren’t going to be any solutions without politics being involved.

        1. DJL

          Hence my point. If Donald Trump personally came up with a drug to cure cancer, the Left would reject it simply because it came from him.It’s a shame that politics destroys real solutions. How do you remove politics? Take out the elected officials. Pretty basic. Not easy – but basic.

          1. Michael Elling

            Rest assured he won’t. But he has added to our deficit and harmed our environment. And tried to befriend 3 despots. Bravo!

          2. DJL

            And lowered healthcare premiums, and lowered unemployment and lowered taxed and raised the stock market and raised the GDP to levels Obama said were impossible. I understand that these facts are uncomfortable and do not fit your narrative.

          3. Michael Elling

            I don’t take sides, but I am a realist and I do have the ability to see through short-term gains at the expense of long-term structural problems.

          4. Pete Griffiths

            No they wouldn’t. They would actually climb over each other to get on a trial.Politics is life. There will always be differences and conflict. Politics is just one of the tools we have to try to resolve them. The state is indeed awful. There is only one thing worse than the state and that’s no state. 🙂

    2. ShanaC

      You know, I once asked a healthcare economist about if the lack of centralization impedes studies about quality of care with new technology, because of a study I wanted to participate in but was being done in GB due to National Healthcare making it easy to recruit and coordinate patients*. apparently this has never been studied, but anecdotally it seems that yes, lack of centralization is actually creating an innovation and adoption drain.BTW, we do have a radical extension of market forces for one aspect of healthcare: Supplements. The FDA has very little control over the supplement marketplace, and what we’ve seen is a plethora of claims (albeit implied claims) and a large number of small suppliers with tainted goods. It is bad enough that there are supplement companies trying to market themselves around the no-taint, precisely measured aspect of this market as a luxury item.*It was about if breast tomographs, aka 3d mammograms, outperform standard digital mammograms in high risk young women. Short answer is it does

      1. Pete Griffiths

        I’m far from persuaded that supplements are much if anything to do with healthcare. :)re 3d – interesting!

        1. ShanaC

          The point about supplements is that we can treat it as a marketing analogue since they are sold for health benefits, not if they actually have health benefits. So you can compare the marketing and the outcomes of say, lipitor to red yeast extract (which is marketed as helping high cholesterol)Lipitor has many problems, but it doesn’t have the problem of not contained the exact amount of lipitor in every pill (not something else, or too much, or too little), it doesn’t have the problem of containing impurities on a regular basis, including lead, and it doesn’t have the problem of not having a lot of scientific studies saying it worksRed yeast extract does.____The study was interesting. I thought it was extremely upsetting that it wasn’t done in the US, since theoretically it would have been easier to recruit patients here. It bothers me because I feel it is very important to join clinical trials as a healthy person from an ethical point of view.Just to give you an idea of how difficult these sort of studies are, I really want to join the All of Us study the barriers to joining because of data transfer and healthcare coordination are extremely high. You’re left floundering collecting your own data because of the lack of centralization.

          1. Pete Griffiths

            Totally agree about supplements; purity dosage let along effectiveness.If you’re a healthcare insider perhaps you can clarify something for me. In the UK cancer patients are under the care of a team. All relevant disciplines are represented . It is very easy to do this because they are all under health service management. How does this work in the US?

          2. ShanaC

            I’m not an insider per say, just someone who has a cancer doctor as a high risk patient and who’s mother is in treatment for another round of cancer now.I also understand breast cancer best, so I am using it as my baselineNormally what happens (not me) is your general provider or ob/gyn will refer most women between the ages of 40-50 for a mammogram. The radiologist will send the report back to your provider, who will tell you what happened. If there is an abnormality requiring seconds scans or a biopsy, depending on your location, you’ll be referred further to a breast surgeon.Breast surgeons come in 2 categories.Groups like these:http://www.boulderbreastcen…Or in hospital type groups like this….If you go into an independent clinic, you’ll be mostly responsible for coordination of care. So, for example, if you wanted to have the exact same surgery my mother had (double mastectomy with a DIEP flap reconstruction) you’ll have to find a plastic surgeon with a speciality in microsurgery who can work with your breast surgeon, alongside a radiologist and an oncologist. While your doctor may have recommendations, you are free to find your own peopleIf you go into a hospital clinic, the only responsibility you have is coordination vis a vis insurance. In the case of my mother, she had to switch insurances because the hospital’s doctors don’t all take the same insurance plans. One she switched, the hospital took over. had she needed radiation or infusion, the hospital would have handled coordinating, and probably would have sent her to one of her smaller clinics. If the insurance thing disappeared due to nationalization of healthcare, you wouldn’t even have to do that.As food for thought in this discussion: all the major research group hospitals used the second system. Your five year outcome is much better if you go to a major research group within the US because of the mixture of hyperspeciality and group management. It is super-problematic because outside of major cities, the first category is the normal state of affairs, and it is a major cause of medication and test overuse.To whit, only in the US could you get a Farid Fata…

          3. ShanaC

            @myscrawl:disqus adding because it helps answer your question a bit…

          4. Pete Griffiths


          5. Pete Griffiths

            Farid Fataghastly

  7. Frank W. Miller

    There are forces in health care that work against unbundling in the way analogized to fin svcs. They are cost, primary care, regulation, and perhaps most importantly, privacy. Let me hit each to illustrate.1) Cost: Things have gotten a lot more expensive for lots of reasons. I used to work in my father’s office (he was a general surgeon) when I was in high school. It used to be that everyone came in and got a blood test, maybe a UA and a physical exam. The sheer variety of things that can be done how to address a wider variety in specificity of problems and the increasing complexity of treatments means its just more expensive to deliver.2) Primary care: When something urgent happens, you need to go to a hospital. In general, the bigger the hospital and its affiliation with a University make it better. That means bigger is better.3) Regulation: The reason we spend an hour filling out paperwork (or tablet forms) before even getting to see a nurse is all the rules that are in place that have to be adhered to by law.4) Privacy: When health care is unbundled, patient information needs to move between a larger number of smaller providers. When combined with regulation, this becomes difficult to overcome.While the rise of Urgent Care’s and smaller distributed ER’s is definitely a trend (and a good one), I would be hesitant to look at that as a harbinger of massive unbundling in the way we’ve seen it in telecom and fin svcs.

    1. ShanaC

      5) the system to manage data between these aspects sucks. It’s optimized away from health care and more towards health payouts

    2. LE

      While the rise of Urgent Care’s and smaller distributed ER’sPart of the issue with urgent cares is that they are out of sight and out of mind. They are not the place someone thinks of to go for care when something happens. They think of ‘going to the ER’. Also at the urgent care there are no beds if you need to be admitted. So you’d need to be transported to a hospital ‘if’. What they should be doing, which I assume they are not for a reason, is locating the urgent care on the hospital complex as a pad site building. That way it will be where everyone expects medical care to be not in some shopping center or even a major street where you don’t remember it is there. And being reminded about something is really more important than people realize. Out of site out of mind.

    3. Naomi

      These are all really good points – really appreciate your thoughts on this. The higher costs associated with complexity of treatments are absolutely justified; what unbundling offers is increased price transparency so that people know exactly what they’re paying for. What isn’t justified is paying 4-5x the cost of a service out-of-pocket just because you’re getting passed off within a large hospital system rather than knowing all the options within your local geography. What about being a “bigger” hospital makes it better? Finally, regarding points 3 and 4, there will have to be a solution for fast and secure signing of regulatory paperwork and transfers of information so that smaller providers can communicate sensitive patient data and people.

  8. Alamin Uddin

    This is pretty much the thesis behind NexHealth. As healthcare gets more consumerized and unbundled, users will and are demanding modern 2018 customer service. So we’ve developed a great customer service SaaS solution for dentists and derms.

  9. ShanaC

    TBH outside of low hanging fruit (keeps), I actually see more centralizationMy mother has/had cancer again. She had to switch policies just to book surgery, because it wasn’t really possible to coordinate treatment (or non-treatment in her case) unless everyone and everything was centralized.And she got better care for it. There are too many subspecialities she had to deal with, and centralizing meant she could cut down on who to see, where documents where, how often to see them, or even if obscure doctor number 45 was even necessary to see in person. She’s not on chemo and not doing radiation because all of these people were able to talk to each other due to centralizationI see this with myself. I get better care when everyone is working together, particularly with anything chronic or requires long term monitoringI actually think what will happen will be NPs acting as primary care coordinators (there’s huge cost saving if you have one primary care person) so that you don’t see most doctors unless necessary. They’ll act as a mixture of bundlers and gatekeepers to keep the unimportant stuff off the table, and to make sure communication flows well.

  10. Josh Jackson

    I think, after reading Naomi’s analysis, these areas are starting to take a run at a key component of publishing – smallest viable audience. The scaling that was done in finance and healthcare became way tooooo big to understand the consumer and patient. At the time, being a number or taking a number, was a normal that was accepted. If the average patient only sees a provider for 7-minutes, the “quality of care” is gone. However, others want something that is quick and cheap. The unbundling is perfect because you separate those who are looking for “quality” and those who are looking for “quick.”

  11. Mark Annett

    If Naomi had done her deep dive for the first time, 7 years ago she would have reached the same conclusion. If she were to have done her deep dive for the first time, here in the US, 7 years from now she come up with the same conclusion. My guess is that it will still probably be the same 14 years from now.US healthcare is a an investment/entrepreneurial quagmire.While everyone agrees that the direction Naomi is suggesting is the eventual future there in no pathway other than a state like California on NY legislating a single payer system that the state of stagnation in going to change.Healthcare systems doing pilots with a few thousand patients do not allow change to occurs.In 2015, there 165,000 healthcare apps. By 2017, that number has double to 325,000 healthcare related apps.It isn’t that the solutions don’t exist right now to have people take control of their own health care. I know they exist because I was involved in creating one. There is just no will or economic incentive to move to them.In my mind, there is only one model that makes sense, within the current climate and that is the Pear Theraputics model, which is instead of running away from the FDA, to run towards them and fully embrace it.If you are not pursuing a healthcare app that requires FDA approval you are wasting your time.You need to develop apps in the same way that pharma does and market directly to the doctors, based upon proven efficacy, and let them prescribe your app. On a price that is supported by your efficacy.There is far too much resistance and far too many people with their hand in the cookie jar to be focusing on systems change right now and along time to come based on the current damage being done.The only real pathway it to go completely decentralized and focus on helping individual clinicians solve their patients medical problems.

  12. JLM

    .One of the clearest examples of disruption and the unbundling (siloing) of financial services is the story of Charles Schwab and discount brokerage. He rebuilt an industry from the ground up. When he finished he then added back the services he’d jettisoned, but offered them as stand alone, fee based services.The story is quite interesting and the $4.95 commissions are infinitesimal when compared to where this story started.As to health care, there are enterprises which are close to doing it right. I go to the Austin Regional Clinic which has an incredible digital interface. I can message my doctor and his nurse just like email. All of my admin, billing, lab tests, xrays, scheduling, prescriptions are in my patient site and in the cloud.When I was in Charlotte, I could punch in and show that doctor what was being done to me and why.I buy my prescriptions in Canada and the clinic interfaces seamlessly with them.A lot of clinics like this are popping up.What is missing is any attempt to increase the supply of doctors, to create doctors who are not going to be millionaires, to increase the work of senior, seasoned nurses, and to be able to remotely access medical care. Talking to you, AMA, and your med school accreditations.I don’t think a lot of this is going to be “picked off” because places like Austin Regional Clinic are nimble enough to embrace the best of breed and incorporate the best practices with little or no prodding.JLMwww.themusingsofthebigredca…

    1. Richard

      There should be two tiers of medical schools, one for primary care physicians and one for specialists. This would lower the bar for primary care admissions and increase the pool of primary care doctors. Primary care residency could then be built into the medical school program and probably reduce the costs of medical school as well. And ideally there should be separate medical schools for most of the specialties. It makes no sense for a cardiologist to be a generalist in endochronology.

      1. Salt Shaker

        Medical diagnosis is hardly linear, though. Many dentists, for example, have saved lives given their general medical knowledge.

        1. Richard

          Take a medical resident out to dinner sometime. You’ll learn a lot.

      2. JLM

        .The first step would be just to increase the flow of doctors. There are huge numbers of applicants to medical school who never get in. Just add some meaningful number – 5-10K pe year.This is an AMA accreditation problem. They control the flow of docs. They artificially control the number of docs and thus their compensation.You have the docs regulating the docs.The intern/residency programs plus the med schools do a great job of creating the right specialists.We need to allow very senior nurses to prescribe basic medicines – green snot v white snot kind of stuff.This would be a good first step.JLMwww.themusingsofthebigredca…

        1. LE

          My wife is involved in this. It’s more than doctors. They need residency programs to be trained in.You will be happy to know that the hospitals don’t always even pay for experience. They will replace a doctor with experience with one right out of medical school in order to save money. How do you like that? Do you think that someone out of med school (and residency I mean or internship) is just as capable as someone who has been practicing for 10 years? They are not.We need to allow very senior nurses to prescribe basic medicines – green snot v white snot kind of stuff.I am sure you’d love to know the amount of stupid mistakes that are caught daily at hospitals by Physicians. (And Physicians who catch other’s mistakes as well). It’s like any other situation that you encounter. People screw up. You know as I said in my business “wheel …. of …. fuckups”.

          1. JLM

            .I have been taking a medicine twice per day – one tablet each time – for decades.My new pharmacy noted that it is supposed to be taken – 2 tablets at the same time.The new pharmacist looks to be 11, but has very current training.JLMwww.themusingsofthebigredca…

        2. Richard

          Physicians assistants write scripts California now. Allowing more students into Med Schools doesn’t help unless they do way with residency programs for primary care (this is where the bottle neck is).

  13. Laura Yecies

    Naomi’s examples do not seem to show change in the core healthcare delivery, especially in the hospital setting. As I look at the large health systems in the US – they seem to be merging/consolidating not unbundling.

    1. Richard

      With all dues respect to Naomi, she has no chance as a 20 somethings recent grad sitting in a cubical tied to a blockchain at USV tied of getting this right.

      1. Laura Yecies


      2. aweissman

        You obviously have never met Naomi

    2. Naomi

      We’re just making observations and writing about them. Other players are clearly incentivized to continue rebundling and consolidating, so perhaps what you’re suggesting is that both are happening simultaneously. What we’re excited about is supporting companies and founders who are flipping the status quo in healthcare and building scalable technology platforms to provide lower cost services so that more people that need it, can access it. The concept of network effects – an idea that is core to our investment thesis – has facilitated the growth of companies over a wide range of industries. This blog just shows a few pieces of evidence that a similar bottoms-up movement is happening in healthcare too.

      1. Laura Yecies

        I guess at a meta level my observations mostly conflict looking at the consolidations in big health systems though of course there are some counter startup examples.

    3. Michael Elling

      They (the VC’s supporting these startups) want a settlement free model where they capture value but don’t truly bear any of the outlier costs (real risk) borne at the edge of the network. They are applying the same principles of Internet 1.0 and 2.0 to the healthcare stack.

  14. Pointsandfigures

    as soon as we get it privatized, out of the hands of the government without a bunch of silly mandates the sooner it will get more transparent and efficient

    1. Michael Elling

      The privatization and development of big for-profit health-systems (and even non-profit systems run like for profits) has contributed to this mess. As well as the sham “market” in pharmaceuticals. How about doctor owned radiology centers? Tell me where privatization has worked? BTW, I started working for the leading hospital management and supply analyst on Wall Street in the early 1980s when healthcare as a % of GDP was 6%. It’s now at 18%. Privatization has clearly worked for investors!

      1. Pointsandfigures

        Plastic surgery. Many elective procedures. Don’t be silly as my friend Cliff Asness might say. Don’t look at the health care market and assume it’s a choice between free unregulated and socialist govt controlled

        1. Michael Elling

          I edited my earlier comment, if you missed it. 12% increase as % of GDP is not due to plastic surgery; where only 1/3 of the 16m procedures were for reconstruction and considered health related. And what do you mean by many elective procedures? Is there really a “competitive” market there? Show me the money. Don’t glibly throw things out. Bottom line is that the private sector has already run rampant over our healthcare system and created this mess equally or more so than the government. So a generalization about privatization is false unless proven otherwise.

          1. Pointsandfigures

            Not being globby. If you think you are comparing a free market to a govt one you are being fooled. I pointed out plastic surgery and LSix along with many elective surgeries are the closest thing you’ll see to a somewhat free market.There are reMs of academic papers and other things you can easily find that would show a better structure. TLDR. Put power in the hands of individuals. Transparent pricing like a hot dog stand. Not a lot of mandates (price ceilings) and vouchers. Competition across state lines for insurance and no quotas (the AMA will restrictions the amount of doctors in a specialty)The problem is a lot of people only believe in the government. Government always screws it up. In the UK you don’t get a new hip you get a cane and wait in line

  15. sigmaalgebra

    Since I don’t have much information or any opinions about “hacking health care” — as long as the health care hacked is not mine!!!! — and since I just watched the movieThe Sting with Paul Newman (Gondorff), Robert Redford (Shaw), and Robert Shaw (Lonnegan), I have an off topic comment!At the end of the big poker game, due to the stacked deck, Lonnegan KNEW that Gondorff had been dealt 4 threes. So, when Gondorff showed 4 Jacks to Lonnegan’s 4 Nines, immediately Lonnegan should have realized that there had to be more than 4 Jacks on the table, likely 8 Jacks.. If at least one of those 5 Jacks was still in the deck and not dealt to any of the players, then it was clear to everyone that Gondorff had brought at least 1, likely 4, Jacks to the table, had not been dealt all 4 of those Jacks, and had been cheating, and Lonnegan, without any evidence that he had also been cheating, should have claimed that he won the pot.Gondorff was taking a big risk bringing extra Jacks to the table, but Lonnegan was dumb enough to miss his chance to catch Gondorff.I haven’t been able to find any place on the Internet where this point has been made. So, maybe I’m the first, and Gondorff’s gambit was relatively safe!!!!Back to hacking health care — but not mine!