Healthcare TsunamiTom Peters/09.12.2004

HealthCare2004

Consumerism X Demographics X IS/Internet X

Quality X Information Consolidators X Genetics &

Devices Revolution = YIKES!

Golden Age of Patient-centric, Genetics-driven Healthcare Looms!

Current status: $1.3T. 30M-70M uninsured. 90K killed and 2M injured p.a. in hospitals. 85%

treatments unproven. Cure depends on locale in which treated. 50% prescriptions do not work.

2X docs. 2X hospitals. IS primitive. Accountability & measurement nil.

And everybody’s mad and feels powerless: docs, patients, nurses, insurers, employers,

pharma & device cos, hospital administrators and staff.

1. Consumerism (Patient-centric Healthcare Arrives)

Anne Busquet/ American Express

Not: “Age of the Internet”

Is: “Age of Customer Control”

Amen!

“The Age of the

Never Satisfied Customer”

Regis McKenna

“The Web enables total transparency. People with

access to relevant information are beginning to challenge any type of

authority. The stupid, loyal and humble customer, employee, patient

or citizen is dead.”

Kjell Nordstrom and Jonas Ridderstrale, Funky Business

“Parents, doctors, stockbrokers, even military leaders are starting to lose the authority they once had. There are all

these roles premised on access to

privileged information. … What we are witnessing is a collapse of that

advantage, prestige and authority.”

Michael Lewis, next

“Teens and young adults are flocking to the Web for health-related information as much as

they are downloading music and playing games online and more

often than shopping online, according to a national survey

from the Kaiser Family Foundation.” —Reuters

“A seismic shift is underway in healthcare. The Internet is

delivering vast knowledge and new choices to consumers—raising their

expectations and, in many cases, handing them the controls.

[Healthcare] consumers are driving radical, fundamental change.”

Deloitte Research, “Winning the Loyalty of the eHealth Consumer”

“We expect consumers to move into a position of dominance in the early

years of the new century.”

Dean Coddington, Elizabeth Fischer, Keith Moore & Richard Clarke, Beyond Managed Care

Today’s Healthcare “Consumer”:

“skeptical and demanding”

Source: Ian Morrison, Health Care in the New Millennium

“Medical care has traditionally followed a ‘professional’ model, based on two assumptions: that patients are unable to become

sufficiently informed about their own care to allow them a pivotal role, and that medical judgments

are based on science.”Joseph Blumstein, Vanderbilt Law School

“He shook me up. He put his hand on my shoulder, and simply said,

‘Old friend, you have got to take charge of your own medical care.’ ”

Hamilton Jordan, No Such Thing as a Bad Day (on a conversation with a doctor pal, following Jordan’s cancer diagnosis)

“If healthcare organizations don’t wake up, smell the coffee—and get online with real services, transactions, and

more for these e-consumers to do—the newly empowered e-consumers will become even more disgruntled with the hornet’s nest of paperwork that

plagues the system.”Douglas Goldstein, e-Healthcare

“It may be the most far-reaching evolution of them all: the metamorphosis of passive patient into consumer – and well-informed,

assertive consumer at that. The defining axiom of traditional medicine – ‘doctor’s

orders’ is being turned on its head. These days it’s the patients who are armed, the

doctors who must get wired to keep nimble.” “E-health is the new house call.”

Richard Firstman, “Heal Thyself,” On Magazine

“What’s needed are comprehensive strategies that leverage the latest

technology and provide the services that eHealth consumers are demanding,

including convenience and customized services such as online physician

interaction or online management of health benefits and customized disease

management programs.”

Deloitte Research, “Winning the Loyalty of the eHealth Consumer”

“Consumerism”: HMO backlash (e.g., plans with more choice). Alternative Medicine, Wellness & Prevention bias. Info availability (disease, health,

docs, support groups, outcomes). Boomers (“I’m in charge!” Discretionary $$$$ to spend:

cosmetic surgery, vision improvement, fertility,

etc.). Self-care (chronic disease). High expectations (genetics, etc.) …

Consumer Imperatives

ChoiceControl (Self-care, Self-management)

Shared Medical Decision-makingCustomer Service

InformationBranding

Source: Institute for the Future

“E-consumers …

want knowledge

are already connected

want convenience

want it to be all about themwant control.”

Douglas Goldstein, e-Healthcare

“Savior for the Sick”

vs.

“Partner for Good Health”

Source: NPR

“No one currently ‘owns’ the eHealth Consumer. It’s an

open playing field.”Deloitte Research, “Winning the Loyalty

of the eHealth Consumer”

“We find that eHealth consumers are willing to

pay—and even switch health plans—for the

services they most want.”Deloitte Research, “Winning the Loyalty

of the eHealth Consumer”

“The ‘curative model’ narrowly focuses on the goal of cure. …

From many quarters comes evidence that the view of health

should be expanded to encompass mental, social and

spiritual well-being.” Institute for the Future

“In many ways, the nursing profession is the most qualified to respond to current changes in the health system. Nurses’ training focuses more on the

behavioral and preventive aspects of health care than does that of

physicians.” Institute for the Future

“A 7-year follow-up of women diagnosed with breast cancer

showed that those who confided in at least one person in the 3

months after surgery had a 7-year

survival rate of 72.4%, as compared to 56.3% for those who

didn’t have a confidant.”Institute for the Future

Internet User, F41

$63,000 HHI64% work FT54% moms

6 hours/week onlineSource: NetSmart Research

“Self-medication is the wave of the future, whether the [pharmaceutical] industry

likes it or not.”Wall Street Journal

DTC > Professionals

ClaritinPravachol

ZybanEvista

PropeciaPrilosecPrimera

Source: JAMA

Make time for your most important

asset. Your health.Ad for Mayo Clinic Executive Health

Program/Jacksonville, Orlando Airport

“Online Medical Records Seen Empowering

Patients”

Source: Headline, Boston Globe, re 1K docs and 700K patients @ CareGroup

Determinants of Health

Access to care: 10%Genetics: 20%

Environment: 20%

Health Behaviors: 50%Source: Institute for the Future

Message: Patients aren’t.

Consumers [will] rule.

2. Demographics: The BOOMERS Reach 60 in ’05!

“NOT ACTING THEIR AGE: As Baby Boomers

Zoom into Retirement, Will America Ever Be the

Same?”USN&WR Cover

50+

$7T wealth (70%)/$2T annual income50% all discretionary spending

79% own homes/40M credit card users41% new cars/48% luxury

$610B healthcare spending/74% prescription drugs

5% of advertising targetsKen Dychtwald, Age Power: How the 21st Century Will Be Ruled by the New Old

Boomer World

“From jogging to plastic surgery, from vegetarian diets

to Viagra, they are fighting to preserve their youth and

defy the effects of gravity.”M.W.C. Howgill, “Healthcare Consumerism, the Information

Revolution and Branding”

“Pick up any copy of Glamour or Men’s Health, and you’ll see pages of advertisements encouraging readers

to enlarge their breasts, retard baldness, correct their vision,

improve their smile, or relieve stress through herbs, massage therapy,

acupuncture—you name it.”Coddington, Fischer, Moore & Clarke, Beyond Managed Care

Message Boomer: (1) “There are

l-o-t-s of us.” (2) “We have the $$$$$$. (3) “We’re/I’m in

charge!” (4) “We’ll take no guff from from anyone.” (5) “We

know the emperor has no clothes.”

3. The IS/Web REVOLUTION

“Some grocery stores have better

technology than our hospitals and

clinics.” —Tommy Thompson, HHS

Secretary

Source: Special Report on technology in healthcare, U.S. News & World Report (07.04)

Info Revolution

Consumerism (research, consultation, B2C, etc.)

Clinical Info Systems (guidelines and outcome measurement, etc.)

100% Web-based (internal) SystemsElectronic Medical Records

Patient-physician email-consultationTelehealth-Remote Monitoring

(biosensors, home testing, etc.)

Telemedicine (consultation, invasive treatment, “global medical village,” etc.)

“We’re in the Internet age, and the average

patient can’t email their doctor.”

Donald Berwick, Harvard Med School

Want email consultation: 90% patients, 15% docs.

Evidence: Patients do not pester docs. Time is saved. No one has sued (shows “care & connection”—

the absence of which is the major cause of suits).

Source: New York Times

Henry Lowe, U. of Pitt. School of

Medicine: “Broadband, Internet-based,

‘multimedia’ electronic medical

records”

“Doctors Without Borders”

World Clinic/Dr. Daniel Carlin: e-mail consultation & treatment for ex-pats, global execs, etc. Developing world: “They have the primary care doctors,

but no infrastructure to train specialists. We become the

specialists.” More: “Telemedicine Kiosks in Central America.” Etc.

Source: On Magazine

Telemedicine: E.g. …

HANC* [Home Assisted

Nursing Care]

*BP, ECG, pulse, temp

Telemedicine …

Reduces days/1000 patients and physician visits for the chronically ill

Decreases costs of managing chronic disease

Expands service areas for providers

Reduces travel costs to and from medical ed seminars

Douglas Goldstein, e-Healthcare

Detroit Med Center: $100M IS Makeover

Experiment: Surgical residents equipped with Palm IIIxe. Med Director: “It’s not unusual to have

a team of 5 or 6 residents responsible for the patients of 25 doctors. For each resident, that

could mean seeing 40 patients spread across 10 floors and 5 buildings.” Records work was

manual; but “Now you export the list of patients to your Palm, with the room number for each

patient and with lab results from the last

72 hours.”

“Patient by patient, problem by problem—drug reactions, hospital

caused infections—Salt Lake City’s LDS Hospital has attacked treatment-

caused injuries and deaths. One of the secrets of LDS’s success is a custom-

built clinical computer system that may serve as a national model for how

to save patient lives.”Demanding Medical Excellence: Doctors and Accountability

in the Information Age, Michael Millenson

The VHA gets it! E.g.: Laptop at bedside calls up patient e-records from one of 1,300 hospitals. Bar-coded wristband confirms meds. National Center for Patient Safety in Ann Arbor. Docs and researchers

discuss optimal treatment regimens—research center in Durham NC. Doc measures & guidelines; e.g.,

pneumonia vaccinations from 50% to 84%. Blame-free system, modeled after airlines. “What’s needed in the U.S. is nothing short of a medical revolution and

the VHA has gone further than most any other organization to revamp its culture and systems.”—

Rand/Source:WSJ 12.10.2001

“Our entire facility is digital. No paper, no film, no medical records. Nothing. And it’s all integrated—from the lab to X-ray to records to physician order entry. Patients don’t have to wait for anything. The information from the physician’s office is

in registration and vice versa. The referring physician is immediately sent an email telling him his patient has shown up. … It’s wireless in-house. We have 800 notebook computers that are wireless. Physicians can walk around with a computer that’s

pre-programmed. If the physician wants, we’ll go out and wire their house so they can sit on the couch and connect to the

network. They can review a chart from 100 miles away.” —David Veillette, CEO, Indiana Heart Hospital (HealthLeaders/12.2002)

4. “Quality”: COULD IT TRULY BE

THIS AWFUL?

“Without being disrespectful, I consider the U.S. healthcare delivery system the largest cottage industry in

the world. There are virtually no performance measurements

and no standards. Trying to measure performance … is the next

revolution in healthcare.”Richard Huber, former CEO, Aetna

“A healthcare delivery system characterized by idiosyncratic

and often ill-informed judgments must be restructured

according to evidence-based medical practice.”Demanding Medical Excellence: Doctors and Accountability in

the Information Age, Michael Millenson

“As unsettling as the prevalence of inappropriate care is the enormous amount of

what can only be called ignorant care. A surprising 85% of everyday medical

treatments have never been scientifically validated. … For instance, when family

practitioners in Washington were queried about treating a simple urinary tract infection, 82

physicians came up with an extraordinary 137 strategies.”

Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

“With little fanfare, a gathering revolution is transforming the everyday

practice of medicine. Owing more to laptops than lab coats, this

is an information revolution, one that is beginning to yield answers to the

most basic questions that haunt those who are sick: Who shall live and

who shall die?”Demanding Medical Excellence: Doctors and Accountability

in the Information Age, Michael Millenson

“Quality of care is the problem, not

managed care.”Institute of Medicine

RAND(1998): 50%, appropriate preventive care. 60%,

recommended treatment, per medical studies, for chronic

conditions. 20%, chronic care treatment that is wrong. 30% acute care treatment that is

wrong.

CDC 1998: 90,000 killed

and 2,000,000 injured from nosocomial

[hospital-caused] drug errors & infections

HealthGrades/Denver: 195,000 hospital deaths per year in the U.S., 2000-2002 =

390 full jumbos/747s in the drink per year. Comments: “This should give you pause when you go to the hospital.” —Dr. Kenneth Kizer, National Quality

Forum. “There is little evidence that patient safety has improved in the

last five years.” —Dr. Samantha Collier

Source: Boston Globe/07.27.04

1,000,000 “serious

medication errors per year” … “illegible handwriting, misplaced decimal points, and missed drug

interactions and allergies.”

Source: Wall Street Journal / Institute of Medicine

Answer: (1) Physician order-entry system, (2)

stick to treatment guidelines for high-risk

patients, (3) adequate ICU staffing.

The perils/costs of folk wisdom:

Pills vs. IV/ $100 per use.

Various studies: 1 in 3, 1 in 5, 1 in 7, 1 in 20 patients “harmed by

treatment”

Demanding Medical Excellence: Doctors and Accountability in the Information Age, Michael Millenson

RAND (1998): 50%, appropriate preventive care. 60%,

recommended treatment, per medical studies, for chronic

conditions. 20%, chronic care treatment that is wrong.

30% acute care treatment that is wrong.

YE GADS! New England Journal of Medicine/ Harvard Medical Practice Study: 4% error rate (1 of 4 negligence). “Subsequent investigations around the

country have confirmed the ubiquity of error.” “In one small study of how clinicians perform when patients

have a sudden cardiac arrest, 27 of 30 clinicians made an error in using the defibrillator.” Mistakes in

administering drugs (1995 study) “average once every hospital admission.” “Lucian Leape, medicine’s

leading expert on error, points out that many other industries—whether the task is manufacturing

semiconductors or serving customers at the Ritz Carlton—simply wouldn’t countenance error rates like

those in hospitals.”—Complications, Atul Gawande

“Established state-of-the-art cancer care—about

which there is no longer any debate—is erratically applied.”

Source: Institute of Medicine’s National Cancer Policy Board

“In health care,

geography is destiny.”

Source: Dartmouth Medical School 1996 report

Geography Is Destiny

E.g.: Ft. Myers 4X Manhattan—back surgery. Newark 2X New Haven—

prostatectomy. Rapid City SD 34X Elyria OH—breast-conserving surgery. VT, ME, IA: 3X differences in hysterectomy by age 70; 8X tonsillectomy; 4X prostatectomy

(10X Baton Rouge vs. Binghampton). Breast cancer screening: 4X NE, FL, MI

vs. SE, SW. (Source: various)

PARADOX: Many, many formal case reviews …

failure to systematically/ systemically/ statistically

look at and act onevidence.C.f., Complications, Atul Gawande

Deep Blue Redux*: 2,240 EKGs … 1,120 heart attacks.

Hans Ohlin (50 yr old chief of coronary care, Univ of

Lund/SW) : 620. Lars Edenbrandt’s

software: 738.

*Only this time it matters!

“Most physicians believe that diagnosis can’t be reduced to a set of generalizations—to a ‘cookbook.’ … How often does my intuition lead me astray? The radical implication of the

Swedish study is that the individualized, intuitive approach that lies at the center of modern medicine is flawed—it causes more mistakes

than it prevents.” —Atul Gawande, Complications

Probable parole violations: Simple model (age, # of previous offenses, type of crime)

beats M.D. shrinks.

100 studies: Statistical formulas > Human

judgment. “In virtually all cases, statistical thinking

equaled or surpassed human judgment.”—Atul Gawande,

Complications

Geography Is Destiny

“Often all one must do to acquire a disease is to enter a country where a disease is recognized—leaving the

country will either cure the malady or turn it into something else. … Blood pressure

considered treatably high in the United States might be considered normal in England; and the low blood

pressure treated with 85 drugs as well as hydrotherapy and spa treatments in Germany would entitle its sufferer to lower life insurance rates in the

United States.” – Lynn Payer, Medicine & Culture

“Practice variation is not caused by ‘bad’ or ‘ignorant’ doctors. Rather, it is a natural

consequence of a system that systematically tracks neither its processes nor its outcomes,

preferring to presume that good facilities, good intentions and good training lead automatically

to good results. Providers remain more comfortable with the habits of a guild, where

each craftsman trusts his fellows, than with the demands of the information age.”

Michael Millenson, Demanding Medical Excellence

“In a disturbing 1991 study, 110 nurses of varying experience levels took a written test of their ability to

calculate medication doses. Eight out of 10 made calculation mistakes at

least 10% of the time, while four out of 10 made mistakes 30 % of the

time.”Demanding Medical Excellence: Doctors and Accountability

in the Information Age, Michael Millenson

“With meticulous detail, historical accuracy, and an uncommon

understanding of the clinical field, Millenson documents our struggle

to reach accountability.”

Journal of the American Medical Association, on Demanding Medical Excellence, Michael Millenson

It’s (measurable, systemic) outcomes,

stupid!

Leapfrog Group/med errors: “Not since Jackson Hole Group guru

Paul Ellwood, Jr., M.D., coined the term ‘HMO’ in 1970 has one idea so

fully captured the imagination of the healthcare industry.”—

HealthLeaders

Leapfrog Group:

CPOE/Computerized Physician Order Entry*ICU staffing by trained intensivists**EHR/Evidence-based Hospital Referral***

*Duh I: Welcome to the computer age.**Duh II: How about using experts?***Duh III: If you do stuff a lotta times, you tend to get/be better. Source: HealthLeaders

Empire Blue Cross and Blue

Shield: 4% quarterly bonus for hospitals that meet Leapfrog’s CPOE and

ICU-staffing standards.

Source: HealthLeaders

The Benefits of … FOCUSED EXCELLENCE

Shouldice/Hernia Repair: 30-45 min, 1% recurrence.

Avg: 90 min, 10%-15% recurrence.

Source: Complications, Atul Gawande

Computerized Physician Order

Entry/CPOE: 5% of U.S.

hospitals

source: HealthLeaders/06.02

“When a plane crashes, they ask, ‘What

happened?’ In medicine they ask: ‘Whose fault was it?’ ”—James Bagian, M.D. &

former astronaut, now working with the VHA.

Winning By Acknowledging Failures

Wernher Von Braun, the Redstone missile engineer who “confessed” &

the bottle of champagne. Award to the sailor on the Carl Vinson—for reporting

the lost tool. Amy Edmondson & the successful nursing units with the

highest reported adverse drug events.Source: Karl Weick & Kathleen Sutcliffe, Managing the Unexpected

5. The “Consolidators”: Fat or Thin?

WebMD (or heirs

and assigns)

“Virtual health care webs force providers to focus on their areas of excellence and to

invest in areas where they can generate a sustainable

competitive advantage.”Healthcare.com: Rx for Reform, David Friend, Watson Wyatt Worldwide

“The future of hospitals is murky. A combination of technological advances,

managed care, and changes in Medicare reimbursement policy

means that the underlying demand for inpatient services

will continue to fall.”Institute for the Future

“America has twice as many hospitals and physicians as

it needs.”Med Inc., Sandy Lutz, Woodrin Grossman & John Bigalke

Message: Somebody is

gonna get this right!

6. Genetics, Devices, the Future of Big

Pharma

“Recognizing that a single misspelled gene means the difference

between being poisoned and being cured was the

first victory for the new science of pharmacogenetics.”

Newsweek

Genetic data: 2X every 6 months.

Source: Financial Times

Genetics & Devices

Pharmacogenomics (“mini”busters, rational drug design, personalized medicine,

gene therapy, vaccines--20% to 50% prescriptions not work)

Neural Stem Cells

Minimally invasive surgeryAdvanced imaging

“Pharmacogenomics could

fundamentally change the nature of drug discovery and marketing,

rendering obsolete the pharmaceutical industry’s practice of spending vast amounts of time and

money to craft a single medicine with mass-market appeal.”

The Industry Standard

E.g., Genentech’s Herceptin, useful in 25% of advanced breast cancer cases.

Would probably have been uneconomic if subjected to 9X

patients in phase III clinical trials.

Source: FT

Pharmacogenomics: End of Blockbusters by End-of-Decade (Reuters)

Barrie James, Pharma Strategy Consulting: “We’re moving from a blunderbuss approach to laser-guided munitions,

and it marks a sea change for the industry. The implications for existing business models are

devastating.” Allen Roses, SVP Genetic Research,

GlaxoSmithKline: “minibuster.” Rob Arnold, Euro head of life

sciences, PWC: “Once you start dealing with minority treatments, small biotechs who are more nimble and don’t need $500-million-a-year drugs to make money

could be at a real advantage.”

“BIG DRUG MAKERS TRY TO POSTPONE

CUSTOM REGIMENS. Most drugs don’t work well for about half the patients for whom they are

prescribed, and experts believe genetic differences are part of the reason. The

technology for genetic testing is now in use. But the technique threatens to be so disruptive to the

business of big drug companies – it could limit the market for some of their blockbuster

products – that many of them are resisting its widespread use.”

The Wall Street Journal (06.18.2001)

Forbes100 from 1917 to 1987: 39 members of the Class of ’17 were alive in ’87; 18 are in ’87 F100; the 18 F100

“survivors” underperformed the

market by 20%; just 2 (2%), GE & Kodak, outperformed the market from

1917 to 1987.

Source: Dick Foster & Sarah Kaplan, Creative Destruction: Why Companies That Are Built to Last Underperform the Market

Biotechs: Amgen, Genentech, Biogen, Genzyme, Celltech,

ImClone Systems. Bioinformatics: Accelrys, Cognia, Double Twist,

IBM Lifesciences, NetGenics, SAS Institute.

“Imagine the day that your surgeon performs your heart bypass sitting at a computer thousands of miles from the

operating table. That day may come sooner than you think.”

Newsweek

“There is no question in my mind that the future of heart

surgery is in robotics.”

Dr. Robert Michler, OSU Med Center, upon the FDA’s approval of robotic partial-bypass surgery

Message pharacogenomics:

(1) There is a drug revolution

coming. Pretty damn fast. (2) My

bet: Most Big Pharma will get run over!

The Future of Reps:

Whoops

“Consultative selling requires dialogue … and

the time for that dialogue. Unfortunately, this seldom

happens in today’s hurry-up complex world of

pharmaceutical selling.”—newspost/spbt

Study of 500 Reps: 65% “had face-to-face conversation with the

physician for less than 30 seconds per visit. In fact, more than half of the 65% admitted that

the average time is less than 15 seconds.”Source: newspost

“Research reveals no evidence of overall superior selling behavior related to

experience beyond five years. Quite the

opposite …”—newspost/spbt

Pediatric cardiologist & practice head: “I don’t see them, period. I study, write papers, use the Web, attend a minimum of 4 or 5 major conferences a year. My staff may

see them, but I in general find their views uselessly prejudiced. Call it, I’m afraid to say, ‘hucksterism.’ ”

Urologist: “A few of them—a very few—are excellent. The good ones

are self-deprecating. If their product is not all that great, they’ll admit it. Mostly, it’s a waste of my

time. I let the staff handle it.”

Family Practice Office (3 Docs, Midsize town) Administrator

TP: “How often does Dr. X see Reps?”PA: “He doesn’t.” [Emphatic.]

TP: “That was sharp in tone! Why?”PA: “We used set aside a two-hour block, once a month. But a lot of the Reps missed appointments. That, however, was the least of it. The biggest problems were the Reps who kept pushing the same thing, visit after visit. They had absolutely nothing new to say.”TP: “So how does Doc X keep up?”PA: “The Internet.” [T.O.V. = “What else?”]

Internist (Silicon Valley): “The Web is generally better. I spent a year of painstaking study, and now I have a system that keeps me informed in a ‘push’ fashion. I began as a skeptic, harassed by a few of my

techie patients, and I’ve become a ‘believer’ and proselytizer.”

Oncologist: “They are, or can be, helpful to the two-thirds of docs, to

be frank, who don’t study much. I’ve got one or two I’ll call, but otherwise I’m ‘not available.’ ”

Pharmaceutical exec: “Truthfully, we hire attractive women as much as we can get away with. That plus

pens are huge influencers—it’s what our focus groups tell us.” (The

“attractive young women” theme was a constant refrain. “I find it laughable, to a point,” a female M.D.

told me. “What I fear is that it works.”)

ER doc/exec: “It’s pathetic. The docs are half assed in their learning styles.

Most don’t even pretend they are keeping up. Reps? She who has the best pens wins. Health care is out of control—and laughingly unscientific. Whatever your nightmare stories are, trust me, the reality is much worse.”

Plastic surgeon & practice head: “My practice has changed 100% in the last 10 years. Sadly,

that’s not true for three-quarters of my colleagues. Information technology is a big part

of it. It’s extremely user-unfriendly. It took me and my partners and office staff a year to

customize our approach—and as we did so the role of the reps became less and less important.

I won’t even let our staff schedule time with them. It’s inefficient, and most of them are

humorously biased—and insult us by imagining it’s not transparent.”

Big Pharma (Summary):

(1) Discovery … too complex, wrong scientific emphasis. (2) Distribution … reps’ role

under heavy fire. (3) “Solution” = More consolidation = Stupid. (D + D = G???) (4) Short your stock.

7. Conclusion.

Golden Age of Patient-centric, Genetics-driven Healthcare Looms!

Current status: $1.3T. 30M-70M uninsured. 90K killed and 2M injured p.a. in hospitals. 85%

treatments unproven. Cure depends on locale in which treated. 50% prescriptions do not work.

2X docs. 2X hospitals. IS primitive. Accountability & measurement nil.

And everybody’s mad and feels powerless: docs, patients, nurses, insurers, employers,

pharma & device cos, hospital administrators and staff.

Message Summary: (1) An unparalleled time for

imagination and bold action. (2) A time of unprecedented

opportunities. (3) A time

of unprecedented risk.

HealthCare21

HealthCare21: 21 Ideas for Century211. Hospitals kill people. (And many of those they don’t kill, they wound.) (And they deny it.) (ERRORS RULE!) And: Hustling ambulances kill pedestrians—and don’t save patients.2. Doctors are spoiled brats—who don’t like measurements. Or any form of “interference.” Docs are also cover-up artists. The REAL Hippocratic Oath: “DON’T RAT ON A FELLOW DOC”. 3. Most prescription drugs don’t work—for a PARTICULAR patient. Current drugs = Blunderbusses.4. Think … WELLNESS. Think … PREVENTION.5. THERE IS LITTLE “SCIENCE” IN “MEDICINE.” (See state to state variations … country to country variations … the general lack of agreed-upon treatments.)6. You could save thousands of lives (think Schindler)—if you just outlawed handwritten prescriptions.7. “Detailers” will disappear … when GenX docs arrive.

HealthCare21 (Cont.)8. IS/IT in hospitals is sub-primitive (despite enormous expenditures).9. Systemic IS/IT is worse—links between docs, insurers, providers, patients.10. ELECTRONIC MEDICAL RECORDS …TO UNIFORM STANDARDS. (NOW.) (PLEASE.) 11. THE WEB WILL LIBERATE. (Info = Power.) (BELIEVE IT.) 12. 80M BOOMERS RULE. ($$$$$. Desire for c-o-m-p-l-e-t-e CONTROL. NOW. “LEADERSHIP” OF AGING PROCESS.)13. “Drug Discovery” processes at Big Pharma are … hopelessly over-complicated. (???: Bye Bye … Big Pharma.)14. 90% of the “healthcare fix”: HARVEST THE LOW-HANGING FRUIT. “They” are … NOT … the Enemy. “I have seen the enemy … and it am me.” Damn it.

HealthCare21 (Cont.)15. The number of U.S. un-insured is the nation’s #1 disgrace. That said, insured “consumers” are spoiled brats. They/we/me act as if healthcare were a free good … and believe that an incipient hangnail calls for at least a CAT scan … or two. ANSWER: MAKE US FEEL THE PAIN.16. Genetic engineering & biotech change … EVERYTHING. (Within 15 years.)17. New Medical Devices change … EVERYTHING. (Within 15 years.)18. IS/IT changes … EVERYTHING. (Within 10 years.)19. New Docs change … EVERYTHING. (Within 10 years.)20. New Patients change … EVERYTHING. (Within 5 years.)

* *

HealthCare21 (Cont.)

21. ALL THIS = ENORMOUS OPPORTUNITY. The

Opportunity of Several Lifetimes. (For the Bold & Brave.) H’Care WILL be … TOTALLY … re-invented in the next two decades. (And, hey, it is our largest “industry.”)

HealthCare2

Healthcare’s 1-2 Punch

1. Hospital “quality control,” at least in the U.S.A., is a bad, bad joke. Depending on whose stats you believe, hospitals kill 100,000 or so of us a year—and wound many times that number. Finally, “they” are “getting around to” dealing with the issue. Well, thanks. And what is it we’ve been buying for our Trillion or so bucks a year? The fix is eminently do-able … which makes the condition even more intolerable. (“Disgrace” is far too kind a label for the “condition.” Who’s to blame? Just about everybody, starting with the docs who consider oversight from anyone other than fellow clan members to be unacceptable.)

2. The “system”—training, docs, insurance incentives, “culture,” “patients” themselves—is hopelessly-mindlessly-insanely (as I see it) skewed toward fixing things (e.g. Me) that are broken—not preventing the problem in the first place and providing the Maintenance Tools necessary for a healthy lifestyle. Sure, bio-medicine will soon allow us to understand and deal with individual genetic pre-dispositions. (And hooray!) But take it from this 61-year old, decades of physical and psychological self-abuse can literally be reversed in relatively short order by an encompassing approach to life that can only be described as a “Passion for Wellness (and Well-being).” Patients—like me—are catching on in record numbers; but “the system” is highly resistant. (Again, the doctors are among the biggest sinners—no surprise, following years of acculturation as the “man-with-the-white-coat-who-will-now-miraculously-dispense-fix it-pills-for-you-the-unwashed.” (Come to think of it, maybe I’ll start wearing a White Coat to my doctor’s office—after all, I am the Professional-in-Charge when it comes to my Body & Soul. Right?)