Creative Destruction: What Doctors Must Know To Thrive in the Brave New World of American Healthcare

Creative Destruction: What Doctors Must Know To Thrive in the Brave New World of American HealthcareYuri Kruman

10/14/15

Bio / ApproachB.A. in Neuroscience (UPenn) Ph.D. coursework in neuroscience (NYU)J.D. from Yeshiva University (Cardozo School of Law)Law: helped defend physician from lawsuit by insurance companyFinance: project manager in banks, hedge fundsHealth Tech: co-founded MoreSpinach, Inc. (Health Insurance), Finance/Operations at Maxwell Health (Benefits Admin SaaS), Product Management at Liazon (Benefits Admin SaaS), Doctor Acquisition at Baby Doctor (Pediatrics-on-Demand app, launching this week)

OverviewMedicine is BusinessLegacy Thinking in the Medical ProfessionCurrent Trends in Healthcare DeliveryThe ACA for Docs Burden or Boon?Personalized Medicine The Future or Myth?Where Tech is Taking MedicineThars Gold in Them (Data) Hills!In An Ideal WorldTakeaways for Doctors and Med Students

Medicine is BusinessEffects of ObamaCare Kaiser Study on Effects of ObamaCare on the Medical ProfessionMalpractice insurance, admin costs are only increasingConsolidation of insurance companies (fewer plans available, prices will rise) Increased costs for claim reimbursement, higher procedure prices, lower reimbursement ratesConsolidation of hospital systems (more streamlined care, but more expensive)The cost of price transparency for procedures market forces will lead to increased competition, lower prices and commoditization of healthcare

Legacy Thinking in the Medical ProfessionBusiness as Usual while Rome BurnsGuild mentality and over-regulation, as in the legal profession (also in the process of being creatively destroyed) Medical Paternalism (avg. of 17 years training before practice)Ex: The AMA lobbied the Obama Administration to prevent patients from accessing their own genomics data.90% of physicians surveyed expressed discomfort with using genomics data in their diagnoses and to determine treatmentSlow adoption of EHRs, technology, experimental and alternative medicines chronically behind the curve of science and technologyShifting healthcare landscape means every doctor is either a savvy entrepreneur or an hourly wage worker

Current Trends in Healthcare DeliveryOnly 30% of doctors remain in private practice today getting lower by the dayHealth systems hold all the power of scale and leverage over physiciansMalpractice insurance and overhead admin costs risingClaims reimbursed at lower rates with ACAs Medicare provisionsFewer people entering the professionNearly half of physicians said they would not advise a young person to pursue a career in primary care.Barriers to Entry = Death by Acronym: ACA, EHR, MU, PCMH, PQRS, MOC, ACOs, PPO, HIPAA, etc.Central actors: Health system CEOs, politicians, NOT doctors or patientsKeys to the equation: cost containment, effective treatment direction by health insurers and politiciansSmartphone as primary vehicle of healthcare delivery, doctor-patient communication Telemedicine and on-demand medicine becoming more prevalent without shared recordsEHRs and secure patient data storage: a thousand vendors and security breaches

Current Trends in Healthcare DeliveryBiggest population serviced: retiring Baby Boomers (also end of life care)ER-ization of Medicine: Per aMay 2015 poll by the American College of Emergency Physicians (ACEP), 75% of emergency physicians report that emergency visits are going up. This represents a significant increase from just one year ago when less than half reported increases. Rather than trying to keep people out of emergency departments, policymakers need to recognize the value of this model of medicine that people want and clearly need.CityMD and other local ER centers have popped up like mushrooms all over NYC in the last 5 yearsSpecialization = Survival > death of the GPCompetition with Dr. Google everyones an instant expertPrice transparency tools gaining ground market forces taking rootSpecialized concierge services, including medical tourismTeam-based approach to ongoing treatment outsourcing to NPs, PAs to deliver ongoing treatments

The ACA for Docs Burden or Boon?Physicians opinions of the law: highly polarized, but not reflecting actual effect on practiceKaiser Family Foundation / Commonwealth Fund Study (June 2015):many providers reported seeing an increased number of patients since the coverage expansions went into effect, but not an accompanying compromise in quality of care. large majority of primary care providers are satisfied with their medical practice, but a substantial percentage of physicians expressed pessimism about the future of primary caremany providers feel that the amount of time they have with each patient and the time they spend on insurance administration issues have gotten worse. reported rate of new patient acceptance among primary care physicians has declined slightly (89% to 83%), but the share accepting new Medicaid patients remains about the same at 50 percent.Most providers said their ability to provide high-quality care to all patients has not changed since January 2014 whether or not they have experienced increases in their Medicaid or newly insured patient populationsa large majority of primary care providers Democrats and Republicans alikeare satisfied with their medical practices. In fact, satisfaction levels are slightly higher than what was reported by primary care physicians in 2012, before the ACA.

Personalized Medicine The Future or Myth?Eric Topol: population health is on its way out in favor of personalized medicineWearables/Biosensors soon-to-be ubiquitous, but often inaccurate and a privacy nightmareEverything from FitBits to diagnostic diapers (SmartDiaper) everything will be monitored to death and increase anxiety among upper middle classAffordable Diagnostics: genomic testing (23andMe), blood testing (Theranos) microbiome testing (uBiome) still huge privacy concerns re: data1% + Tech Elite vs. everyone else huge gap in availability and information due to cost Will this gap remain or disappear with economies of scale, insurance coverage and better data privacy laws and tech?

Where Tech is Taking MedicineMOBILE smartphone as the new center of gravity in diagnosis, adherence, communicationOptimizing sleep, blood glucose and other critical health habits through appsSecure communication between doctor and patientSecure patient data storage, sharing on social mediaSmartphone detection of skin and other cancers, other diseases (Mobile ODT, SkinVision, MoleScope, CellScope, others) Wearables FitBit, Jawbone, etc. Questionable accuracy of data; only a matter of time before standards are established. Question as to the real value of this data beyond the basics.Genomic and microbiome diagnostics - 23andMe, uBiome, etc. endless diagnostic and preventive usesPreventive Dentistry catching signs of chronic disease years before they developLongevity - Blue Zones, Calico mimicking diets and lifestyles of long-lived peoples, supplementing with results of scientific research

Where Tech is Taking MedicineCrowd-sourcing diagnoses - CrowdMed- helping solve entrenched medical mysteries3-D Printing: organs, tissues, prosthetics on demandMedication adherence tools AdhereTech, etc.Telemedicine Teladoc, HealthTap, MDLiveOn-Demand Medicine Baby Doctor, Pager, Heal, PediaQ Improved claims software Virtual Benefits Administrator, Plexis Payer Platforms, etc. automatic claims processing, lowering overhead costs and errorsCare pricing transparency tools - Castlight Health, Zakipoint Health enterprise health spend optimization; Symbiosis Health consumer out-of-pocket spend optimization

Thars Gold in them Hills (of Data)Ex: Penn Signals - tools for building predictive applications based on historical data, as well as real-time data in Penn Meds EHR systemEx2: NIHs BD2K (Big Data to Knowledge) initiative - allows physicians to analyze patient data and vast healthcare histories databanks to determine which patients may be at greater risk of developing conditions such as diabetes or heart diseaseEx3: State of Indiana: the state government is analyzing population data to prioritize funding for the most effective programs, including those that reduce infant mortality ratesBiggest concern: patient data security (from hackers, scammers, fraudsters, etc.)Crowdsourcing Epidemiological Data Citizen Science, crowdsourced studies (ex: Cell Slider: sharing images from tumors with the general public, enabling them to score tumor markers independently through an internet-based interface.)Predictive Analytics Google searches as harbinger for epidemics; Kaggle competitions (for-hire model), signs of depression in the Facebook feedBioinformatics Advances Epigenetics, proteomics studies to supplement genomics data for a more 4-D approach

In An Ideal World

Takeaways What Do I Need To Know?For now: the more things change, the more they stay the same (day to day).Legacy Thinking => Out of Business; Be Flexible or Become ObsoleteDont worry too much about ObamaCare (unless youre in private practice)Tale of Two Medicines Elites vs. Everyone Else Care and Delivery DivergingSpecialize or Die! The real money and prestige come with more trainingGet Social (but dont socialize) with patients! Stay Ahead of Your Patients with New Treatments and Tech (Good Luck!)Know Your Competition (and Price Accordingly)Pathways from here: Entrepreneurship, The Academy or Wage Slavery in a hospital (Make Your Own Portfolio Career!)