In many ways, it is the best of times for those among us who are interested in transforming American health care.
With the emergence of COVID19, there is deep, broad recognition of our deeply fractured system of healthcare and public health and the long road ahead to improve on it. The question is no longer whether we should strengthen our healthcare infrastructure but how.
For the ﬁrst time, we have broad recognition of both the power of American medical science and, also, its limitations. Whatever we think about the current science and the state of treatment for COVID19—there is growing and broad appreciation of the importance of the biotechnology, pharmaceutical and vaccine industries, where public sentiment previously biased towards scorn. For a change, we are waiting with breath for the output of their work, not debating pricing and effectiveness. Whether Gilead’s remdesivir and other therapies prove miraculous or incremental, we are grateful that they exist and for the chance they give us.
On the regulatory side, federal and state governments are biasing towards common sense rather than rote prescription of law. Tele-medicine—delivered through the handheld devices that have been ubiquitous for more than a decade—is finally being reimbursed at parity to in-person visits by Medicare and Medicaid and private health plans have followed suit. State medical boards, previously bound by arcane professional license regulations, are now more readily recognizing medical license across state lines to enable the healthcare workforce to travel to problem areas where they are needed.
Finally, for the ﬁrst time in years, the public is expressing broad appreciation for the humanism and heroism of US healthcare workers. When I started as a student in medical school, medicine (and other allied health professions) standing as a noble profession was under attack by its economic model and the adversarial position it sometimes placed providers and patients. Today, you cannot open a newspaper, magazines, or social media site without some appreciation for the US healthcare workers who have put themselves in harms way, oftentimes without appropriate personal protective equipment (PPE), to help stem the COVID19 crisis.
And yet I worry that when the crisis is over, that we may waste this moment and the powerful murmurs of intransigence that have dominated our health care system—and surrounding political environment—will return. I worry that underneath the smoke of health care innovation, transformation, and rebirth, there is no fire. I worry that rather than this being the single most important moment in the evolution and renaissance of our country's health care system—it will be remembered as a missed opportunity to get things right.
I worry that we are living in a COVID19 “innovation bubble.”
In the healthcare innovation community, there is a “change layer:” the cloud in which visionary ideas about transforming health care resides. But there is also a “reality layer:” the place where most care is delivered. Both are necessary, but until COVID19 struck us, there was little mixing between them both. Modest investments in digital health and value-based care transformation are now paying off handsomely for organizations that made them. When COVID19 is behind us, will we complete the swing? Or will we go back to the way things were, to business as usual?
Before COVID19, many elements of the change layer—startup companies, innovation centers—were structured to isolate and incubate change. The most charitable view is that new models of patient care needed to be supported separate from the rest of an unmoving enterprise; that innovative solutions and models are too disruptive and must be protected; that over time, these new innovations that arise from the change layer will trickle into the reality layer. But COVID19 is now proving that we were more ready to adopt change than we ever acknowledged—that the now forced mixing of the change and reality layers was indeed always possible. Many of the excuses that we used to justify a slow pace of change were just that, excuses.
When I was a medical student, I excitedly read a Boston Globe cover article about a health plan that piloted a program to pay physicians to respond to patient email inquiries. At the time, it felt truly visionary—an opportunity to use technology to incent care delivery in new ways. Almost twenty years later, we are celebrating payment for telemedicine—when this was technically and financially possible years ago.
We must ask “why did this take so long?”
As a research fellow in the early 2000s, I studied capitated models of payment as a means of aligning clinical and financial incentives, creating consistent cashflow for medical groups, and for improving the quality of care delivered to patients. Today, after years of delayed and non-adoption, they are being heralded as a potential savior to the liquidity crisis faced by many physicians across the country.
Again, we must as “why did this take so long?”
Working within the pharmaceutical industry, I watched with curiosity as the industry launched countless initiatives to fund development in high-cost diseases such as cancer, while distracting focus from anti-infectives and vaccines. Until recently, the industry was unable to sustainably think about a future outside of high margin molecules—just as many hospitals and medical groups were unable to think of a future without fee-for-service payment.
Again, we must as “why did this take so long?”
So, going forward through the COVID19 pandemic, what are the obligations of those of us who exist within the change layer? How can we make the change layer more impactful in the long run? How can we not waste this special moment in history where change is so necessary—and suddenly so possible?
One of my mentors in medical school was Jim Yong Kim, previously of Partners in Health, Dartmouth College, and the World Bank. Jim spent much of his career arguing that we need a greater focus on the “science of delivery,” studying how interventions are scaled in order to enable and facilitate greater diﬀusion of innovation to close the gap between best clinical science and best practice; he recently made a related argument about COVID19 in the New Yorker. I believe Jim is right.
Yet, I think a science of delivery is not a replacement for good leadership. We need leaders coming out of this crisis in healthcare—that has spilled so strongly into a crisis for all of our society—who deﬁne their jobs as closing the gap between the change layer and the reality layer, leaders who aim to converge their aspirational visions for the future and the frontlines of clinical care. The science of delivery rather than being a science of “how do we scale,” is really common-sense organizational behavior, integrity, and leadership. The fundamental task of the person leading an organization on the heels of COVID19 is not to invent the new idea or develop the new solution—but to use this crisis and the conditions that follow it to lead us to new, better ways of delivering care.
More than anything, we need to adopt and demand a new pace. Somewhere along the way, it became acceptable in healthcare to have change management timelines that stretch from days, to weeks, to months, to years for things that we already know work. Somewhere along the way on the front lines of health care delivery, we convinced ourselves that change is necessarily slow. COVID19 is proving that we have always been capable of more.
Having worked in the federal government, academic medicine, and also large corporations, many people are often surprised when I say that the pace of change was fastest in the federal government. The reason for this pace was that there was a clear sense of urgency and a culture of speed and accountability created by our leaders.
I would argue that any of us who desires to change health care must not just challenge the system with new ideas, but also with new expectations of pace and scale that engage both the change layer and the reality layer. I often jokingly say that pilot is a 4-letter word. We need fewer pilots and more will, momentum, and frankly, courage to implement change. We are proving that when armed with real courage and a burning platform—we are able to make momentous things happen.
This view is not without its skeptics. The nation is populated with health care leaders who have lost their jobs (and their shirts) by pushing a change agenda too far, too fast. But when I put on a clinical hat, there is actually an ethical dimension to our pace—namely that if we take too long to implement changes to health care delivery that we know will beneﬁt patients, we are withholding necessary improvements of care. We must push forward our best new ideas to transform care at scale, because it is the right and ethical thing to do for patients.
The real secret in closing the gap between the change and reality layers is in creating a new post-COVID19 health industry culture where innovation is not viewed as the domain of the few—but as the responsibility of many.
Most large healthcare organizations have optimized themselves for the core business of health care delivery, but in so doing have sub-optimized themselves for real innovation. Organizations are successful at achieving real innovation by making it the job of frontline staﬀ to implement creative ideas every day—not as part of a special project or initiative. This is the lesson from the organizations that have been most adept at responding to the COVID19 crisis.
Without this cultural imperative, most innovation would return to its place as a tasty side dish, not the main course. This mindset shift post-COVID19 requires a culture that enables, allows for, and even rewards a healthy disdain for the status quo. But many organizations and their leaders instinctively hold on to the status quo because it is what made them successful previously. In such cases, no amount of energy or agitation from the change layer will ever ﬁnd its way into the reality layer; this was the nature of life pre-COVID19—and, if we are not vigilant, we can easily return to this state.
We have all the ingredients to make the most of this moment in healthcare. But we also have historical inertia to which it will be all to easy to return. My hope is that by flagging this risk, we can begin to have authentic dialog about how we might begin to narrow that gap—and bring these two layers—the change and reality layers—together for good.
(This is an update of an earlier essay called the “Innovation Bubble” that appeared in Healthcare: the Journal of Delivery Science and Innovation.)