Health 3.0: Where Medicine Needs to Go.

The rip-off

Have you or any of your loved ones experienced our health care system lately?

If so, how was that experience for you?

Were you pleased with your care? Were you able to access the system easily? Did it treat you with dignity, respect, and competence? Did you feel well after your engagement with the system? And were you satisfied afterward that you got what you paid for?

Or did you feel like the system failed you? That it addressed your acute illness but not your overall health? That it moved you around like a cog in a vast machine? That it never met your unique need? And ransacked your pocketbook in the process?

According to a study by Fidelity Investments, a married couple in their 60s in the U.S. will need an average of $245,000 to cover medical expenses before they die. That figure doesn’t even include over-the-counter drugs, long-term care, and most dental care.

My wife fell and hurt her hand some time ago while playing tennis. We went to an urgent care center close by. The nurse practitioner on duty spoke to her for not more than a minute or two and never examined her hand. She did order an X-ray, which fortunately showed no fracture. The total bill for this visit? Over $1600. The contracted insurance rate knocked the cost down to a little over $600.

Mind you, this was a simple health matter. In our experience as front-line community physicians we’ve found that as the illness gets more complex, it only gets worse. Perhaps you’ve experienced the same.

Does it seem to you, as it does to us, that our health care system is at a critical crossroads?

I’ve discovered his weakness

We love Superman. Not the newer Superman films, but the Christopher Reeve Superman.

There’s a scene in Reeve’s Superman II in which the villain General Zod is fighting Superman high above the streets of Metropolis. Zod sees Superman saving the citizens from his mayhem. Before this point, Zod doesn’t know what Superman is really about. Now he thinks he gets it:

This “super-man” is nothing of the kind; I’ve discovered his weakness…He cares. He actually cares for these Earth people.

Many doctors we know actually care for their patients. But the changes in medicine being touted as the “new health care” are eviscerating our power. And we don’t feel so super anymore.

To understand why, it might help to outline the trajectory of health care so far.

Health 1.0

With the Scientific Revolution, we set off the human body and mind from the natural world and the divine. This move led to modern medicine as we’ve known it.

“Health 1.0” has dramatically increased our lifespan. But it’s essentially run health care as a cottage industry without evidence-based guidelines, quality measures, or standardization. You mess with my physician autonomy and my patient’s autonomy at your peril. And volume trumps value.

So we’ve done excessive tests and procedures and practiced wasteful, unreliable medicine.

We’ve realized that Health 1.0 has shortchanged the quality of our health care.

And nearly bankrupted us.

Health 2.0

“Health 2.0” seeks to upgrade health care into a 21st –century industry. We no longer see health care as a fragmented, piecemeal jumble of individual patient-doctor interactions. It can actually be an integrated system for delivering standardized medicine across different systems. Communal guidelines have priority over my physician autonomy. And I’m rewarded for the value of the health care I provide, not the volume of health care I deliver.

In Health 2.0 evidence-based medicine comes fully online, and adoption of the electronic health record is central to its cause. Silicon Valley promises to track, data-mine, and algorithmically diagnose anything and everything that can be measured. From health IT emerges the “e-patient,” who uses electronic information systems to assume an equal partnership with the doctor.

Sounds great, doesn’t it? And in many ways it is. There can be no going back to a health care system that was evidence-ignorant, volume-based, and cost-unconscious.

But we argue that Health 2.0 isn’t playing the highest game to be played in health care.

Perhaps the biggest reason for this is that doctors have become disengaged from a health care system that’s not honoring the sanctity and uniqueness of the patient-doctor relationship. A relationship that can’t be pigeonholed into the generic flatland of quality measures and performance metrics.

And in not getting this crucial relationship right, Health 2.0 misses the mark.

Physician Danielle Ofri writes about an encounter with a patient in her forties who asked about getting a mammogram. Dr. Ofri knew evidence for this screening test in this age group has been quite conflicting. But a memo from her department administrator was urging her to order the test. Why? Because regulatory agencies were using mammograms as a “performance indicator” to grade her hospital’s quality of care.

Dr. Ofri spent extra time explaining the controversy regarding the test. The patient decided to have the mammogram. But if she hadn’t, Dr. Ofri’s performance indicator would have been penalized.

So who’s offering the higher level of care? The doctor who shepherds her patient through the messy imperfections inherent in much of medical decision-making? Or the doctor who plays to the metric?

In the midst of this fundamental void embedded in Health 2.0, many doctors are just checking themselves and their practices out of the story. They’re selling out to big hospitals and health care systems.

Or they’re simply hanging it up.

When you have the keystone of our health care system, the doctor, checking out — you’ve got a problem. It seems “Big Medicine” isn’t fulfilling us. For all its merits, we feel impotent in Health 2.0’s shadow.

Health 3.0

It’s high time to present a viable alternative. A health care system with greater depth than Health 2.0. One that doesn’t regress back to a paternalistic medicine of the past, where power was exclusively in the hands of the physician. Or careen forward to a faceless medicine where power is being transferred to administrators, algorithms, and inhumane EMRs.

In “Health 3.0,” technology won’t be a tool for meaningless abuse. Everything that can be automated will be. But the patient’s visit to a Health 3.0 clinic will feel anything but automated. He’ll feel like he’s entered a sacred space for healing, where everyone from the receptionist to the billing staff is invested in his being well.

As doctors in Health 3.0, we’ll present ourselves as what John Mackey, cofounder of Whole Foods Market, calls servant-leaders. We’ve renewed our calling to the practice of medicine: not to an insular, antiquated practice of yesteryear, or to one that caters to the lower common denominators of health. No, we’re in service to something bigger and deeper. This gives us great power.

We ground this power in the time-tested patient-doctor relationship. We listen to the patient with full awareness and presence. We’re actively building the trust so critical to this relationship. This trust allows both the patient and us to be appropriately accountable to each other. We’ll have the patient bear the responsibility to help herself to health. And she’ll have us bear the responsibility to guide her.

The relationship isn’t so much equal and symmetric as it is a full embodiment of what both of us can bring to the table. The e-patient is expected to take an active role in the management of his health. And he gets to decide what fits best with his own unique needs and treatment philosophy.

But unlike in Health 2.0, we are “e-doctors.” We feel empowered to enlist our unique knowledge, experience, authority, and autonomy in teaching the patient how to manage his health. And we’ll seamlessly blend our autonomy with communal guidelines.

In this more enlightened health care system, we practice evidence-informed medicine. Not evidence-ignored medicine or evidence-enslaved medicine.

We won’t order a bunch of unnecessary, costly tests and procedures that aren’t evidence-based. We’ll recommend medications where necessary, in accordance with well-designed trials. But we’ll also examine the patient’s diet, stressors (environmental, community), and unique purpose. Because we know these things matter to her well-being. Through both experience and intuition.

We welcome metrics. But metrics aren’t just meant to standardize doctors to shifty, population-based guidelines. As said in the past by The Wall Street Journal:

the illusion that science can provide some objective answer that applies to everyone…is a special danger.

More sophisticated metrics can measure and validate what’s real in health care. Not just what’s true. But what’s beautiful, and good. So we can fairly judge what’s working uniquely for the patient. And ourselves be fairly judged on the results.

Let’s say our patient is sick enough to need hospitalization. Imagine him being admitted to a hospital where all the principles of Health 3.0 are fully online. Where doctors and nurses practice acute care medicine and “root care medicine” side by side. Where his care is carefully coordinated among his health care team, instead of multiple specialists parading into his room with little clue as to what each other is doing.

And where administrators actually view the hospital as a cost center, not a profit center. Their entrepreneurial goal isn’t to play the dubious game of keeping hospital beds filled with patients just sick enough to utilize a smorgasbord of high-dollar services, while getting them out before the length of stay eats into profits. They don’t engage in a medical arms race with other hospitals to see who can market the biggest, baddest equipment in town — especially when evidence supporting the equipment is questionable. They don’t lobby Washington cronies incessantly to prop up their mercantilist medical complexes. They’re not interested in doctor-employees churning out health care dollars, in a mad effort to grab a bigger piece of a finite health care pie.

No, these administrators actually seek to grow the whole pie. They’re invested in a deeper, more integrated health care system that will be profitable to all stakeholders — doctors and other health care professionals, patients, families, nurses, researchers, employers, employees, lawyers, lawmakers, taxpayers, and the administrators themselves.

And as one of the key stakeholders, we physicians will be tapping into the spirit of the entrepreneur. We’re value creators, not wealth stealers. And we’re creating something more transformative than, say, some clinic in Walmart where we’re just a commodity in the business of medicine.

We’re transforming the patient’s relationship to illness and wellness. But the beauty is, it’s a two-way exchange. In the process of helping her, we ourselves are transformed. Because what we’ve done together is to bring out in each other our unique selves: the irreducibly personal essences of who we are, from which our unique gifts flow.

We’ve invoked our patient’s unique self to uplift her to renewed health. And she’s invoked our unique selves to rejuvenate our calling to the practice of medicine.

In this relationship of connection and trust, health care itself is transformed.

We care

General Zod didn’t get it. He didn’t discover Superman’s weakness. He discovered his strength.

We care. And we need a system that renews our care, rather than beating it into submission.

Health 1.0 is over.

Health 2.0 isn’t good, beautiful, or true enough.

Let’s play a much bigger game. Let’s create a unique symphony of servant-leaders, who call one another to our unique selves so that together we reclaim our health, power, and well-being.

Health 3.0.

By | 2017-07-24T07:00:05+00:00 July 28th, 2016|Categories: Concepts|Tags: , , , |5 Comments

5 Comments

  1. Larry Bobbitt September 10, 2017 at 10:24 am - Reply

    Since I’m on Medicare, I’m very much interested in Health 3.0. Anything that would gives Seniors a better chance of surviving a fall or a serious illness is a good thing. I’m all for better health care!!

    • Venu Julapalli, M.D. September 14, 2017 at 3:32 pm - Reply

      Seniors are among the most vulnerable to the weaknesses of Health 1.0 and Health 2.0. In upcoming tenets, I’ll explain how.

  2. Deborah L September 16, 2017 at 9:44 pm - Reply

    This all sounds amazing! Love the idea , what more can I do as a nurse ? I very much want to get the patient more engaged aware of functional medicine and incorporating a healthy life style as an adjunct to medicine and maybe more !

    • Venu Julapalli, M.D. October 3, 2017 at 9:42 pm - Reply

      We have a big idea coming, one that will involve nurses committed to the ideals of Health 3.0. Stay tuned…

  3. Nadereh Diane Shamloo October 1, 2017 at 11:28 pm - Reply

    Each reader of this article will filter the information through his or her own lens. As for me, I am reading this article with my librarian/teacher glasses on and responding to it as it makes sense in my world.
    Several years ago, while enrolled in a masters degree program in library science, I was required to take several courses in information technology. It was during this time that students were introduced to an exciting new frontier in online technology: Web 2.0.
    The biggest difference between the new, improved, and less filling Web 2.0 and the old, static World Wide Web, aka Web 1.0, was a chance for each user to be part of an online social symposium. The web was no longer just for finding and downloading information, now one could interact with other users: sharing content, giving input, collaborating, and so on.
    Fast forward to a future already in the making and arrive at a new threshold in Internet technology: Web 3.0. This version of web technology is almost telepathic. It is intuitive. It can anticipate your information needs and responds accordingly. Here, the user is the center of the Internet universe and the web adjusts to the needs of the user.
    One could draw a parallel between these upgrades in Internet technology and the continuing metamorphosis of the healthcare system in the U.S.
    Healthcare 1.0: Care provider is omniscient. Patient is obedient and may not see himself as a stakeholder in his own care. Doctor disseminates information; patient consumes information (Web 1.0).
    Healthcare 2.0: Doctor is still the expert, but he is no longer the only source of information for the patient. Patient is empowered through social networking applications and portals to interact with his doctor, join health forums, consult a tele-doc, and access medical records and other online health information (Web 2.0—a forerunner to Web 3.0).
    Health 3.0: Doctor is a member of a team of experts delivering integrative care. Patient is the center of the healthcare universe but at the same time is required to be actively engaged in his own health matters. Social media and online tools play an even bigger part in the management of patient data and accessing services.
    I think that by the time we come to wrap our minds around health 3.0, health 4.0 is going to emerge on the scene. How can it not? Just like the Web, healthcare is dynamic not static. For one thing, it has to keep pace with faster-than-the-speed-of-light technological breakthroughs—especially remote/mobile applications. Also, since the patient (the consumer) is the lifeblood of the healthcare system, changes in health behaviors (evolving sophistication of the patients themselves, becoming increasingly more health literate, patient expectations for individualized and transparent care) will continue to create paradigm shifts in healthcare delivery.
    The financing of the care is also changing. New payment models are replacing the inefficient fee-for-service (volume-based care) system. The Brooking Institution, a nonprofit public policy organization based in Washington, D.C., in a 2014 online article, “The Beginner’s Guide to New Health Care Payment Models” schools the reader in the 101s of a reform movement that has been underway for some time. The article lists four alternative payment models that have already begun to challenge the inefficient fee-for-service shebang. One model in particular, Patient-Centered Medical Home Model (PCMH), sounds radically different from what the average patient is accustomed to in paying for medical services. In this “radical” model, a cohort-approach to patient-care delivers services specifically tailored to the health needs of the consumer for a set monthly payment. This type of reimbursement plan may have other working components like the aforementioned fee-for-service method just to name one. One may be surprised to learn that there are actually almost a dozen payment methods supporting PCMH.
    Remember what Heraclitus said about change being the only constant in life; if you believe that then you can be sure that a change is gonna come in how health services are delivered, consumed, and paid for. The catalyst for change is the consumer—the demand side of the healthcare equation. Social media and upgrades in web technologies have shifted the power in favor of the consumer, and the consumer in turn will exert influence over the change continuum in the healthcare system.
    But go and tell that to the folks in Washington D.C. who believe they’re put there to micromanage aspects of our lives through regulatory chokeholds and mother-may-I legislation. Sadly, they fail to understand that taking control away from the consumer and placing it in the hands of a group of bureaucrats only results in a healthcare delivery system that provides at best mediocre care. Wasn’t it Jonathan Gruber, the obamacare architect, who called the American people too stupid to understand the monstrosity they coined the “Affordable” Care Act, and that it was this stupidity that led to the passage of the bill?
    However, the consumer is waking up and becoming wise to the shenanigans played by those naughty politicians who think they know what is better for the masses. The care they promised turned out to be not so “affordable,” and not everyone got to keep their plans and doctors.
    Oh, yes, the change is gonna come.

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