Reaction to The Future of Healthcare: Humans and Machines Partnering for Better Outcomes

In his recently published novel, The Future of Healthcare: Humans and Machines Partnering for Better Outcomes, author Emmanuel Fombu, MD, MBA, takes you on a suspenseful, back to the future journey to discuss the intersections between science, fiction, technological advancement, healthcare system antiquation, human adaptation, robotic disruption, society today and society tomorrow. There are a plethora of novel examples, stories, quotes, and analogies that are divided into an introduction and sixteen chapters, but further thematic partitioning will help the book be better organized.  The book can really be divided into four parts according to common themes: The Future vs. Present Healthcare Systems, Technological Advances of Today, What the Future Looks Like for Every Stakeholder, and Opportunities and Challenges for Man and Machine. Dr. Fombu first introduces the reader to the United States’ $1.7 trillion healthcare system followed by his correct supposition that it is unsustainable, expensive and inefficient. Further, the current fee-for-service model has not prioritized patient health (preventative medicine) over patient care (conventional medicine) relying on volume-based practices to fill hospital beds instead of preventing patients from being sent to the hospital in the first place. There are no incentives for providers to seek less expensive, value-based care options unless forced by payers such as Medicare that plan to increase value-based care by 50 percent. Dr. Fombu provides a vision for pharmaceuticals using patient characters like Diana, Omar and Budd who each reap rewards from technologies including Amazon’s Alexa voice assistant nurse, health tracking devices monitored remotely by doctors, machine learning data-driven diagnosis, biomarker disease screening and patient peer support platforms. Some of these technologies are being used today! The future looks transformational for patients, providers, payers, pharmaceutical manufacturers, hospitals and governments but it is clearly a slow, evolutionary process in its current state. While Dr. Fombu does an exceptional job of presenting the value of digital health alternatives to today’s healthcare system, his tangents can distract from his overarching message, and the novel reads like a primer to investors rather than a guide for pharmaceutical professionals. This novel’s futuristic topics impact our U.S. healthcare system and the pharmaceutical industry, but there is room for further investigation.

“Let’s say you, like me, are one of the 20 million Americans who work for themselves—no boss, but also no corporate-tax deduction for health insurance. The smart move is to get a high-deductible insurance plan. Now it suddenly matters what doctors charge: $500 to take your blood pressure and bang your knee with a rubber hammer, $1,200 for a blood test that uses pennies worth of chemicals to tell you your hemoglobin levels are fine. Plus, four months to get an appointment, and then the doctor asks you to fax an authorization. What? It’s 2019. It’s time to fire your doctor” (Kessler, 2019). This opinion piece from Wall Street Journal correspondent, Andy Kessler, is one sample from the millions of Americans who have similar sentiments about the cost and quality of the services provided to them within the current U.S. healthcare system. Frustrated patients have already turned to data enabled healthcare apps to track everything from blood glucose levels, blood pressure, atrial fibrillation through Apple Watch, telemedicine appointments, Doctor on Demand, and AI -enabled diagnostics; all at a fraction of the cost of a traditional doctor’s visit (Kessler). Patients have initiated the movement towards value-based care by no longer accepting the status-quo and rejecting the fee-for-service business model. What would adoption of value-based services result in? Let’s take a page from the Commonwealth Fund’s Mirror, Mirror report: five imperative health care system results the U.S. must achieve are care process, access, administration efficiency, equity and health care outcomes (Schneider, Sarnak, Squires, Shah, & Doty, 2017).

What is also important to measure is Dr. Fombu’s message that providers must be able to keep up with this patient produced data and be participants in the next digital wave, instead of casualties. That’s how digital healthcare can truly provide value rather than being like EHR systems that are currently burdensome technologies for providers. “Even if a patient is using wearable technology (such as a Fitbit or an Apple Watch), it’s ultimately useless unless providers have time to analyze the data and implement the best course of action for each patient” (Fombu, 2018) I agree with these sentiments but I disagree Dr. Fombu’s later sentiments that HIPAA itself is the problem since EHR systems can do as they wish with your healthcare data without you having any access whatsoever. HIPAA is the heath information portability and accountability act which provides protection to your healthcare data and maintains privacy between you, your provider and your payer. Its purpose is very important, but it is a hindrance for the patient who wants access to their own data. In a later chapter, Dr. Fombu introduces blockchain technology applications in healthcare which is promising in its security, smart contract technology, accuracy and can deliver interoperable EHR systems. These types of systems will make it much easier for HIPAA compliant data sharing between payors, providers and patients without sacrificing the need for privacy protections.

Dr. Fombu also introduces his opinion on health scoring systems utilized by payers that determines your disease prevalence based on risk factors like living a healthy lifestyle, exercise, preexisting conditions and so on. The higher your health score, the more affordable your health insurance will be. Mobile health companies would be tracking your data and passing it along to your specified insurer who then would be responsible for risk adjustment pricing. This idea sounds like music to your ears, until you dig deeper into payer practices in the years following ObamaCare. Insurers were known to notoriously use community rating systems that forced premiums to be the same for all patients regardless of health and not following risk adjustment mechanisms to support sicker patients causing the most ill patients to be stuck with limited coverage and higher out-of-pocket costs (Goodman, 2018).

In his chapter about the future for big pharma, Dr. Fombu covered the major bases but left much to be desired in understanding how pharmaceuticals will usher in a future augmented by machines. He explains that pharmaceutical companies must adopt a new business model by charging a premium for precision, tailored, personalized medicines such as Merck’s Keytruda that targets genes for specific tumors. He then provides examples of AI and machine learning to run clinical trials using in vitro simulations. Use of big data to aggregate genetic information and pharmacological data to deliver meaningful insight is another big opportunity he mentions. He also mentions outcomes-based pricing like Novartis’ CAR-T cell therapy which is priced at $475,000 for one-time treatment but will only take payment for patient response. Finally, he delves into a report on future models of care for providing a wider range of services, preventative medicine, initiating innovations, and broad-sweeping collaborations amongst big pharma and healthcare providers. Although I agree with these examples, I was hoping for a little more imagination by him other than what has already been developed and proposed. Robots being used by pharmaceuticals to provide in-home care to critically ill patients, augmented reality for pharmaceutical sales reps to meet remotely with providers in the process of prescribing drugs to patients, pharmaceutical managed market professionals using AI to build the best outcomes-based contracts that are unique to each payer are a few examples where Dr. Fombu could have been more creative.

Let us take a step back and look at the U.S. healthcare system focusing on the top. The U.S. government is by far the single largest payer of prescription drugs and medical services through programs like Medicare for persons over 65, specifically disabled and with end-stage renal disease; Medicaid for the indigent and disabled; CHIP for eligible children; Veteran’s Affairs clinics; Indian Health Service and other medical programs. In Dr. Fombu’s chapter about the future for governments, he describes how digital health is changing healthcare delivery starting with the FDA’s regulatory challenges. He then descends his argument into how fee-for-service models are antithetical to innovations that are supposed to provide better outcomes but end up being costly due to misaligned incentives. He continues with the FDA’s role in approving innovations according to the mandate from the 21st Century Cures Act and how regulations will have to evolve where the “FDA must lean forward and adapt [their] processes” (Fombu). His next argument aligns well with the payer aspect of government when he states, “One of the main roles for the government, then, will be to facilitate private companies – such as Amazon, Google and Apple – by passing legislation which protects the general public while simultaneously giving private companies freer rein to disrupt the healthcare industry” (Fombu). He then goes on a digital innovation tangent describing the next generation technological innovations that have the potential to disrupt like Amazon’s proposed PBM partnerships, Google’s medical digital assistant, and Apple Watch diagnostic monitoring. Finally, he asserts that the government will face challenges in adopting innovations due to red-tape and will need to be aggressive in adopting tech to compete with the likes of China, but he does not propose any solutions for the major government payers and patients mentioned in the beginning of this paragraph. It is of the interest of the government to adopt value-based care models that include new innovations for Medicare patients who need technical solutions for their myriad disabilities, for Medicaid patients who need access to patient support services at the palm of the hands, for children who need outcomes-based treatments for juvenile diabetes and cancers, for veterans who need technical assistance with PTSD and Native Americans who just need better access to healthcare treatments and facilities. Dr. Fombu took a narrower view of government’s role in healthcare with respect to the technology approval process, and that is just the tip of the iceberg.

It would be impossible to cover all the details of Dr. Fombu’s novel in this short book review, but I have strategically narrowed in on the key elements of importance to U.S. healthcare systems and the pharmaceutical industry. My definition of digital health innovation is “technology that delivers medical, data, information and services, improves health-care systems and provides better access to patients.” I believe the novel does an excellent job of addressing the former but falls a bit short in describing how health-care systems must improve and how better access to patients can be achieved from a managed markets perspective. This novel does not serve managers in government, pharmaceuticals, or healthcare systems but it is a primer for learned investors and layfolk. We must focus these new technologies on patient-oriented solutions and clinician-oriented solutions so that real value can be brought direct to the end users where it can have the most impact (Toloui, Eapen, & Jain, 2018). How can pharmaceuticals address these challenges? The answer is head on­—instead of being disrupted by the Amazons, Googles, and Apples of this world, they must be transformative in the technologies they develop and become tech companies themselves (Mims, 2018). Big pharma must focus on the end-user patients and the largest payers of these services while delivering the most value within the new value-based framework. As a U.S. healthcare system, payers, providers, pharmacies, PBMs and distributors must all focus on improving the United States’ delivery model that tackles care process, access, administration efficiency, equity and health care outcomes (Schneider, Sarnak, Squires, Shah, & Doty, 2017). Only then can the U.S. $1.7 trillion healthcare spending stabilize or shrink as a proportion of U.S. national GDP. In the future, robots, automation and AI will be integral in helping stakeholders achieve the triple aim of “providing better care for individuals, improving population health management strategies, and reducing healthcare costs” (LaPointe, 2016). We must be ready for such a future by tackling those challenges and accepting these opportunities as individual patients, as healthcare providers, as government, as private payers and as a healthcare industry leading the way.

References

Fombu, E. (2018). The Future of Healthcare: Humans and Machines Partnering for Better Outcomes. New York: Emmanuel Fombu.

Goodman, J. C. (2018, Jun 26). ObamaCare Can Be Worse Than Medicaid. Retrieved from Wall Street Journal: https://www.wsj.com/articles/obamacare-can-be-worse-than-medicaid-1530052891?mod=searchresults&page=1&pos=3

Kessler, A. (2019, Feb 10). It’s Time to Fire Your Doctor. Retrieved from Wall Street Journal Opinion: https://www.wsj.com/articles/its-time-to-fire-your-doctor-11549829009?mod=searchresults&page=1&pos=3

LaPointe, J. (2016, Jun 7). What Is Value-Based Care, What It Means for Providers? Retrieved from RevCycleIntelligence: https://revcycleintelligence.com/features/what-is-value-based-care-what-it-means-for-providers

Mims, C. (2018, Dec 4). Every Company Is Now a Tech Company. Retrieved from WSJ: https://www.wsj.com/articles/every-company-is-now-a-tech-company-1543901207

Schneider, E. C., Sarnak, D. O., Squires, D., Shah, A., & Doty, M. M. (2017, Jul 14). Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care. Retrieved from The Commonwealth Fund: https://www.commonwealthfund.org/publications/fund-reports/2017/jul/mirror-mirror-2017-international-comparison-reflects-flaws-and?redirect_source=/publications/fund-reports/2017/jul/mirror-mirror-international-comparisons-2017

Toloui, O. B., Eapen, Z. J., & Jain, S. H. (2018, Apr 26). How to Accelerate the Adoption of Digital Health Technology. Retrieved from Harvard Business Review: https://hbr.org/2018/04/how-to-accelerate-the-adoption-of-digital-health-technology