We know the 80/20 rule — majority of consequences result from a few causes. Examples include how a big portion of wealth is concentrated in fewer individuals, how a small portion of population contributes to majority of healthcare spending, how bulk of company revenues come from a minority of customers etc.

US national healthcare expense has surpassed $4 trillion. Per-capita spend is over $12,000 per year. Talking about health expenses and our healthcare system beats flogging a dead horse.

Does the 80/20 rule, the Pareto principle, apply to how we spend money for our overall wellbeing? Is the bulk of our spending targeted towards where the impact is highest? Do we spend $4 trillion to solve a 10 percent problem.

Let’s examine this through four lenses:

1. Our system of care
2. Comparative health outcomes vs. spend — US vs. similar countries
3. Health of our populations
4. Impact of clinical care on our overall wellbeing

Our System — Complexity is Our Pride

We’ve a healthcare system that has elements of every other system in the world buried inside — from single payer to private insurance to employer-financed sub-systems.

The myriad ways we get our care and pay for it requires a complex dance of providers, administrators, insurers, employers, and technology makers.

One would think we’ve purposely designed a complex system to care for a complex system — our body.

The system ingests $4T a year and spits it out. For an infographic on how it happens, see the X-ray of a tapeworm.

The Outcomes — Not Getting our Money’s Worth

Comparisons of US health care system and spending with other economically advanced countries galore. It can be summed up as “ not getting our money’s worth”.

Measured by the ultimate metric — life expectancy at birth — vs. per-capita spending, US is an outlier. We’re the run-away train when it comes to spending as shown above over nearly 50-years. Other non-financial measures such as DALYs and QALYs — disability-adjusted life years and quality-adjusted life years — or detailed disease burden data tells the same story of poorer outcomes.

Population Health — We Have Issues!

The answer to the simple question “how are you doing?” can be answered at the population-level: We have issues.

We are a crucible of chronic conditions. Nearly 3 out of 4 of us are obese or overweight. And the bad news gets worse from there as health conditions pile on top of each other.

About 1 in 3 of us live with co-morbidities and are deemed polychronic.

All this makes one wonder if the state of our population is the product of our system or if the state of our system the product of our state of health?

Yes, we’ve heard these facts ad nauseam, and the rhetorical questions that accompany them! What does all this have to do with the Pareto principle?

Beyond Clinical Care

This picture shows NEJM research from 2017 — only 10% of our wellbeing is attributable to clinical care. 60% is due to our behaviors, social circumstances, and the environment.

In other words, we spend $4T to solve a 10% problem.

This needs to be restated, perhaps perversely, to conform to the Pareto principle — most of our health spending is concentrated on solving a few of our problems.

This still leaves the question of impactful spending unresolved.

Summary

Depicting the state of our health care would look as shown below and would read as follows:

We spend $4 trillion via a complex system to care for an unhealthy population without getting our money’s worth while solving for a 10% problem.

Be assured that enough smart people are working on pieces of this problem. CDC’s Healthy People 2030 initiative should help. The increased awareness post-pandemic will help. However, it remains to be seen how fundamentally our system of care will change to focus on the 60% problem — those driven by social, behavioral, and environmental factors.

Hope springs eternal!

Originally published at https://www.linkedin.com.

The post How to Spend $4 Trillion on a 10% Problem? Pareto Principle And US Healthcare appeared first on Hari Harikrishnan.

We hear about technology-enabled healthcare innovations constantly. Peloton’s camera for better strength training using vision AI; Microsoft’s acquisition of Nuance for conversational AI; Google using AI for drug-discovery; Amazon’s Amazon Care for employee health benefits; The list goes on.

When technology meets healthcare — arguably the most complex industry — some of us think of the status quo and regulations stifling innovation. We hear about an industry that adopts technological innovations such as digital technologies slowly compared to others. All this until a pandemic arrives, perhaps?

How do we connect the dots across all these technologies? It is more than just medical innovations and digital technologies. Keeping in mind that there is more to innovation than just technology, let’s explore how various technology innovations are reshaping healthcare.

This is a straightforward guide to making navigating technologies in healthcare easier so that the next time you hear about an innovation, you will know where to place it in the landscape of technology innovations in healthcare. This is not meant to be exhaustive, but directional.

Read on to see the infographic that puts multidimensional technological innovations in perspective.

A Top-Down View

We know innovation comes in many shapes and forms. To understand technological innovations in health care, we must look at the innovations from the vantage point of healthcare services we receive as consumers or patients.

Let me categorize the innovations into three broad areas as shown here:

1. Health Services: Primary care to specialty care, hospital care, diagnostics, and health insurance fall into this category

2. Products — Medical Devices and Drugs: Complex implants, surgical devices, wearables, vaccines, and even the common tongue-depressor that the clinician uses to examine us fall into this category of products.

3. Technologies: They fall into three categories — A) molecular technologies (chemical or biological), B) digital technologies (information & communication technologies), and C) materials (chemicals, plastics, metals, etc.)

Even simple health care services require the use of devices or drugs powered by these technologies. Think of the technologies inside the products used for routine medical care — blood pressure monitors, thermometers, x-ray machines, and medications.

We will use this hierarchy of services, products, and technologies to put in context the slew of technologies we will look at next.

1. Technology-enabled Services

Let us look at the type of innovations in each category of services, products, and technologies.

New and Existing Services Improved

How we think of innovations as fast or slow is relative to each of our baseline assumptions. Regardless, rest assured that the march of innovation is relentless.

Health Services Portfolio and Underlying Workflows

Some highlights from the services innovation include:

• Telemedicine: Covid unleashed a level of creativity and innovation in delivering care remotely, enabled by digital technologies
• Digital insurance: We are still in the early stages of ways to provide health insurance services using our individual data
• Surgery: Robot-assisted surgeries that augment clinicians are becoming more widespread.
• Rehabilitation: Services using apps abound. Exoskeletons and prosthetics driven by robotic technologies or new materials are proliferating.

Workflows and Processes

Service innovations require process changes and underlying workflows. These processes and workflows undergo dramatic change anytime a new medical device, drug, or technology is introduced.

Examples include:

• Clinical trials are made more accessible by mobile technologies to recruit participants and keep them engaged
• Drug discovery enabled by artificial intelligence (AI).
• Patient and clinician education using mobile, videos, augmented/virtual reality (AR/VR)

2. Products: Medical Devices and Drugs

Medical devices and drugs comprise about 15% of US healthcare spending. Within these two markets, innovation continues, enabled by digital, molecular, and materials technologies.

Products powering health services

A classic blood pressure monitor becomes smart and connected, enabling a telehealth service. Wearable medical devices blur the lines between classic medical devices and consumer electronics. Diagnostic devices such as ultrasound machines become smaller and portable, making their use at points-of-care more prevalent.

COVID accelerated the journey from research to trials to productizing new therapies on the drug front. mRNA vaccines being the prime example. The trend of acceleration of development is slated to continue, taking advantage of the change in global collaboration, regulatory environment, and process digitization.

3. The Technologies

Depending on our industry perspectives, we may think of medical technologies as falling into “medical” vs. “digital”. Here, I have classified the technologies into three categories — molecular, digital, and material technologies.

All Tech in Healthcare

This article aims not to describe each technology exhaustively but to provide a sampling of what is brewing in each category.

There are exciting innovations in each category. Molecular technologies boast mRNA and genomics; digital holds promise with robotics and AI while materials maybe the unsung heroes in this group.

Select examples in material technologies include:

• Titanium or platinum in implants
• Nano-scale materials in batteries, sensors, or molecular technologies
• Polymers that makeup contact lenses
• Plastics in catheters used in minimally invasive surgeries
• Carbon in replacement heart valves

Just as drug discovery is being accelerated by AI, material discovery and testing are being boosted by AI. 3D printing offers exciting possibilities to create biomaterials for exoskeletons.

The convergence of these three technology realms — molecular, digital, and materials — with each reinforcing the other will be a tremendous boost for new health services and therapies in the next decade.

Applying the Guide as a Compass

This infographic puts together into one view the health care services, the products (drugs and devices), and the technologies.

Health Services, Products, Technologies

Here is how to use this guide to make sense of the innovations we discussed earlier -Peloton, Google, Amazon, or many others that will surely make headlines:

• Peloton is integrating digital technologies (vision AI) with their smart exercise equipment to offer wellness services
• Google uses digital technologies (AI and Cloud) to discover new drugs or enable others to discover drugs faster. Pharmaceutical companies are using digital and molecular technologies to find new therapies.
• Amazon is starting to offer services (employee benefits/insurance, pharmacy) using digital technologies, including Amazon Web Services.

This graphic also lets us see the alternative ways a medical solution can be introduced in the future using a one or more of these technologies.

For example, will we solve an orthopaedic issue on our knee using a 3D-printed metallic knee implant, an exoskeleton, or regenerative therapy?

The actual intervention would really depend on our specific condition and the availability of the technology when we need it.

In short, we are integrating technologies from molecular, digital, and materials categories to build new drugs and devices to deliver new health care services.

Summary

It may seem challenging to keep up with the pace of technological innovation unleashed in healthcare by combining technologies from molecular to digital to materials. Mapping these technologies to the wide portfolio of health services — insurance, primary care, surgery, etc. and their underlying workflows — clinical decision making, scheduling, drug discovery, etc. — will make it easy to apply innovations to improve our health care system and health outcomes.

Originally published at cxotechmagazine.com

The post The Really Simple Guide to Navigating Health Care Technology Innovations appeared first on Hari Harikrishnan.

Warren Buffet memorably termed the healthcare industry the tapeworm of the US economy, referring to the apparent crowding out of investment in other industries as healthcare costs exceed 17% of US GDP — $3.8T in 2019.

See below on how $100 flows in and out of the “tapeworm”.

The inflow (shown with ‘+’ sign) is the funding originating from various participants in the system.

Inflow = Consumer contributions and direct spending + Govt spending + Employer contributions;
Outflow = Provider spending + Drugs/Device Makers revenues + Insurance Costs + Govt Admin cost;

Every large bucket of funding and spending is shown as % of total expenditure, so that we can see the elephant (or rather the “tapeworm”), at a glance. When one player says the problem is with another, we know the size of the pie each player represents, if not their influence in the industry.

Are our passionate debates on US healthcare spending — the highest in OECD countries in absolute terms and per-capita — calibrated to the size of each participant’s funding or spending?

For example:

• Pharmaceuticals is 10% of the pie, but hearing the debates on big pharma would make one think that we can solve our cost problem by reining in Pharma.
• We hear about the middlemen problem. The middlemen — insurers and PBMs (pharmacy benefit managers, these days part of insurers) is a 6% problem.
• Private sector employers fund 19% of spend, but the portion of consumer spend tethered to private plans adds clout to them since 50% of the population is enrolled in employer plans.
• Consumers fund 28% ($1T) in taxes, premiums, and out-of-pocket expenses. The high portion of spend doesn’t seem to translate to influence
• Provider spending is 70%. Before we get excited about that tranche, reflect that this is a highly labor-intensive industry. We know wages aren’t sky-rocketing here or in the economy as a whole. Do we think more utilization reviews and prior authorizations by insurers and more optimization on how we price each service (via relative value units or RVUs) will help?

Where are the possible hundreds of billions in cost-savings hidden? Yes, we have room to tighten this all around in the many layers below these buckets. Still, how can large swathes of costs be drained from this system?

Does the answer lies outside this frame, in non-clinical approaches to health and wellbeing? Is this “X-Ray” a mere reflection of how much it costs to care for our population? Are we too focused on cost of disease and not on the whole persons in our populations?

The old quote from Dr.William Osler springs to mind:

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.

The post The X-Ray of a Tapeworm: Visualizing Money Flow in US Healthcare appeared first on Hari Harikrishnan.

New headlines loom large every day about investments and initiatives from Microsoft, Apple, Google, Amazon (MAGA, for short if you can’t remember them) in healthcare. Some of the initiatives promise miraculous cure to the ills of the state of healthcare, some promise disruption, some are more of the same. Often we hear of their high-profile attempts and equally high-profile exits.

Getting a summary view into their forays by tallying up their inventions and investments can be found here. For a quick distillation of Big Tech in healthcare, read on.

All of them have their clouds whether for B2B or B2C businesses. They all have their AI — embedded in their products or for others to develop and to enhance their products. You can find something even more specific like “voice-enabled AI healthcare solution” or “vision AI for radiology”?

Rather than itemize their trophies to quantify their place in the health-tech race, here is an at-a-glance view on how much disruptive threat they pose to large healthcare incumbents in the US.

At a Glance — Big Four Tech in Health

The graphic below is a look at the posture of Big Four Tech in healthcare innovation & the threat they pose to incumbents — device makers, healthcare providers, and insurers. The threat-level follows the arrow based on the capabilities and investments each firm is making.

1. Microsoft: So far, Microsoft remains a provider of innovative technology to the industry — a classic stance of tech players towards most industries. Not threatening incumbents, but providing infotech solutions for industries to leverage.
2. Apple: Apple’s posture is similar to Microsoft’s. Apple too remains rooted in being a technology provider while making advances into new class of digitized medical devices — like the Apple Watch or SaMDs (Software-as-a-Medical-Device) and services enabled by them.
3. Google: The similarities between Apple and Google in healthcare starts and ends with devices (phones, and FitBit, for example). Google’s ambitions range from life sciences — genome projects, enabling drug discovery — to health insurance and care delivery. Investments in new-age health insurer Oscar Health, in telehealth provider Amwell etc are examples. In addition, Google invests more in technology for imaging and diagnostics.
4. Amazon: Based on available offerings and ambition, Amazon looks the most threatening to status-quo healthcare. No other player in the Big Four has direct-to-consumer service offerings such as pharmacy (Amazon Pharmacy) or planned care delivery like Amazon Care. Amazon’s appetite for wide range of business models makes them a threat in many aspects of healthcare. We’ll set aside their failed joint venture “Haven” for this discussion.

How will this shape healthcare industry partnerships with the big four? How will this threat evolve as these new entrants gain experience in health? Will their investments wax and wane as they shift priorities?

The post Big 4 Tech Players and Threat to Healthcare Incumbents appeared first on Hari Harikrishnan.

Why women report more Covid-19 side effects — Three Bs: Biology, Behavior, and Bias.

By early Jan 2021, almost 80% of Covid-19 vaccine side effects reported in the US came from women. This article from USA Today from April 2021, covers the possible reasons.

Here’s a graphical summary of the findings.

1. Biology

Women show greater immune response to vaccines — almost twice as much as men. Having more “ T helper cells” that activate the immune system one reason attributed to this.

Women’s immune cells having more estrogen receptors also makes the immune response, “adaptive”.

2. Behaviour

So, women are prone to higher side-effects. Are they also more inclined to report adverse effects more than men? Do men report less?

It would appear so on both counts. Women are more engaged than men in health care, per this WHO study. Women seek care more actively unlike men. Women being in charge of care for children and the family makes them more engaged than men.

3. Bias

Dosage of vaccines and meds not adjusted for women. Unlike pediatric care where dosage is adjusted by weight, men and women get the same adult dose. Trials and studies have started to include women only recently.

Women were not included in clinical trials until 30 years ago (“for their own good”). The National Institute of Health Revitalization act of 1993 in the US established new norms for clinical research equity for women and minorities. However, research for most drugs in the market pre-dates these reforms.

Combine this bias with the biological response and we get findings that suggest half the typical dose of flu vaccine is enough for women, as compared to men.

Epilogue

In an era when we talk about precision medicine and personalized health care delivery eloquently, it is sobering to realize that gender equity in health care is far from reality.

In case we walk away thinking that men are in better shape, sadly not so.

Historical clinical research emphasizing white males of certain types and men’s lack of engagement, puts them at a higher risk. The extent of the risk is manifest in the life expectancy gains men have not achieved, when compared to women.

That’s a story for another time.

The post 3 Reasons for Women Reporting More Vaccine Side Effects Than Men appeared first on Hari Harikrishnan.

In 2020, we did not discuss how the labour force has to outrun the automation-and-AI bear. Instead, we were preoccupied with unemployment, with the pandemic shuffling the deck on jobs across industries. Rightly so. As we hit a reset on this decade (discounting 2020), our need to learn constantly has not changed. If at all, it has grown.

When was the last time you looked around your office or school to see who is doing work differently from you? Or gained knowledge or skill from a colleague, or enhanced an idea you got from a colleague? Can we map out what we learn and what we need to learn?

Based on my observation as a practitioner in the workplace, here’s a framework to inventory our skills. This not a Hogwart’s sorting-hat to put us in a bucket, but a frame to help assess ourselves. Any human skill categorization and cataloging is fraught with pitfalls. I’ve focused on keeping these categories focused on key skills vs. human qualities that contribute to skills.

I think of our skills as belonging to these four broad categories.

1. Technical Skills: Based on our field/domain of study. This category can be broadly sub-divided into STEM (science-technology-engineering-mathematics) and non-STEM.
2. Vocational Skills: Skills we use in the workplace based on the business functions we work in — from developing products or services to selling them.
3. Interpersonal Skills: Being the sentient beings we are, and the need to work with others to get anything of substance done, these soft-skills become more important as our careers advance and our tasks grow complex.
4. Integrative Skills: From simple to complex decision-making, we assemble and analyze information in disparate forms, use our judgement to perform “executive” functions. These skills also assume greater importance as we go from new workers to “seasoned” professionals.

The idea of lifelong learning applies to all four categories above. Arguably, these four categories are shown in the order of difficulty to be good at. Categories 3 and 4 require very aware nurturing to master. These two are such horizontal skill categories, cutting across your field of study or your business function.

Let’s dive into each category in this Technical-Vocational-Interpersonal-Integrative skills framework. T-V-I-I or TeeVee, if you want a mnemonic to remember them by.

1. Technical Skills

I’ve clubbed most fields or domains we study academically into this “technical” category.

This includes, science, humanities, and sports/athletic pursuits. Quite often, our training in these fields determine which industry or vocation we choose when we graduate and enter the workforce.

Much emphasis is placed on STEM-centric education lately. At the same time, there is emerging realization that a blend of STEM and non-STEM (should we call it Root?) education may serve us better in the long-run, so that we may end up becoming more rounded individuals vs. uni-dimensional.

Here is a zoomed-in view of technology fields in STEM to illustrate how old and new technologies are evolving and complementing each other.

When viewed across the four skills categories described in this article, diversification within this technical skills category itself may require us to hone our skills in the other categories.

2. Vocational Skills

The vocational-skills category is about our careers and job functions in the work place — from developing and selling offers in the market as well as supporting the efforts to build and sell those offers, as shown below.

I have used development to denote any type of product or service creation that happens in a company. The sub-roles within it could be engineering, construction, researcher, actuary, film director, content creation in many forms, and so on.

These development roles will vary by industry and closely tied to the technical skills categories in quadrant 1. Given our long careers and the need to stay relevant, switching functions within the same firm or across firms is imperative to keep our skills diversified. E.g. people moving from sales to marketing or from engineering to products and marketing.

Such moves across functions is often harder than acquiring knowledge in a different field of study. i.e. you could learn machine-learning easily if you have a mathematics background, but can you go from engineering to sales? These career transitions require developing skills in the categories below.

3. Interpersonal Skills

These appear self-explanatory at the outset, but mastering them is no easy feat and is in itself a lifelong journey.

For example, it is obvious that communication skills are imperative for our success in work and life. It runs the gamut of non-verbal, verbal, written, unwritten etc. — well expressed in this German saying, “Keine Antworten ist auch eine Antworten” — no answer is also an answer.

Beyond the message content (or the absence of it), we have so many ways and means of communication that in addition to getting our message right, we need to perfect the mechanics of its conveyance. Should we do a LinkedIn message, text message, WhatsApp message, email? Slack? Zoom or Skype? Choices and decisions abound.

Good collaboration is easier said than done when we have a diverse set of expertise, styles, and work-life experiences around our virtual tables. We know that purposeful collaboration is the only way to achieve good outcomes from complex undertakings — be it a workplace project, your startup, or your social-impact endeavour. Compassion serves as a key enabler for both communication and collaboration. You may see references to this skill under empathy.

4. Integrative Skills

Think of integrative-skills category as a decision-making skill category. This set of skills needs to integrate skills and knowledge from other categories to pursue a course of action.

Analysis lies at the root of our decision-making — big or small. Curiosity feeds it, so that we ask the right questions and explore areas that relate to the decisions at hand.

The next two skills in this category verges on the realm of neuroscience. I’ll stay at a practical level and describe them, keeping focus on day-to-day applicability and not their underlying capabilities or human qualities.

4.1 Abstract Patterns, Copied

Our complex brain can recognize patterns across a wide-range of topics ranging from simple drawings, to music scores, to societal changes, as well as copy ideas creatively from one realm to another. Think similes, metaphors, and analogies, when we think of abstractions and patterns.

For a visual pattern example, the Art Deco style Chrysler Building in New York City has arches that resemble fish scales. It has portions inspired by parts of a car. Both good examples of copying and abstracting to create something new. Both apply integrative skills to technical fields in quadrant 1.

Beyond such visual patterns, some patterns could be drawn from different fields of study or business processes.

One of my favorite patterns cuts across skill categories 1 and 2. In sales & marketing, we do lead generation to prospect and close potential customers. Conversion ratios indicate how successful we are in converting a lead to a customer. This is similar to lead-generation in pharmaceuticals ( H2L: hit-to-lead), where, as part of drug discovery, we do high-volume screening to unearth new compounds that have biological or pharmacological value.

Neuroscientists attribute a capability to our brain called compression which lets us distill large amounts of data to its essence, like creating the summary of a book — page after page compressed into a few sentences that serve as the skeleton of the book. Capabilities to compress and copy underlie our ability for abstraction, pattern recognition, and creativity.

4.2 Integrating, Leading, Creating

Finally, leadership skills. We wax over what it is and what it is not. I wrote about business leadership for the digital age some years ago. The core ideas there are still relevant.

In the context of this framework, leadership requires blending skills within and across the four categories — technical, vocational, interpersonal, and integrative skills. We all have leadership skills to varying degrees. Our training and how we develop what we need for our personal and business situations is where we diverge.

Summary

A new year, especially one succeeding the terrible year we’ve had globally, is a great time to examine our skills and careers. I do hope this T-V-I-I framework offers directional insights on how to navigate your decades ahead or create your own frame-of-reference.

How you would categorize your skills? What you think are important for the decade ahead? All the best for a great 2021.

Originally published at https://www.linkedin.com.

The post The Skill Map to Anchor Us for the Decades Ahead appeared first on Hari Harikrishnan.

2020. Annus horribilis. The year when considerations of health outweighed those of wealth globally, though we found them inseparably intertwined as millions lost their livelihoods.

The debate about how the pandemic transformed healthcare globally and in the US will go on for eons — everything from vaccine development to regulatory pathways, health policy, continuum of care delivery, and our response — individually and collectively.

I am sure we each have our unique takeaways based on the lens with which we view society, industry, and our own personal health or economic situation. Here’s my lens.

3E’s Shaping US Healthcare

In a year of turmoil not just in public health and its economic fallout, but also in social justice, 3 areas jumped out for me as shaping the future of our healthcare — 1. Expectation of patients, 2. Equity for populations, and 3. Existence of care providers.

Expectations of Patients

Before the Internet era, health information was hard to access. Several decades of information access via Internet has empowered us to do symptom checks before we show up for a doctor’s appointment. The pandemic has made it necessary for patients and providers to adopt Telehealth.

Patient empowerment has taken on a new dimension with the remote care

Trust barrier that existed around care from far has been shattered — both from patient’s acceptance of remote care and the provider’s existential imperative to offer it (or go out of business), along with policy changes to get compensated for it.

This is an irrevocable change in consumer behavior that is not going to go away once we get past this pandemic. How we build on this new foundation of behavior and receive care in different care settings and modalities — face-to-face, virtually, live, or offline — and how this affects efficacy and economics of care will be interesting to observe.

[ Related: Thoughts on whether great expectations beget better outcomes in this article on patient experience].

Equity for Populations

The awareness about inequities in social justice has reached a level we have not seen before. 2020 saw global repudiation of long-standing artifacts of racial and social injustice. Against this backdrop, unrelated to the pandemic though coinciding it, we saw how virus devastates certain groups.

Virus maybe an equal-opportunity parasite, but it is not a great leveler.

We will discuss at length the color of covid in the broad context of social equity.

For the healthcare industry, the pandemic throws more spotlight on the social determinants of health (SDOH) and how we should bring more accessible care to groups across the spectrum of colors in our society.

Existence of Providers

During the pandemic we cancelled our screenings, our routine visits, our dental care; postponed our surgeries or elective surgeries were suspended. To providers of non-urgent, non-critical care, their patients vanished overnight (some came back on camera).

Pandemic seen from some providers’ view is ironically akin to entire patient populations becoming healthy overnight.

We joke about our healthcare being really about sick-care. It isn’t anything to laugh at when small and big provider business models, built on sick-care, are threatened by no-shows induced by the pandemic. At the peak of a health contagion, we were laying off people or shutting down clinics.

Independent physician practices to hospitals are in various stages of financial distress. The existence of providers, especially the small businesses who can’t absorb the economic shock, is threatened.

About a 100 years ago, health insurance came into existence to prevent surprise medical bills that bankrupted people by stabilizing patients’ monthly expenses.

On the other hand, bulk of the physicians are paid by fee-for-service reimbursements for service rendered per visit or incident. There is no stability in their income. In 2020 most practices will see diminished revenues and a majority of primary care practices will lose money per this McKinsey survey.

More than ever, the fragility of providers’ existence, founded on sick-care, is exposed.

How will the provider’s payor-mix (sources of income from medicare/medicaid reimbursements, private insurance, patient-paid etc.) change? Will we see an accelerated shift to concierge-care where providers move to a patient-paid model? Will we finally move away from the fee-for-service model with its perverse incentives to a new payment model to stabilize healthcare provider incomes to ensure their financial health?

Our Response

How will the healthcare industry and policy-makers respond — from makers of drugs and devices to providers and payers? We have many balls to juggle and many large jugglers.

Will improving access to care and patient experience outweigh singular focus on cost? The push towards value-based care in the last decade saw us trying to balance quality and costs via accountable care and bundled payment initiatives. What incentives exist in the system today to improve access and experience for the long-run at scale?

Whatever we do to improve quality, access, costs, and experience, the 3Es of expectations, equity, and existence need to be factored in.

Do share your thoughts on key post-pandemic drivers for healthcare reforms in the US or in your country.

Originally published at https://www.linkedin.com.

The post Beyond the Pandemic: 3 Es Shaping US Healthcare appeared first on Hari Harikrishnan.

Safety concerns with our lightly-used 25-year old car sent us scurrying for a new car in pre-pandemic 2020. We kept our options wide open at the start which resulted in us trying a gamut of brands and models.

n this age of electric vehicles (EV), we had to consider them. Unfortunately, other than Tesla, the other popular electrics failed our driving preferences and finicky expectations on aesthetics and UX.

I’ll focus my design notes on three cars culled from the pack — Tesla Model 3, BMW 3 series, and Mazda 3.

In 2020, automotive design spans industrial design, experience design, and digital design. It is impossible to cover all aspects of their design. Beyond good handling, these are the aspects of design that jumped out:

1. The Front / The Face
2. The Side and the Rear
3. The Console
4. The infotainment System

1. The Face

Grills (or the lack of them) give cars personality.

BMW’s kidney grill is famous even though it didn’t always start out kidney-shaped. Mazda sports the “apron” grill (or “half-shield”). Electrics can live without it as Tesla does. Made me wonder if BB King were alive to see the transition to EVs, he might have rendered, “The Grill is Gone”.

There is nothing objectionable about the above faces. In fact, there is something to like about each. Until this happens…

The Mazda design looks fine, especially up close. Designers did a great job with the grill. Unfortunately we get to put on the license plate. Voila! The car looks vandalized! I noticed the extreme despair of a Mazda fan who attached the license plate away from the grill on the side. Saddest automotive spectacle that I ever saw!

It used to be that we designed-for-manufacturing (DFM) and we designed-for-use (DFU). This seemed an abject example of designed-for-defacing.

2020 — The Year of the Grillzillas

Before we leave the discussion on face design, I must segue into the trends in grill design. They were striking. It struck fear!

As if Covid wasn’t enough, we have an attack of the car grills. By 2020, some brands have increased grill sizes by more than 40% vs. prior year models.

See examples below.

I looked, cringed, and ran to escape this assault on the senses. It was Scary Movie #5. It was Aliens remake #10.

They each vie for the Top GrillZilla honour, but if looks could kill, Lexus would be my nemesis.

All this has given raise to internet memes on grill-roadmap’ing. See the projected evolution of grills by 2060, starting with the 2020 BMW.

BMW has deemed naysayers like me “Boomers” who don’t like change. Perhaps some tastes do need to be acquired. Horror movies aren’t my thing!

Clearly boomer BMW fans, do not have to reprise BB King, rather double down on, The Thrill is Gone.

2. The Side & the Rear

Variations abound in how the rear is configured.

Tesla’s fastback modernizes the classic hatchback look, but it does give it a tent’ish look. [Guilty, this is a nit. However, once you see it, you can’t unsee it.]

Tesla’s rear visibility is severely limited due to the raised backseats and trunk. It is annoying unless you get used to the rear camera view to see behind the car.

BMW and Mazda stick to sedan’s classic saloon form. Mazda extends the roof a bit closer to the rear than BMW sedan, seemingly a cross between fastback and sedan.

What I found catchy on the Mazda is the “ridge-less” side.

Taking a closer look, you can see how the side flows front-to-back without any bulges or ridges. This makes for a distinctive look for the car where you can recognize a Mazda by seeing just the side. [More on this flowy design later on.]

This is not an easy feat at a time when most cars look similar and the only way to tell them apart is by the logo or other signage. As a bonus, how light falls on the side body makes for nice natural effects as seen above.

The Door Handle

Before we get inside the car, a quick pause at the door.

Tesla has its unique flush door-handle vs. the traditional pull handles. It wins on looks hands-down.

Alas! Design is a compromise between function, usability, and aesthetics.

A few uses of this handle and it becomes apparent it is not meant to be opened by a hand holding groceries.

Nor is it for the arthritis-afflicted. Nor for the left-handed. Nor for those with even a minor temporary hand injury…

Intentionally or not, the designers’ aesthetic sense beat out the engineers!

3. The Console

Other than the grill (sans-grill or grillzilla), the place that has the most visible changes in the last decade is the console. Because consoles have gone digital.

See Tesla 3 and Mazda3 consoles below.

Tesla is all digital with no remnants of the internal-cumbustion-engine days. The minimalist, uncluttered Tesla stuns at first. The vast panoramic front view is expansive too.

That is until you look critically at the laptop screen that juts out from the middle like a billboard. It will take some getting used to, if you are a stickler for unbotrusive designs.

Mazda has a more traditional look. It is partially digitized with even digital dials like speedometer made to look analog. The navigation and infotainment screen is angled towards the driver — a thoughtful touch that fits the display neatly in the driver’s peripheral vision.

The utility of this angled design is immediately apparent if you’ve ever used a navigation system not angled towards the driver, but straight across the driver’s view as below.

Call it pretzel-centric design, given the twisting you’ve to do to get to the controls.

BMW has the best of both worlds. The screen is somewhat angled towards the driver with recessed housing on the console, so as to not stick out like the Tesla.

4. The Infotainment System

Tesla rolls its own proprietary interface for infotainment. Tesla’s closed non-platform approach to infotainment makes it impossible to bring-your-own content and apps to your car. As competition heats up in the EV space, they may have to revisit this.

BMW infotainment controls retain the legacy rotary dial for now, while adding touchscreen and providing wireless Car Play support. Given their 20-year history with their iDrive system, this may well rank high as a full-featured and mature infotainment experience.

Mazda, like others, have opted for Apple Car Play and Android Auto integration — a smarter move given the convenience for consumers and the difficulty in keeping up with innovations in digital interactions (e.g. touch, voice, visual design) from Apple and Google. However, navigating between the car’s built-in menu options and your apps is a long way from seamless.

For all those considerations for angled display screen and human-centric design philosophy (read about Kodo design here), Mazda chose to make its display, not a touchscreen. Navigating the screen is via a knob next to the shift, apparently to enable the drivers to operate it in their normal seated position.

Well, dear folks at Mazda, it’s 2020. We are way past jiggling some proxy knobs and joysticks to get our work done on a computer.

Yes, we are well aware that it is a substantial redesign of the console to have it be angled, touch-enabled, and fit with the rest of the console. Just do it, please!

Finis

After all these observations and complaints, we ended up buying a Mazda 3. I handled so much better than the Tesla. Mazda 3 met our requirements for utility and drivability. Its design was elegant in many respects and adquate in others. Not surprisingly, the BMW outshines the Mazda in driving experience, but that’s not a fair comparison given the consumer segments they each are after.

After rifling through over 10 brands and 20 models we were resigned to settling on some mediocre or expensive automotive. Zarathustra came to the rescue. We thanked the prophet and his Supreme God, Ahura Mazda, for their namesake creation and sparing our pocketbook from years of devastation.

Epilogue

During this shopping episode, Tesla Model 3 repeatedly reminded me of a Mazda RX-7 I had years ago. Comparing a newer Mazda (MX-5 / Miata) to a Tesla 3 does suggest more than a modicum of shared sisterly DNA.

Is it a coincidence, I wondered. Upon researching, I found that Tesla’s designer, Franz von Holzhausen, used to be a Mazda designer. In fact, he was responsible for a flowing 2010 Mazda design called Nagare.

Is the flowing side-body of a 2020 Mazda 10-years in the making? Was it because production couldn’t realize designer’s vision?

How much of Tesla’s design language owes itself to Mazda? Given the same constraints on size, price, and aerodynamics, won’t different designers end up with common elements across their designs anyway?As humans, don’t we carry our sensibilities, skills, and tools across jobs?

Now, for the design and marketing geeks…

Mazda logo and lettering is in itself a study in brand identify and visual design.

The ‘M’ in the logo — suggesting wings that give it flight — is a great design element for numerous variations in print and digital. You can see it accentuated in TV advertisements (in the end-tag of the ad spot).

Why is the ‘M’ circled, I wondered? Most traditional automakers have circular logos. Not Tesla, which has a styled ‘T’.

Was the circle a design compromise for manufacturability in its time and Tesla wasn’t burdened by it? Or was the circle for symmetry or meant to imply “holistic”? I suspect manufacturability had a lot to do with older logos being circular.

For the ultra geeks: Mazda lettering uses the font SF Automaton. This font lets you combine upper and lower case for a uniform appearance. Imagine how out-of-place a ‘d’ in Mazda logo or ‘h’ in my “Ahura logo” would’ve looked with any other font.

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We’ve all heard about the trillions of dollars of value at stake in the business of the Internet of Things (IoT), have heard of immense value to be captured from selling and using IoT-enabled solutions.

How do we make sense of the numerous innovations and use-cases? What lies ahead? What lessons from industrial IoT are applicable to healthcare, the toughest vertical industry innovation problem of the 21st century?

IoT in Three Waves

Let’s start by looking at IoT evolution from three perspectives — Operational Innovation, Product Innovation, and Consumption Model Innovation. I’ll tag them IoT 1.0, IoT 2.0, and IoT 3.0, respectively.

Each innovation area is best seen through the lens of the 4-stages of a Thing Lifecycle — the very same thing that we are connecting to the Internet. The four phases of a thing’s lifecycle where the maker of a thing designs and manufactures it (thing is called a product) and its buyer procures and uses it (thing is called an asset) — design-phase, manufacturing-phase, procurement-phase, and use-phase — are shown below.

Over the last two decades we’ve seen makers and buyers innovate in all the quadrants of the thing lifecycle. With this lifecycle in mind, let’s look at each type of IoT innovation below.

IoT 1.0 — Operational Innovation

The predominant IoT use case we were awash in during the last decade, has been product or asset maintenance — maintenance services that varied in nomenclature from proactive, to predictive, to preemptive. Each adjective tried to parse asset maintenance transitioning from time-based to condition-based in nuanced ways. They all addressed the use-phase of the thing lifecycle just do use things, not the design, manufacturing, or procurement phases. See quadrant-4 of the thing lifecycle below for the core operational processes affected by IoT in the use-phase.

IoT 1.0 is the era of aftermarket IoT, since in most cases, the thing — the capital asset we connected — wasn’t natively designed to be connected to the Internet. It required intermediate devices to translate data and send to the Internet.

The extent of value extracted from this step towards condition-based maintenance varied across industrial markets. In some cases, it was simply about visibility into the asset and data collection. Depending on the organization, we automated certain level of maintenance over the last 20 years to augment a labor pool using automation, while reducing downtime and driving capital efficiencies.

IoT 2.0 — Product Innovation

IoT 2.0 affected quadrants 1 and 2 of the thing lifecycle as shown below. The connectivity and smarts that are needed to network the capital asset were designed into the product itself. Manufacturing-phase of the thing lifecycle, adapted to this design change by integrating electronic and industrial supply chains and processes.

I call this, Native IoT.

If after-market IoT was like installing GPS in a car after we bought it, native IoT is like a car with built-in GPS.

Data from the use-phase, both functional and experiential, fed into design-phase of products. It is easy to see how IoT influenced a designer’s life. (Hint: Design Thinking!)

IoT 3.0 — Consumption-centric Innovation

Quadrant-3 of the thing lifecycle deals with packaging, pricing, and delivery models to enable new ways to consume the thing. IoT-driven changes to this procurement-phase changes the prevalent asset-consumption model from owning, to subscribing, to on-demand use, as shown in quadrant 3.

Some examples of IoT 3.0:

• Air-as-a-service from Kaeser Kompressoren
• Train-as-a-service from Hitachi
• Care-by-Volvo from Volvo
• Book-by-Cadillac from GM

Arguably, stage-3 changes to thing lifecycle could be done even without IoT. IoT makes this more easily and sustainably doable, while mitigating financial risks.

For a detailed dissection of various consumption-models is here: How IoT Transforms Business Models.

Mapping IoT Waves to the Thing Lifecycle

Below is a summary of generic IoT use-cases mapped to the thing lifecycle and categorized into the three waves of IoT evolution. You can see detailed industrial IoT use-cases and firms adopting them here.

Whither IoT from Here?

We are still in early days of IoT 2.0 since we are dependent on capital refresh cycles for an installed-base-level change towards native-IoT assets.

IoT 3.0 is disruptive not just to makers and buyers, but to the entire ecosystem that sells, finances, insures, and services capital assets in any industry.

A prime example is auto dealers suing Volvo when it started its car subscription service that combined lease, insurance, maintenance, and upgrades, a la AppleCare.

Elsewhere, in the healthcare industry, IoT evolution is still in its early days when compared to other industries. The lessons from industrial IoT asset monitoring and consumption models apply in healthcare industry too. E.g. Use of medical devices such as surgical robots (the ones shown in the graphics above), durable medical devices (DME), and even pharmaceuticals, could be monitored and sold as subscriptions.

While in industrial IoT we monitor things, in healthcare we are monitoring our selves. It may be more aptly termed IoS — Internet of Souls.

IoS would be an unprecedented amalgamation of digital and medical technologies, care delivery ecosystem, and public policy, building on IoT 3.0.

IoS = IoT 3.0 + Healthcare Ecosystem + Public Policy

A well-worn cliche says hindsight is 20/20. If so, IoT hindsight from the last 20 years should give us a head start on what lies ahead in the 2020s.

— —

First published on LinkedIn.

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Day 1

2:30am:

I am stepping off a flight in New Delhi. Air is chunky and warm, overpowering me with its familiar smells.

I’m living the mundane life of an arriving passenger — navigating the pesky walkways and phone issues, to find my Uber driver.

I hear what sounded like military jets in the air. Dismissed it.

8:00am:

Called my brother. Asked him how things were. “Every hour he is deteriorating”, he said. Trust my brother to lay it out succinctly, as always.

I’ll see you in the evening, I said.

8:00pm:

2 flights later I am in Kerala — a thousand miles South of Delhi.

During the flights, I learnt that 40 Indian reserve military men were killed by a suicide attack in Kashmir a day ago.

I recalled hearing the military jets in Delhi. The country was in mourning. Soon we’d follow.

I scan the arrivals for a ride from the airport. Wishful thinking!

For 30 years, it had been my brother-in-law who would always pick me up cheerfully. Not this time.

9:00pm:

I am at the Regional Cancer Center in Thiruvanathapuram, Kerala.

I see him finally — my brother-in-law, the laboured breaths, the slow drips of the IV. Other circumstances would have had me joke about Chinese water torture. Here drops were succor.

The Crab had encircled his lungs and vertebrae — his cage constricted, limiting his ventilation. Every breath was a willful act of courage, seemingly under water.

Juxtaposed in that hospital-room was what cancer can do to a loved one and what modern medicine cannot do.

That’s when I met Sanju. Dressed in gray shorts and a blue half-sleeve shirt, he was the in-room nurse. Sanju was in his twenties, pleasant and upbeat — incongruous under the circumstances — but soothing and quietly efficient.

As I watched him attend to the patient, I noticed that caring seemed to come to Sanju naturally. Extreme human suffering was a thing he took on with equanimity, it appeared.

What made him choose a career path like this, I wondered. Did he have a mentor or career counsellor who influenced it? Unlikely. He seemed to divinely glide into care giving.

Later, I remember him tactfully dissuading us from straining the patient with our well-intentioned presence.

Called it a night. The sea breeze was merciful in the hot and humid late-night. Never found sea air as teary.

I took out my own palliative medicine — my sombre music list fed to my brain. Songs from many languages curated for their tempo, timbre, and tone. They all sounded the same to me.

Bist du bei mir… If you are with me, then I will go gladly unto death and to my rest…

Was the record player in my brain stuck? Or did every song in every language in my melancholic collection, when stripped of its ornamental glory, convey the same meaning? Or was my cognition and jetlag playing late-night tricks on me?

Day 2

Back at the hospital, the drumbeat of the IV drips has accelerated.

Morphine on steroids…I reflected morbidly. The faster they drip, the slower the breaths get, until…breath becomes air.

The treatment is all on plan. We are not on any futile, rescue-care pathway. Not on some magical curative pathway. This is end-stage comfort care — palliative only.

And to think that just a year ago, him and I were celebrating him overcoming a stage-4 cancer spectacularly… never mind! This ain’t the time for what-if’s.

I observed from the chair next to the bed how Sanju cared for my brother-in-law. He called him “Achan” — the local language word for Father. He was gentle and persuasive, making sure the patient was comfortable, anticipating his needs. He was an all-rounder — a nurse, family caregiver, and a good waiter. That’s beyond clinical services alone!

Sometime that afternoon, my brother-in-law recognized me. He took my hand. Attempted to say something. He could not. He had already said it generously last week on WhatsApp, when he was more able.

Even if he had said something, we couldn’t have heard it.

For, in that instant, all around the building, a Kerala temple-procession broke out with the vigour of local drums (“chenda”) — as if the Arabian sea sighed and slammed tumbleweeds on to the building noisily.

A benediction of nature for an auspicious good bye?

Day 3: Devotional Service as The Way of Life

Morphine marched faster.

Sanju came back from his break with his father and mother. We talked about their home town — a place close to where my home was. Them three seemed to be completely at ease with the situation in front of them. Without any overt expression of concerns, they seemed to be in the groove of what needs to get done — the groove of being in service with compassion.

I found out that Sanju’s father was a member of the national reserve military force bombed by terrorists. I offered my condolences towards his lost mates. He stared ahead, avoiding my eyes. He could not hide in his steely eyes his pride and dedication to national service.

I went for lunch. Cafe was crowded and spartan. The staff made sure I got everything and was served well throughout my meal. Is the universe just being extra nice to me? Why is this focus on service so striking?

Perhaps I forgot, having not lived in Kerala for 3 decades. It seems to be the norm here. Whatever you ordered, and whoever you are, you deserved to be served right. No exceptions!

Back in the room. I had missed the doctor’s rounds.

Doctor’s orders: Time to bring close family back. We all assembled by evening one last time.

We encircled the bed, as if to provide a human palliative cocoon in addition to the chemical cocktail in the bloodstream…or so I hoped.

Then we withdrew, leaving one in charge for the night.

Epilogue

The nightwatch ended in the wee hours of the morning.

I flew out the next day. The Crab had its day for now in Kerala, just like terrorists had in Kashmir. I had witnessed acts of service with compassion and devotion.

Flying back to San Francisco, I carried the weight of an infinite sense of gratitude, duty-free.

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