How Healthcare Shapes Our World

Those of us inside the healthcare industry often talk about the drivers of healthcare. There are many: politics, economic trends, culture, consumerism, changing burdens of disease, technological advances, and many more. A big shift in any of these factors can have a significant impact on how healthcare is delivered and paid for.

Perhaps less obvious, though, is the way in which the reverse can also be true. Rather than merely being a product of what’s going on around it, healthcare can be an active driver of much of what happens in the world.

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The political arena is one place where healthcare’s growing influence is obvious. Here in the US, healthcare policy discussions rarely came up in election stump speeches. Now it’s a major campaign issue, which means that the state of healthcare and approaches to healthcare financing are playing a role in determining who will be the nation’s leaders, not just vice-versa.

Healthcare’s political influence is as great or greater in many regions of the world. That’s especially true in countries where healthcare has long been lagging behind the most industrialized nations, but is now advancing on the shoulders of rapidly growing middle classes. Many nations in Asia and Latin America fit that description. In Peru, Colombia, Malaysia, and India, to name a few examples, healthcare has been a significant campaign issue in national elections. In other countries, such as China and the United Arab Emirates, where national leadership is less likely to shift via election, governments still find it important to be responsive to public demands for better healthcare and are investing heavily in it.

In the economic realm, too, healthcare serves not only to reflect trends but also as a driver. In the US, the number of people employed in healthcare dwarfs employment in most other industries, and that’s increasingly true around the world as well. New high-tech healthcare companies are as a group one of the fastest-growing and most important segments of the high-tech startup world, and established high-tech giants including Google, Apple and Microsoft are all investing heavily in pushing the boundaries of healthcare-related information systems. Meanwhile, on the negative side of the economic equation, private healthcare insurance has become a major budget item for most consumers, as well as a daunting cost to employers.

Healthcare is also a key component of important social trends. Thanks to those advances in technology, more and more people are integrating healthcare-related activities, communication, and metrics into their daily lives via apps and online tools. More important, healthcare improvements have helped ensure that many of us are living longer lives and enjoying a higher quality of life throughout our later years than have previous generations. That’s a very good thing, of course, but it has also led to the challenge of society’s needing to provide much more eldercare than in the past.

I could go on, and discuss healthcare as an element of international diplomacy and trade, as a magnet for educational achievement in high-school through post-graduate programs, as a factor in community building, and more. And I’m sure healthcare’s sphere of influence will only expand and intensify in the coming decade. So, though I wouldn’t go as far as saying that healthcare is the dominant force in the shaping of our world, I think it’s pretty clearly a significant component. Hopefully healthcare will be a driver of mostly positive change moving forward. But only time will tell.

 

Piecing Together a Healthcare System from Around the World

We often read that the healthcare system in one country or another ought to be taken as a role model for the US, or for other countries that struggle with healthcare quality, access or costs. But as I like to point out, wherever you go in the world you can find plenty of people who complain about the healthcare there.

Besides, even if it were true that some country really does have healthcare all figured out–and I don’t think it is–it’s unlikely that system could be ported wholesale to a different country. There are too many differences in culture, economics, expectations, healthcare infrastructure, the burden of disease, and on and on.

HeartSew_ShutterstockBut that doesn’t mean we can’t learn from other countries, and find elements that could inspire productive imitation. You just won’t find them all in any one country. A better idea might be to try to piece together the best and most applicable aspects of different countries’ healthcare systems. Here are a few places worth considering as possible sources:

Singapore: There are a lot of things to like about Singapore’s healthcare system, even if I don’t quite buy into the hype that it’s a role model for the world. One feature certainly worth highlighting is the way in which the system essentially rewards patients for shopping for better values in care by sharing any savings with the patients themselves. Making sure patients have a little skin in the game, cost-wise, can work wonders.

UK: The government provides good and nearly free care in government-run facilities for anyone who wants or needs it. To get solid outcomes at reasonable costs, the government relies on a diverse panel of experts and citizens to determine which drugs and other treatments offer the best evidence-backed results for the lowest cost. Those higher-value treatments are offered for free, with costlier or less-effective alternatives available only at some cost to the patient.

France: The government pays for most healthcare, though most clinicians provide it through private practice. The highlight of this blend is one of the most efficient and effective uses in the world of primary care to reduce unnecessary visits to costly specialists, leading to good outcomes at reasonable costs.

UAE: The country has been aggressive in investing in better and mostly free healthcare for the population in recent years. But a true shining example in improving health lies with local governments’ sharp, thoughtful efforts to try to reverse serious problems in the population with health-related behaviors, ranging from smoking and bad diets to reckless driving. Dubai has even offered cash incentives to citizens for adopting healthier habits.

India: Access to good healthcare varies widely from region to region here, and is often sub-par. But what healthcare there is tends to be of relatively good value–not surprisingly, perhaps, given that most of the population pays out of pocket for it. India has also employed the principles of mass production in ophthalmic and cardiac surgery to drive down cost and variability to improve outcomes and value.

China: While working hard to build more hospitals and improve existing ones, especially in the vast rural regions, one area where the country is ahead of a lot of the world is in wellness. Much of the focus in health is on diet, exercise, and addressing stress, and in the end all that probably can do as much for population health as good hospital care can. (Though smoking is still a big problem there.)

Brazil: The country, which largely relies on an employment-tax-financed public-private blend of care, has struggled to provide decent, consistent care to the unemployed, especially outside of cities. But the government has made significant strides in that regard, and the focus on improving care to the poor is why infant mortality and infectious disease rates have plummeted, and life expectancy has climbed steeply. It has also been at the forefront of equity in pharmaceutical distribution in the area of HIV management.

US: Overall spending is off the charts, and overall outcomes aren’t correspondingly great. But the quality and accessibility of specialty and advanced care is the best in the world. And much of it is made available by the government to the elderly, the poor, and veterans at little or no cost to patients.

Would it really work to grab various components of healthcare system approaches from different countries and stitch them all together? I suppose it could be the best of all worlds–or it could be the Frankenstein’s monster of healthcare. I suspect the truth is somewhere in between. But what we know for sure is that we all have to keep trying to learn from one another as part of a never-ending push to do better and better.

It May Be a Good Deal, But Is It Mission-Worthy?

I’ve spent much of my career structuring healthcare deals, partnerships and collaborations across borders around the world. Though the deals that get signed are the ones that garner attention, I feel that the deals that I walk away from are every bit as important. As it turns out, I usually end up walking away from those deals I enter at the early discussion stage. I often urge my colleagues and counterparts at other organizations to do the same.

Why do I say “no” to most deals? There are all kinds of reasons, ranging from concerns that they’re too poorly defined, or they’re underfinanced, or they carry too much risk, or there are better comparable deals. Deals that are a no-go are often deals that on paper seem like winners in almost every way, except for one: they’re not consistent with our organizational mission.

Jigsaw_ShutterstockIn healthcare, the mission objective to provide and improve patient care is a relatively clear one. But every organization has, or should have, a mission that informs leadership on how to focus resources and set goals. Likewise, any deals the organization enters into should be consistent that mission.

It’s my observation that in practice many leaders have trouble saying no to a solidly profitable deal with an appealing partner, even though the deal might veer away from the organization’s mission. That’s a significant mistake. When an organization starts lending its attention, money and name to efforts that don’t align with a clear definition of what the organization stands for, the results will probably ultimately be confusion, stress, weaknesses, and a dilution of the organization’s brand and reputation. As challenges to an industry mount, organizations that have strayed from their mission are much less likely to find a clear path forward.

Mission alignment is especially important in healthcare. I often meet with potential partners who are eager to impress on me the assured profitability of an arrangement. After all, how could I say “no” to a deal that offers a high likelihood of good return on investment, with little risk on our part? I’ve learned that sort of pitch requires an especially careful review. That’s because fixating on profitability over all else often isn’t compatible with the mission of providing high-quality care of patients. Many critical aspects of advancing and applying medicine, such as clinical research or extending care to the poor and vulnerable, just don’t pay off in that way. So when a potential partner keeps emphasizing financial returns over all else, I know the partner is not right for us, and politely close the talks down, often in the middle of the first conversation. I’ve never once regretted it.

Mission alignment is not always an easy thing to assess. One of the resources healthcare leaders and organizations have to build up is an ability to apply mission-worthiness tests to new opportunities. That’s harder than it sounds, because healthcare today encompasses so many components, from financing, to science, to hospitality, and so much more. For those of us working to extend healthcare’s span to a global scale, it only gets more complicated as we add to the equation governments, private investors, NGOs, foundations, and many other players, all with their own interests and offerings. Still, through it all, the healthcare organization must retain that sense of alignment with the mission.

On the other hand, we can’t afford to err in the other direction–that is, by having so constrained a notion of what’s in tune with the mission that we don’t allow room for new types of ventures. Healthcare is rapidly changing, most notably in the way it’s moving beyond the walls of the hospital. Some of the most important new partnerships are those that will help take the hospital into these new territories. And that requires the ability to envision how these novel ventures can yet connect to and align with the mission, even if it at first glance they seem somewhat removed from our routine.

All these demands add up to the need for a strong sense of clarity about the mission, without ever putting on blinders. When, and only when, an organization has achieved an internal clarity about the mission, and what does or doesn’t align with it, is the organization ready to start taking on bold new projects and relationships that will define its ability to thrive in a new world of healthcare.

Which Countries Should You Be In?

DifCountries_ShutterstockIn my last post I mentioned that healthcare organizations looking to expand globally through collaborations often seize on China as their main or even sole focus. I also suggested that while China certainly presents some extraordinary opportunities, it is often not the single best choice for an organization that may be relatively new to the global healthcare scene.

OK, so what country is ideal for an initial exploration of a healthcare collaboration? The best answer, of course, is that there’s no simple answer to that question. But we can consider some of the factors that could lead to an optimal choice for any given organization. First off, there’s the obviously important issue of how large and fast-growing the healthcare market is in a country. In the U.S., annual healthcare spending growth has slowed to 6.5 percent, according to PwC. In China annual spending growth has been and will likely continue to be in the vicinity of an average of 15 percent, according to McKinsey–and China’s population is four times that of the U.S.’s. No wonder everyone is eyeing China!

But there are many other fairly large, fast-growing markets, even if they don’t measure up to China in size. And more important, there are many other factors to consider besides potential market size and growth. Here are some of the other questions that should be carefully weighed before narrowing down a search for healthcare partners to a particular country:

Is there a sustainable commitment to financing continued healthcare growth? Double-digit growth rates in healthcare spending eventually lead to a big burden on even a robust economy, as we in the U.S. know all too well. Those rates will slow unless the government and population are highly motivated to keep pushing the healthcare system forward for the long haul.

What’s the competitive environment? There may be a big demand for more and better healthcare, but if the field is swamped with healthcare industry players capable of providing it, there may not be many opportunities for other players. In particular, if the government closely runs most healthcare, outside players may have little chance of getting a foothold or finding investors.

Is the environment stable? Some countries are more likely than others to face wrenching economic, political or social upheavals. That sort of drastic change can bring growth opportunities to a screeching halt.

What are the cultural differences? I’ve found that U.S. organizations frequently grossly underestimate how challenging it can be to navigate the myriad demands large and small that culture and tradition can make on doing business. That challenge is much more pronounced in some countries than in others.

Can the infrastructure support growth? You may be able to structure a collaboration in another country, only to discover that executing on it is extremely difficult due to shortages of key personnel, training institutions, supplies, financial transaction systems, travel access, and many other resources taken for granted in the U.S.

Is there a workable regulatory and legal framework? Even the most promising schemes can be worn down by excessive or unfriendly regulation, a lack of enforced legal protection, or outright corruption.

As daunting as this list may seem, it’s only a partial one. I’ve seen collaborative healthcare efforts fizzle out under the weight of any number of problems that really could have been avoided, or at least anticipated, by understanding more about the country in which the venture was to be based. Finding a country that matches up with a would-be healthcare collaborator’s needs, capabilities and limitations is a critical first step that trips up too many global healthcare ventures. Not that everything is easy if you’re dealing with a country that matches up fairly well. But at least you’ll have a much better shot at making it work.

How Not To Enter Into a Global Healthcare Collaboration

There’s a certain conversation I’ve had repeatedly with a wide range of healthcare colleagues and counterparts over the years. It starts off with the other person telling me that he or she has been approached by a healthcare leader or investor in a developing country, has struck up a good relationship with this person, and the relationship is developing into what sounds like an institutional collaboration.

I respond with a simple question, one that you might think anyone would want to pose at this point: What sort of collaboration?

The answer almost always boils down to: I don’t know.

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That’s right. I have many, many times been told by highly competent and respected healthcare leaders that they are bringing their venerable institutions into a new country under terms that are apparently completely mysterious to them. In some cases, they’ve even signed agreements, but can’t tell me exactly what they’ve agreed to. What concerns me is the growing frequency with which I’m hearing this.

Sensing my skepticism–or dismay, if the person telling me this is someone in my own institution–the would-be collaborationist defends his or her position by detailing how influential and successful and well-connected the partner is, and how eager the partner’s institution is to move forward into a mutually beneficial partnership. The message I take from this is: I don’t actually know what I’m getting my institution into, but whatever it is, I’m sure it will work out, because my partner seems impressive and wants to plunge ahead.

Let me state the obvious, or what should be obvious. Establishing a business contact, no matter how impressive or eager the contact seems, is not an automatic entryway to a successful collaboration. That’s especially true if the contact was made randomly–someone you bumped into at a conference, contacted you via email or met through a colleague–or if the contact sought you out rather than the other way around.

This is what I call the “I know a guy” model of collaboration. It’s often the riskiest way to build institutional global healthcare collaborations. (And most other types of collaborations, I’m guessing, but I’ll stick to my knitting here.) That’s not to say such collaborations can’t succeed. It’s just that they have much less chance of succeeding than collaborations built the right way.

The “right way” is based on intentionality and due diligence. By intentionality, I mean you’ve taken the trouble to determine, as best you can, your strategic objectives, exactly what sort of collaboration is most likely to benefit your institution, and what sort of partner makes the best choice for entering into that type of collaboration with you. By due diligence, I mean you’ve researched a pool of potential markets and partners, and assessed the relative risks and rewards of a collaboration with each one.

That’s when it’s time to find a business contact–after you know whom you want to collaborate with and what you want the collaboration to be. Starting with a contact that falls out of the sky and hoping it will lead to a great collaboration is, well, to put it mildly, not a great idea. Trust me, even when you do it the right way, global healthcare collaborations are tricky to pull off. If you’re relying on the “I know a guy” model, you’re really skating on thin ice.

It is interesting to me that healthcare leaders who would never take this sort of approach in exploring partnerships in their own territory seem eager to make a leap of faith when moving into the global arena. I think I understand why. They often don’t know enough even to understand how little they know, and don’t have the experience or frame of reference about how to get up to speed. When a contact comes along who seems to have some notion of what a good collaboration is, and offers to forge it with you, it probably sounds like trusting him or her to set it up is a wonderful shortcut out of the dark, dense forest of global possibilities. Well, it might be–but it almost certainly isn’t.

Adding to this willingness to plow ahead into dubious waters is the fact that healthcare leaders today often feel highly motivated to get involved in emerging healthcare markets, such as China. Some almost seem afraid to not be in China. But if they did their homework, enabling themselves to be a bit more strategic instead of purely opportunistic, one of the first things they’d probably discover is that it will usually lead them to a country much more similar to their own. Nothing against reaching for more bold collaborations–I’ve been involved in several good collaborations in many developing countries, and know of many others who have as well. But having a clear strategy and well-developed decision criteria will make you a much better collaborator and a much better chance for success.

That’s really the stuff of another post, though. For now, I’ll just point out that whatever corner of the global healthcare market you want to enter, you don’t want to do it simply by knowing a guy.

What does China’s Economic Swing Mean to Healthcare?

China Stock Market

There’s been quite a lot of hysteria over China’s apparent economic troubles. It started with a China stock-market swoon in August, followed by signs that the country’s manufacturing sectors are contracting. “The Great Fall of China,” headlined The Economist. “China’s economy is at a tipping point,” warned Reuters.

These events, to hear many tell it, are leading the global economy, and especially the economies of middle-income developing countries, into a possible meltdown. As The International Business Times put it: “China’s economic problem is worse than we expected and it is crushing other markets.”

Scary stuff! And it has people who are directly involved in emerging markets particularly spooked. As someone who to a large extent focuses on healthcare growth in these developing markets, I’ve been fielding nervous questions by others who are or who hope to be active in these healthcare markets–markets that many have seen as being the likely source of most of the future growth in healthcare globally. Won’t these sudden economic collapses torpedo many of the planned healthcare-improvement projects, especially in China, but also in the rest of Asia and throughout South America, among other regions?

People tend to be surprised by my answer, which is: “No, I don’t feel that healthcare is likely to be heavily affected by an economic slowdown”.

First of all, let’s take a step back from all the teeth-gnashing and remind ourselves that it’s really too soon to say whether we’re really seeing the start of a serious, protracted period of economic turmoil in China or anywhere else. Calmer voices are already being heard over the sky-is-falling wailing that dominated at first. The International Monetary Fund suggested China was “moving to a ‘new normal,’ characterized by slower yet safer and more sustainable growth.” Fortune pointed out that the drop in the Chinese stock market isn’t necessarily predictive of economic problems there. And the ever-sober Economist hedged its gloomy headline with the caution that “fear about China’s economy can be overdone.” China’s GDP may still be growing at as much as seven percent a year, which would look a bit anemic relative to previous years but isn’t in itself a bad rate of growth.

Even if the feared problems materialize and China suffers a big slowdown, and the difficulties spread to other middle-income countries, I still think healthcare will continue to grow in those countries at a brisk pace. That’s because healthcare isn’t like other markets. It is in many ways more like a social service, with the demand for it remaining strong regardless of what other markets or the economy are doing. Governments aren’t likely to heavily cut back on it, or to allow the private sector to do so in countries such as the U.S. where healthcare is largely privately provided and paid for, because there’d be swift and furious political ramifications if they tried. Consumers will put off all sorts of purchases in hard times, but with the exception of the most elective of procedures, they generally won’t put up with skimping on healthcare.

(I hope no one will mistake any of this as my gloating over protected profits in U.S. healthcare. Healthcare may not be at risk of shrinking, but here in the U.S. at least, all healthcare organizations are under tremendous pressure from all sides to cut costs, and competition has never been more intense. Profit is anything but assured.)

In China and other middle-income countries, the demand for healthcare hasn’t merely been holding its own, it has been growing fiercely. Populations in these countries have gained access to information that has made them aware of what sort of healthcare advanced countries have that they lack, and political trends have left them feeling more empowered to demand that governments meet their basic needs, including healthcare. Add to that a growing disease burden from aging populations (especially in Asia) and increasing rates of chronic diseases such as cardio-vascular disease, cancer, diabetes and Alzheimer’s.

True, real-estate might suddenly seem overbuilt in China, leading to a predictable cooling in prices. And demand for what China’s factories produce may (or may not) shrink, and that shrinkage might lower the demand for commodities from other countries, adding up to an economic slowdown that ripples out from China through the developing world. But none of that is likely to have a strong impact on what happens to China’s or anyone else’s plans for hospitals and clinics.

Let’s hope for everyone’s sake, and for many reasons, that we’re not facing a serious global economic slowdown. But it would take more than that to derail the rapid progress of healthcare in the developing world.

Care vs. Bricks

I was looking over three articles recently that look at very different aspects of a single theme, the most important theme in all of healthcare: improving patient care. That theme encompasses a lot, obviously. But I felt these three articles did a nice job of calling out specific aspects of how medicine has at least until now been missing the boat when it comes to doing more for patients’ health.

Room_ShutterstockOne of the articles looks at a major study published earlier this year of whether patients in newer, “patient-centered” facilities feel they are getting better care and have a better overall experience. The healthcare community certainly seems to think that’s the case, since, as the article notes, there has been

….a growing trend toward patient-centered design, which includes incorporating features such as well-lit private suites, sound-reduction paneling, appealing art, healing gardens, water features and sleeping accommodations for family members. In fact, an estimated $200 billion is being spent on hospital construction and renovation in the United States, and developers anticipate further expenditures. Some hospital leaders have long believed that improving facilities with patient-centered design will automatically improve overall satisfaction.

To test that belief, the researchers conducted a careful, extensive study, taking great pains over many months and with thousands of patients to precisely pinpoint the specific impact of improved facilities on patients’ perceived experience. That impact, the researchers found, was not very large. As the researchers put it, “[though we] did see significant improvement in facility-related satisfaction scores, we did not see significant change in satisfaction related to care―or overall satisfaction, for that matter.” So, yes, patients thought nicer facilities, were, well, nicer. But it didn’t much affect their overall experience.

(I think it’s also worth noting that the researchers are affiliated with Johns Hopkins Medicine–my employer for the past few decades until I came to the Brigham last year–which only a few years back opened its massively redesigned and expanded flagship hospital featuring the very sort of patient-centered design that this study suggests does not strongly improve patients’ overall experience. Kudos to Hopkins and the researchers for publishing research that may run counter to their own interests.)

This isn’t about thumbing our noses at efforts to give patients nicer facilities. Hey, look, I’ve been a patient, and I’d just as soon have nicer facilities as the next person. I hope more and more hospitals do remake themselves into patient-centered places. But this study is about better understanding what really matters most in improving patient experiences, so that our focus and resources are properly placed. To quote the article about the study again:

‘Hospital leaders will have to stop blaming poor patient satisfaction scores on aging buildings and units,’ [says Dr. Zishan Siddiqui, one of the study authors.] As an alternative, Siddiqui and his colleagues propose that priority projects should also include a focus on training providers on personalized care, educating patients and involving families in care decisions.

The researchers also note that redesigning facilities would likely have a more positive effect on patients’ experiences if the redesigns went beyond pampering patients to improving clinician work flow, efficiency and productivity, among other elements of care. And finally, the study notes that improving patient satisfaction isn’t necessarily the same as improving patient health, and calls for examining that relationship more closely so as to do both. Here, here.

The second article I was looking at emphasizes a point I’ve tried to make here many times: That much and probably most of what has to happen in healthcare in the coming years to improve it won’t be happening in the hospital at all. Rather, it has to happen in the home, the workplace, and wherever the patient is. As this article by a respected internist and medical educator Dr. Fred Pelzman puts it,

….We need to figure out how to target patients before they come to the hospital. Not in the emergency room, not on the inpatient floors, not on the day or two before discharge, but as they start to slide down that slippery slope from their state of best health towards that precipice that tips them over into needing an admission. We will…need to extend care into the community, using family, friends, pharmacists, visiting nurses, community health workers, and anyone else we can rally to the patient’s side. Digital health data about our patients, such as information from wireless scales, personal monitors, health trackers, monitored pill boxes, as well as other data from those helping care for them at home, may further alert us to problems with compliance, decreased effort and exercise tolerance, weight gain, and changes in mood and behaviors that may trigger an impending decompensation, potentially leading to the need for admission.

Effecting these sorts of radical changes in how healthcare is delivered isn’t just a matter of having clinicians transferring their existing medical skills to new environments outside the hospital, any more than placing patients in prettier hospitals will fix healthcare. Rather, as Dr. Adrienne Boissy, the chief experience officer at Cleveland Clinic, explains in the third article, clinicians will have to get good at ways of helping patients that go well outside the bounds of conventional medical knowledge. As Boissy notes:

Every clinician I have come across has the intention of doing the right thing for their patient. The tricky part is, sometimes, our definition of what the right thing is for a given patient is not their own. The ability to let go of the medical agenda, recognize patients need more than our medical knowledge, and partner with our patients in a care plan that encompasses both the medical and human agendas is critical and is the very core of relationship-centered care.

What I believe most people need and would appreciate is healthcare that follows them around and provides the interventions and support that extend length and quality of life, and that focuses on keeping them from needing to be in the hospital. It’s great to see more and more influential voices in medicine driving those points home in different ways.