Healthcare is an enormous part of our economy and arguably the part of our lives that is the most fundamentally important to determining our quality of life and happiness. But there is so much that is inefficient and can be improved. I wanted to briefly describe a few of the major problems, trends, and opportunity areas that excite me about the field.
Doctor payment models Problem: Most doctors get paid on a fee for service model rather than an outcome model. This incentivizes more treatment and tests and does not punish readmissions/disease relapses. Measuring quality and outcomes in medicine is actually a very ill-defined and difficult challenge in and of itself. A medical problem could come from four areas (doctor's advice, patient genetics, patient choices, and external events), with the doctor only involved in one of them. Nonetheless, there must be something better we can do than the current state of affairs. Somehow, it would be nice to align doctor incentives with patient health and allow more fluid access to care when people need it. Some of the current quality-tied compensation schemes are a step in that direction, but they are too narrowly defined and promote gaming the system. Projects like "medical homes" as well as some HMOs are making good progress in this direction. It would be nice if primary care doctors earned more so we had more of them (we are in desperate shortage now, which will only exacerbate with health care reform). They should also have more authority and pay when they keep their patients healthy as well as earn money for extra counseling around lifestyle issues (currently they don't earn for that). Insurance company incentives Insurance companies should incentivize health, not just pay for cures. While it is difficult, prevention is preferable to treatment. Not just HMOs, but all insurance companies should be paying our gym memberships and giving us rewards for using them (check in at the gym), subsidizing our expensive Whole Foods organic food purchases and multivitamins, giving us money for not smoking or drinking, etc. I learned that the reason a lot of this doesn't happen is that people switch individual insurance carriers frequently, and the benefits of positive lifestyle choices are only reaped over the long-term (by which point the insurance company might have been changed out). Insurance companies that see patient claims as "losses" as opposed to normal operating costs seem backwards. I want companies that will incentivize health and be customer-service organizations, chosen by people for their helpfulness rather than simply as a lesser among evils. Electronic medical records There are many EMR systems out there already, and the government provides incentives to install them and "meaningfully use" them. However, from doctors I've spoken to, I've learned that most are still clunky and limited, aren't designed with the doctor and patient in mind (i.e., not human-centered), and most painfully of all, aren't interoperable. The vision of electronic records is that they would enable people to carry their data across providers and improve communication across organizations, but that hasn't yet been solved. Many people complain of doctors who don't communicate effectively, and part of it is behavior change and training, but another part is the tools available. I'm wondering whether countries that offer "universal healthcare" are different in regards to the problems mentioned above. I know they are much worse in terms of doctor waiting times (which are expected to increase substantially in the US after health care reform) and have worse access to the top-of-the-line medical tech. But are their doctors more collaborative? What other problems do they have? Real-time home monitoring technology This is very closely related to what Paul Graham wrote about as "ongoing diagnosis." We only seek care when we have symptoms, as opposed to knowing much earlier if something is sub-optimal in our body and correcting it then and there. This is very aggressive and difficult from the technology standpoint, but that's why it also makes it really exciting for me. I've always dreamed of a machine that can scan my body quickly at home and tell me if I have broken bones or infections. Taking this one step further, it would "push" this info to me whenever my body state changes adversely instead of me having to repeatedly poll for it. This seems really cool and also really hard.
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I recently spent a week volunteering as a camp counselor. I've never done anything like that, and I was really nervous about the experience beforehand. This camp was for kids with chronic or severe illnesses. I had never really worked with kids outside of Reading to Kids, and in particular I had never done a lot hands-on in the medical world. I ended up learning a ton -- about medicine, kids, philosophy, and myself. It was a lot of fun, and I'm sad it went by so quickly. Below are my top 10 lessons learned from the experience. 1. All kids share something unique and human in common. I was initially afraid of the kids, worrying about what they'd be like and how I could possibly "lead" them. It turned out that all the kids were silly, playful, and interested in the same things: sports, art, creativity, imagination, cars, video games, and super heroes. We had a group of boys aged 7 to 11, and there was something core that they all shared as boys and connected through. They bonded as boys and as friends, not as kids who were sick. They were happy, optimistic and interested in having fun. That was so awesome to see and facilitate. 2. Treat people as people, not as illnesses or ideas. The entire experience was about having fun at camp, doing everything you've wanted to do, and having all your medical/physical needs met behind the scenes. While the medical stuff could've been front and center, it rarely emerged or was discussed. Everyone was having too much fun. I recently saw the movie The Intouchables. Not only was this movie awesome because it was in French, but it was a deeply moving story (I'm not ashamed to admit that I cried at the end for a while and am still thinking about the movie). It was about an amazingly authentic and honest man who took care of a handicapped man and treated him like a person, not as a handicapped person. It's so easy and natural for us to label and categorize and generalize. It's much harder but much more effective to deal with the facts of each person's situation and approach each individual as a human with desires and a separate experience, one that might be very similar to your own in many ways. 3. Spending time among men doing manly things is great. I got to spend a week bonding with guys and spending time as men together. it's not something I'm lucky enough to do on a regular basis, and it's something that I've learned is important in a man's development and growth. It was fun to beat our chests, play competitive games, and jointly write our cabin's "Man Laws" which we enforced with vigor and pride. Because the camp was pretty much technology-free for a week, I learned that I can survive perfectly well on 30 minutes of email once per day. That was pretty liberating. 4. Finding your inner kid isn't so hard; you just have to be open to it. When the camp started, I realized how out of place and inside my head I felt. We were doing cheers and games, and I kept worrying about how silly I looked. I wondered how I could let myself be more free, how I could let myself yell and sing. I found that just by practicing some of the camp cheers and being around others who were already more "loose" and open, I could open up too. Doing art and sports helped as well. I'm naturally so much in my head that I found I had trouble relaxing at times, and I kept thinking that my own personality wasn't as funny or silly as some of the other more funny counselors and guys in our group. It took practice and intention, but I found that I could accept myself and feel silly like a kid too if I let my guard and shell down for a bit. It was interesting going through the experience of being a kid while also being an adult. 5. Counselors at camps can have a lot of fun, for the kids and for themselves. We played awesome games, did improv activities, sang lots of funny cheers that I still repeat to myself at home for fun, and ate lots of s'mores. It was awesome. Even during training, with no kids around, we were doing cheers and games. I learned a big lesson about camp culture: everyone at camp is positive, happy, open, and (literally) cheerful all the time, and that's a cool way to be. Maybe this "fun" wears off after a while, but I hope not. I know this "fun" can also get tiring for the staff and takes a lot of work, so I feel very appreciative of and impressed by all the staff who works at camps all summer. I can see the dedication and endurance that requires, and I applaud it. I was so impressed by how down to earth, respectful, energetic, positive, and smart all my fellow counselors were. 6. Kids are great at taking care of themselves, and sickness can force them to grow up quickly. I was really impressed how most of the kids knew about their conditions and knew how to deal with their own treatments very well (keeping the adult nurses on their toes). I can see how experiences cause them to think about "adult" topics like health and medications earlier than one would have to if one didn't have a condition, and I acknowledge what's in them that allows them to grow up quickly in this regard. 7. in dealing with kids, tone of voice and parenting tricks help a ton. In dealing with the campers in my room, I quickly learned that adult tone of voice and reason/rationality don't work that well. I needed to learn a special tone of voice, and I found myself emulating some of the more experienced counselors' words and tone, and that worked much better. It felt to me like the tone sounded more female, higher pitched, which makes me wonder how a modern "man"/father can raise kids without mimicking a mother. I realized that camp is a good place to learn parenting. 8. Games and daily rituals help teach lessons. There were lots of little games and rituals that occurred that gave kids a good structure for the day and also taught them valuable lessons. I thought it was cool how they were learning in such a casual way. For example, there was a song when a meal ended, and it meant everyone would dance and clean up their own dishes. There was a game to see who would get to wash their hands first (and a song for hand washing). There was a ritual of making a wish before a meal. There was a song for drinking water and hydrating. There was a Book of Firsts that announced the proud moments of "firsts" of the various campers' accomplishments for the day. There was also the concept of "warm fuzzies," which were written or oral acknowledgements of each other, good vibes people would send to each other with special hand gestures or little notes placed in individually-designed bags. That was such a cool ritual. If people acknowledged each other in the real world and sent each other warm fuzzies like we did at camp, the world would be a better place. 9. Daily quiet rest hour in the afternoon and cabin chat at the end of day were a great way to collect one's thoughts and lessons learned from the day. A time to rest in the middle of the day and a time to process the day's highs and lows provided some great opportunities for reflection, introspection, bonding, and learning about each other and ourselves. This ritual has direct applications for business and adult relationships. 10. Camp life -- 24/7/365. The lessons and ideas from "camp" can be applied to real life, every day. Cheers can be great even (maybe especially) for adults to relax, cheer up, and drop our pretenses. Camp makes you ask yourself, "How can I practice giving love fully?" Camp is good practice for this, and so is real life. Can you keep an attitude of being in camp all the time in the real world, acknowledging others around you authentically and being positive? I think you can; it just takes some trying and being silly. As part of a class I took on biotech, we were assigned to read Science Business by Gary Pisano. I learned a lot from the class and this book, and it really answered a question I've had for a long time: Why does science/medicine move so much more slowly than technology in general? I learned that the biotech industry as a whole has been barely profitable since its inception, and that there is a severe productivity crisis (productivity as defined by cost per successful drug has been dropping over time, which is very different from something like computer processors which have been dropping in price over time). There is a big "valley of death" between discovery of a compound or process and commercialization. It takes 10 years and $1 billion to get a drug to market, and 1 in 5,000 drugs makes it. WHOA. People are always optimistic about biotech revolutionizing health, and it hasn't lived up to this potential yet. The book explains many reasons for this and suggests some different approaches and solutions, none of which seems easy or straightforward. My full notes are below. I'm curious to see how the industry evolves in the future, as many lives could be saved and improved if things change drastically. I. Preface: The rise of a new industry and a big question a. Big hopes but disappointing financial returns over time b. Biotech firms not more productive in R&D than big pharma c. Fundamental business problems created by science d. Functional requirements of sector; performance comes from how well it’s managing these (poorly) i. Risk management ii. Integration iii. Learning e. Monetizing IP leads to bad info flow, fragmentation, proliferation of new firms f. Biotech can’t just adopt same methods as high-tech g. Can sci be a biz? h. Some businesses doing basic sci; some universities treating sci like biz (selling IP, starting co’s) i. 30 year history of biotech sector data analyzed II. Ch. 1: the science-based business: a novel experiment a. Biotech is convergence of 2 separate realms b. Science biz one that tries to advance sci, not just use it c. Sci biz needs unique mgmt d. Sector profits near zero historically e. Different norms, values, metrics between sci and biz f. 3 main factors i. Profound and persistent uncertainty => needs risk rewarding and mgmt 1. Long time horizons for risk to be resolved 2. Appropriability: ability of biz to capture value from an asset 3. Openness vs. secrecy ii. Complex and heterogenous nature of scientific knowledge => needs integration 1. Cross disciplinary iii. Rapid progress => cumulative learning Part 1: The Science of the business I. Ch. 2: mapping the scientific landscape a. Locks and keys b. Random screening c. rDNA d. mAb e. combinatorial chem f. SNPs g. Proteomics h. RNA interference i. RDD j. HTS k. Growing size, complexity, heterogeneity II. Ch. 3: the complex anatomy of drug R&D a. Can save or kill you b. So much still unknown c. So many places where drug can work wrong d. Target identification and validation: find enzyme e. Lead identification and optimization: find molecule to inhibit it f. Preclinical development: check safety and effectiveness before humans g. Human clinical trials phases 1-3 h. Reg approval III. Ch. 4: drug R&D and the organizational challenges a. Not like processor design; very little knowledge about entire system and overall spec b. Process very complex and can’t be broken into pieces: uncertainty and integrality c. Most R&D on losers d. Active ingredient and formulation both matter e. New scientific advances increase uncertainty; show more what we don’t know f. More choice means more uncertainty g. More advances mean harder integreation Part 2: The business of the science I. Ch. 5: the anatomy of a science-based business a. Many separate technologies b. Cyclical entry c. Genentech started industry i. Close links to universities ii. Biz model innovation: contract w/ big pharma for funding development of drug and royalties in exchange for manufacturing and marketing rights 1. First time pharma did R&D through external for-profit co iii. Pursuit of broad range of opportunities/diseases d. Second generation used more chemistry and focused on research, allowing pharma to commercialize e. Third gen: human genomics, industrialized R&D, platform strategy f. Market for know-how i. More collab w/ biotechs than w/ univ II. Ch. 6: the performance of the biotech industry: promise vs. reality a. Long lag times b. Zero industry profits c. Huge skews for Amgen and Genentech d. R&D productivity, revenue-adjusted III. Ch. 7: monetizing IP a. Txr of IP from univ -> private new firms b. Capital markets (VC) and public equity c. Market for know-how (small firms trade IP for funding from big firms) d. Go public much earlier for funding i. Only 20% of public co’s today have ANY product on market, so basically R&D entities ) (GAAP not as useful) e. Univ research -> startup w/ VC -> IPO for more funding -> license to big co to bring to patient f. 3 requirements for risk mgmt. i. Many options for diversification ii. Adequate info iii. Abilty to reap reward g. Market for know-how -> integration i. But biotech less modular and codified than software ii. IP protection murky IV. Ch. 8: organizational strategies and business models a. Few examples of success, high uncertainty, luck plays big role b. Financing critical for industry and its main measure, but wrong measure because it’s input, not performance c. Alliances/IP monetization are important but not endgame d. Movie studio model for big pharma: produce ideas of independent writers V. Ch. 9: The path ahead a. Venture philanthropy b. Rethinking the publicly held biotech firm (doesn’t match 10 year investment cycle) |
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