Susannah Fox was the chief technology officer at the U.S. Department of Health and Human Services from May 2015 to January 2017. She knows healthcare in our country; she understands the buzz of its power networks.
Lisa Suennen is a sought-after expert on healthcare-related investing — even chairman of the board of a “NASA-funded institute working on health needs of the astronauts heading out on the missions to Mars and deep space.” Her wit needs no sharpening: Lisa is the Larry David of health-related journalism.
More from Jonathon S. Feit
These two power players recently put fingers to keys in service of a new model to understand how and why Big (American) Healthcare addresses—or doesn’t address— the myriad distresses and diseases that get ignored when it comes to long-term focus as measured by research commitment and investment dollars. Consider syndromes, like ALS (commonly known as Lou Gehrig’s Disease), that earn a burst of occasional attention but then, like all ingenues, suffer the spotlight’s wane. (Has the momentum for progress passed?)
Susannah drafted the model in a blog post called “Whose Needs are Not Met?” Lisa responded by “by adding salt:” “Zillions of dollars are pouring into scientific and commercial efforts to serve those markets and patients [such as Alzheimer’s and addiction], but no one has yet fully cracked the code.” (For what it’s worth: Lisa is scarcely as cynical as she plays on TV. She’s actually among the most optimistic people one can hope to know in modern healthcare, convicted of the belief that we can do better).
So much talk of spices made me think of culinary experts. Down the street and over a bridge from Lisa and me, I found the ideal summary of a gap in Susannah’s model — a missing dimension that, if appended, can help explain the plight of the underserved American patient. According to Thomas Keller, world-renowned chef (and generally nice fellow, having met him at a Yountville Bastille Day party): “Salt and acid are flavor enhancers…pepper actually adds flavor, which means it’s changing flavors.” If Lisa adds salt — sharpness and clarity — I’ll dash in pepper, shifting the frame as we seek to understand why certain of America’s health needs go so underattended.
Why are “people[‘s]…needs are met and their questions are answered…If a remedy does not make sense to someone, even if it makes sense to a majority of people, then that person’s needs are not met. In this model, we must listen to the people in pain, the people who are suffering, the people with doubts”?
It hit me like an aftertaste that lingers: Susannah says “people in power” are those who “control access to valuable resources in the current health care system as clinicians, payers, policymakers, regulators, pharmaceutical and device company executives, investors, researchers, etc.”
To Lisa, “there are also many situations…where they do not help or don’t care to help because: 1) they do not believe it will be profitable for them; or, 2) they do not believe the conditions are “real problems” that warrant help and resources. Sadly, these characterizations explain the presence of too many of the items in that dreaded lower left quadrant….”
What if, along a third Z-axis, we ask “do people even realize there is a problem (not being addressed)?”
What if, in the situations where people aren’t helping, it’s because they believe the issues already are being solved, just outside their field of vision? If we assume that people get into healthcare with positive intentions, what if they simply are ignorant to the scale of the need, or that the particular need exists? What if people with power assume that the crisis over there is being solved so they don’t need to advance innovations? What if they just can’t believe that such massive, scary, potentially-lucrative-if-solved problems could persist unabated?
Dark corners lacking innovation are everywherein American healthcare.
Both Susannah and Lisa assume that the problem is disregard — for instance due to a sense that someone else is better suited to solve the issue or because the opportunity isn’t big enough to justify the investment. But few pots of entrepreneurial gold are as large and diverse as American healthcare, so not much is too small to warrant investment. A lack of financial interest may not be the culprit. Rather, perhaps, it is fractured attention that leads to a failure to realize that someone else is not actually addressing the issue? So much has been solved — yet so much remains.
Exemplar in point is the emergency medical services (EMS) industry — my “home industry” that comprises far more than ambulances and fire engines.
Leaders from state health information exchanges (HIEs), standard-setting bodies, and healthcare foundations routinely do not realize — (one cannot say they “fail” to realize because…how should they have known, amid different data standards, different oversight bodies, different payment models, different trade associations?) — that with few exceptions, American ambulance services invoice only by the mile.
Ambulance crews are therefore often unwisely advised to code for billing validation rather than clinical data interoperability. That is, to minimize rejections and ensure due compensation for their efforts and their supplies. Such steps are necessary but insufficient when it comes to measuring the impact of the care that was delivered — even though such measurement is the scaffolding that supports due compensation models. Until March 2021, ambulance-based healthcare services were categorized, by the government’s arbiters of healthcare spending (i.e., the Centers for Medicare and Medicaid Services), to be “suppliers” to the healthcare system, rather than providers of care
As such, emergency medical services use a different data set (several in fact) from those who are officially denoted as “healthcare providers.” They were not incentivized to adopt digital charting (e.g., Meaningful Use). Their data are usually unavailable to regional HIEs. And almost insultingly, they are ineligible for awards designed to spark healthcare innovation, including those pertaining to equity and social determinants of health.
Few venture capital firms go near the ambulance business. The few private equity firms that have done so, have subsequently pursued tremendously damaging consolidation campaigns in response to the aforementioned economic drivers (PE excels at squeezing inefficiencies out of industries where growth requires repetition — flanked by the twin terrors of commoditization and automation).
Here’s the thing: across Silicon Valley, and even the marbled halls of political power, there is an assumption that emergency medical services operate universally. However, they are operated in the backyard of whoever is doing the wondering. Which is to say that:
— In California, the question is often, “Aren’t all emergency medical services part of fire departments?” (No.)
— In Pittsburgh, it’s “aren’t all EMS agencies part of huge hospitals, or else tiny rural agencies dependent on grants and crab feeds for funding?” (No.)
— In Massachusetts, it’s “aren’t there only a few really large ambulance services, and if you’re not working with them, you’re shut out?” (No.)
The tentacles, derivatives, and value props of Mobile Medicine fall into the category that investors Marc Andreesen and Ben Horowitz call “rare knowledge.” Ambulances and fire vehicles are everywhere, after all. A gaping disconnect between perception and reality in the practice of social net-centric healthcare — recognized by no less an authority than SCOTUS Chief Justice John Roberts — seems like it will leave some unfilled potholes (and plenty of risk) in its wake.
Consider this: Which single group of caregivers attend to the patients with ALS (like my late beloved colleague Bruce Graham) whose cruelly ability to express is so cruelly stolen; memory care patients wandering down the street; and chronic pain sufferers who fall, or who self-medicate themselves into an accidental overdose?
Such patients, their conditions, and their caregivers are the hidden heroes that entrepreneur-advocate Alexandra Drane calls the “Unmentionables.” Their hiddenness is ironic because lights and sirens are difficult to miss. But the attention paid to such calls obfuscates the size of the non-emergency medical transport (NEMT) market. Uber, Lyft, and others did not break in because it is small; to the contrary, one medical transportation broker alone (LogistiCare) on its website claims to have “manage[d] more than 63 million rides annually in 50 states and the District of Columbia.”
By comparison, the National Association of State EMS Official published in 2020 that (according to 2019 data), “Local EMS agencies respond to nearly 28.5 million 911 dispatches every year in 41 states.” This means about half of ambulance transports were scheduled, not 911. Such a figure shows that “unmentionables” are indeed receiving care — somehow, and expensively — but they are doing so in the shadows, from professionals who travel to the patient’s side and whose insights are stuck in “separate but unequal” datasets.
How we reached this point is the stuff of history, but a third axis — “ignorance versus awareness of the presence of a solution” so that we can highlight the persistence of the problems per se — will help by incorporating Mobile Medicine care as the care point of necessity for the many patients who were not forgotten after all.