Health 3.0 Pyramid

A Tangled Jumble of Silos is No Way to Organize Healthcare

“Healthy citizens are the greatest asset any country can have.” ― Winston S. Churchill

Last year, Jonathan Bush and I published a two-part series for Health 3.0. We opened with a broad vision in Unbreaking Healthcare: A Vision for Health 3.0 and then expanded on that by looking at the implications for the industry — Health 3.0 Vision: Implications for Providers, Government and Startups. As health benefits get a major overhaul in the employer arena and policymakers determine where publicly-paid healthcare programs will go, we believe it’s imperative to take a fresh look at how we’ve organized our “system” — one of the areas of near-universal agreement across the spectrum is that we should expect far more from our healthcare system. Simply shifting who pays for what does little to address the underlying dysfunction.

Let me repeat that last statement: Simply shifting who pays for what does little to address the underlying dysfunction. We come at this from a fiercely transpartisan standpoint. We also come at this from an open source, collaborative perspective at that is the founding ethos of the non-profit Health Rosetta Institute. We’re empiricists who have been been on a 7-year quest to find what is working in healthcare. Perhaps we go a bit far in the headline on the Health Rosetta Institute homepage but it sums up our belief:

“Healthcare is already fixed. Join us to scale the fixes.”

Naturally, there is much more to do and improve upon. We’d be gravely disappointed if we didn’t radically improve over what we’ve found so far. Nonetheless, more than anything else, this is a call to clinicians to have their voice heard. We were thrilled when Dr. Marion Mass penned this editorial drawing from the Health Rosetta Principles — A doctor’s perspective: Who stands for patients in the health-care debate? — as a voice of a group of doctors.

Naturally, any large group whether they are doctors or any other professionals has a diversity of views. However the successes I highlighted in my TEDx talk (Healthcare stole the American Dream. Here is how we take it back — embedded above) are coming from people across the political spectrum. Progressives are the ones implementing healthcare ideas that people call conservative. Conservatives are implementing ideas that would be called progressive. Each of us has had an awakening that we don’t need a left solution or a right solution. We need an American solution and this good news is spreading like wildfire. We invite everyone, especially physicians, to rip this off, riff of this, tell us where there are gaps or where we’re outright off-base. We hope we are more right than wrong. You be the judge.

The graphic embedded below is the start of developing a “North Star” for how various elements of health and healthcare interrelate with each other. It’s going to require some verbal explanation of where we’re going with this. The “we” is Dr. Venu Julapalli, Dr. Zubin Damania (aka ZDoggMD), Jonathan Bush, and Dr. Vinay Julapalli. The problem we’re trying to address is how healthcare is “organized” in a tangled jumble of silos largely organized around medical technologies (not individuals — aka “patients”). It’s exacerbated by a set of economic models and technology that further impair healing. We believe that fostering an ecosystem that is antifragile should be one of the key design points. Flawed thinking looks at healthcare simply as an expense (or, in the case of the healthcare industry, revenue to be maximized). As Churchill states, health when it’s looked at as an asset causes one to optimize for something completely different. I briefly introduce this in Economic Development 3.0: Playing the Health Card.

For those unfamiliar with Nassim Taleb’s book, Antifragile, he introduces the book as follows: “Some things benefit from shocks; they thrive and grow when exposed to volatility, randomness, disorder, and stressors and love adventure, risk, and uncertainty. Yet, in spite of the ubiquity of the phenomenon, there is no word for the exact opposite of fragile. Let us call it antifragile. Antifragility is beyond resilience or robustness. The resilient resists shocks and stays the same; the antifragile gets better.”

Though it will require verbal explanation, I’ll give a thumbnail sketch of how the graphic is meant to work. Each layer of the pyramid represents a level of (self)care. Clearly, you want to spend as much of your life at the bottom of the pyramid as possible (i.e., the self-care level). When you move up layers, you want to move back down asap (note: self-care is necessary at all levels — see the holarchy comments below for how we incorporate that). For each layer, there are 4 facets (if you look at a pyramid from above, it has four sides).

1. Optimal way to deliver health services
2. Optimal way to pay for care
3. Enabling technology in support of #1 & #2
4. Enabling government role in support of #1 & #2

What we propose is open to any/all input but I’ll describe how it works right so you have full context when you provide your input. You should read the pyramid from the bottom and at each layer look at the 4 facets to ensure they are meeting the goals. Thus, you would see that the self-care layer is at the bottom. When you access the healthcare system next generation primary care is where you should start. In places like Denmark, 94% of what people come to the medical system for can be addressed in a proper primary care setting. “Next generation primary care” is an evolution beyond the Health Rosetta component, value-based primary care. I think of it as full primary care that includes things like behavioral health, interior work, health coaches and physical therapy not to mention some technology such as secure messaging, remote monitoring, and other advances as they prove themselves.

For the things that can’t be addressed in primary care and a physical exam, you’d move up to the diagnostic layer (e.g., lab tests) for deeper insight to rule in/out various things. If you need a script, you’d go to the next layer — pharmacy woven into primary care. Organizations such as ChenMed do this well. If a script isn’t the answer, you’d go up to the next layer to a “professional consultation”. The idea is that this is a consult between the PCP and a specialist that is unconflicted. That is, the specialist isn’t the one who’d profit from whatever intervention specialists might do.

If an intervention was needed, you’d go to the next layer — intervention via focused factory. Jonathan gives the example of his own knee surgery and finding that even the highest volume knee guys in Boston only do less than one-third of what they’d be capable of doing. In order to fill their schedule, they have to do a bunch of other marketing they’d rather not do (e.g., be a “team doctor” for a sports team to market themselves). Most would rather do what they do best the majority of the time. If they did, they could drop their unit price. Finally, for the unfortunate few who have rare and undiagnosed conditions, they’d go to a Center of Excellence (CoE) like the NIH, Mayo, etc. at the top of the pyramid.

To reiterate, the goal even when at higher levels of the pyramid is to move back down the pyramid as soon as possible.

The hope is that if we can flesh this out further as a vision for Health 3.0, it is a common framework that everyone from benefits professionals to technologists to policymakers could use as a guide to their work. We would hope they ask themselves whether their benefits strategies, technologies and policies are helping or hurting the journey to Health 3.0. With Health 3.0 as the “North Star”, the Health Rosetta is the “roadmap” and “travel tips” on how to get there.

As I developed this framework further, I was interested in getting specialists’ feedback. Relatively speaking, I had spent more time with primary care at the base of the pyramid. The quadruple-aim-achieving next generation primary care organizations intuitively understand two key factors:

1. Fostering self-care and caregiving by non-professional loved ones is essential to optimizing healing and health
2. Without a seasoned “ship captain” (the primary care physician), when the medical seas get rough, patients will needlessly suffer from an uncoordinated healthcare system

Specialists, like any group of humans, have many opinions but I will share the feedback from Dr. Venu Julapalli when I shared the framework (he has also been writing about the tenets of Health 3.0). The following are Dr. Julapalli’s italicized comments on the pyramid framework:

I am loving what you guys have come up with:

1. It starts with self-care at the base. That’s key. That underscores personal responsibility in health, which has been woefully neglected in the run-up and roll-out of ACA. But at the same time, it’s got social determinants of health (SDoH) right at the base, where they belong. Which, if government is to have any primary role, it’s there. NOT at the higher levels of the pyramid where a fragilizing centralized government is inadequate to perform the economic calculations (this is the Austrian economist in me coming out) necessary to enable the most efficient system for us humans to employ means to effect our desired ends (that was a mouthful, sorry). I love market accelerator, market accelerator, market accelerator going up the government quadrant of the pyramid (personally, I’m ambivalent about government even being heavily involved at the base and feel private, engaged profits/nonprofits may be better at addressing SDoH [see Elon Musk] but have an open mind on this). Instantly this marries Right and Left, right at the foundation. Transpartisan.
2. It creates a harmonious holarchy among the levels. Holarchy is a term which reflects healthy hierarchies that transcend AND include levels (think concentric circles, rather than rungs on a ladder as in dominator hierarchies, which the Left conflates with healthy hierarchies and therefore seeks to flatten and destroy all hierarchies as evil). Imagine looking at the pyramid from the top — in 2D space, you will have concentric boxes, with self-care transcending and including them all. What I like about this is that it appropriately democratizes health (i.e., health is not owned by Mayo Clinic or Cleveland Clinic or some other such guilded [yes, I made up the word] nonsense, it is owned by you and us) — While at the same time I, as a practitioner with years of training, experience, and wisdom in me, am not unnecessarily dismissed by some Silicon Valley millennial who thinks that he can biohack and neurohack his way into an enlightened Uberman — until he slips on the curb and cracks his skull (figuratively speaking).
3. It properly puts next-gen primary care right near the base. I as a specialist don’t need to be near the base. And in my interactions with primary care, I do need to have as little conflict of interest as possible.
4. It properly puts the specialist focused factory near the top (key again is that that position doesn’t make them the most important, just the most focused). This is what Devi Shetty is executing in India and Cayman Islands — high-volume cardiovascular surgery by experts who love what they do, while dropping unit price ridiculously through economies of scale (one could argue that Shetty is actually not just modeling the focused factory part, in many ways he is modeling the whole pyramid by teaching patients and families on self-care at home, integrating with diabetes health coaches, etc.).
5. It appropriately puts CoEs at the very top — go there for help with rare diagnoses, but keep it circumscribed, i.e., Mass Gen has no House of God, Harvard-Soviet final authority on what constitutes great medicine. In a Talebian sense, that’s non-localist and delusional. We should also never forget the power of the e-patient, who destroys the most expert of doctors when love for life takes over (again, self-care at the base but needs the help of others). See this article as an example — His Doctors Were Stumped. Then He Took Over.

Processes in health care can be scaled. But the patient-clinician relationship can and should never be scaled. It’s not possible, without losing what’s at core of the relationship — trust and intimacy. It’s N=1. Uniqueness.

Overall, I’m loving this pyramid framework. Conceptually, it’s honoring much of what I’ve come to believe on health care, health, and healing. And what I like is that you’re being informed and distilling what empirics, not theorists, have shown you is working in health care, which puts you on the evolutionary, antifragile cutting edge.

What do you think? Where have we hit/missed the target?

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Dave Chase is the Managing Director of the Quad Aim Fund, Executive Producer of The Big Heist (the first fiercely non-partisan film to address healthcare), co-founder of the Health Rosetta Institute (a LEED-like organization for healthcare) and author of the forthcoming book, “CEO’s Guide to Restoring the American Dream — How to deliver world class healthcare to your employees at half the cost.” His recent TED talk was entitled “Healthcare stole the American Dream — here’s how we take it back.”

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