This was pretty much my takeaway after having worked in healthcare tech for ~2 years. The real purpose of the business was to make sure doctors got every $ they were "owed" in as efficient a way as possible, but basically every employee would claim that they were "fixing healthcare".
> Healthcare costs and waste are not a technology problem. They are a policy and incentives problem.
This statement is so broad that it cannot be true and here is an obivous counter example: A high percentage of doctor visits (think 4/5) does not involve physical checkups and could be done remotely - independent of policy and incentives.
Identifying these 4/5 (say) patients is a trillion dollar technology problem that is currently being approached from many different angles: symptom checker and triage, telemedicine and online doctor appointments, etc.
Notable teams working on it are ada and Babylon, among many others.
As an example of why remote visits are a policy problem, ask yourself why video visits weren’t common before the pandemic even though we’ve had the technology in various forms for literally decades (Skype was founded in 2003 as just one example). Turns out, it’s an incentive and policy problem! Video visits weren’t reimbursed the same way (I’ve personally had to haggle with my insurer when a video primary care visit wasn’t tagged with a COVID exception and cost me multiples of the usual $25 copay). See also this article:
“ prior rules and regulations pertaining to telehealth, such as those regarding HIPAA regulations and payer coverage standards, were relaxed to encourage telehealth use”
Also ask yourself why the Obama administration literally had to pay doctors to adopt computerized medicine records. Did the government have to pay Walmart to computerize it’s supply chain in the 1970s? No! It had the right incentives. Does square need to pay small merchants to adopt their cash registers and digitize their menus? Not really, they make the clear case that the digital menu drives more sales. Why do you think doctors needed the extra push? Because the market doesn’t pay them to be efficient record keepers, or penalize them for not doing so.
That’s just 2 examples, there are dozens more.
Virtually nothing in healthcare is a technology problem except for new treatment development. 4 years of working in the sector taught me this. There are places tech can help, (one example is maybe somewhat improved patient management in a managed care context, though that’s a super competitive market) but the big systemic problems are there for regulatory and incentive reasons. I hope I’m wrong, but pretty sure I’m not.
> Virtually nothing in healthcare is a technology problem except for new treatment development.
Again, that's a heavily over-simplified view. You are absolutely right that incentives and policy play huge roles (even more so in the US). I agree that my online doctor example was not the best choice.
However, my point stands that there is a fair share of difficult technology problems that will meaningfully contribute to healthcare:
1) Symptom checking: Identify the state of a patient prior to the point of care.
2) Triage: Prioritise treatment options in conjunction with 1)
3) Assisted decision making: Improve professional decision making, especially for rare diseases.
4) Patient follow-up: Manage the process after care has been received.
5) Symptom tracking / monitoring: Quantify disease severity over time.
6) Adherence to medication: It's estimated 50% of medication is not being taken.
7) Personalised medicine: Match treatment/prevention options to patients (e.g. genetics, gender, circadian rhythm)
...
These are some broad themes from the top of my head, of course there are many more disease specific problems, e.g. the early detection of Parkinson in voice samples, automation and delivery of CBT for insomnia, the list goes on.
Any technological or other intervention in the healthcare system must answer the following questions:
1.) Who pays for it? Doctors? Insurance? Patient?
2.) Who benefits from it? How much? Are they the same as the people who pay for it?
3.) How do you prove it has this benefit? Does the FDA need to approve it? (spoiler: almost always yes if a patient is involved directly and you claim a strong medical benefit)
4.) Whose pocket are you taking money from? Efficiency is just another word for less money sent to someone who profits from the inefficiency.
5.) Who is liable if your technology makes a mistake or leads to someone making a mistake?
6.) How do you integrate with current systems? Are you an app that runs on EMR or other patient data systems? If not, how do you get the data and do you have a HIPAA problem? If so, how do you get those people to go through pain it takes to integrate your system into their 20 year old, barely been updated ever system?
None of these are strictly technical problems, though 6 has a technical component. Having worked at a company that pivoted through a couple of the ideas you list, our failures were often heavily influenced by some combination of the above. Maybe a technology that provides a radical boost to some outcome, or an extremely large cost reduction could overcome these hurdles by virtue of their excellence. That's very rare, and any technology company in healthcare MUST have a strategy around these questions.
Taking your first example:
Check symptoms before visit. How do you ensure measurements are reliable, does every patient need a blood pressure cuff? Does this need to be an FDA approved device? How do we know they used it correctly? Even if the measurements are fine and we need no special equipment, maybe doctors get a payment for doing a vitals check (I don't know for sure), and if they do, why should they promote something that takes, say, $10 out of their pocket? Maybe the doctor can't prescribe a given pill without having run a specific test, so they need to check the symptom directly in the office anyway. Maybe the insurers would like some savings, but how do they force the adoption of something that's not all that widespread in the doctor's patient population? Will they pay for the devices the patient needs at home? How will that money get to the patient?
None of these things are insurmountable, but they are tricky to navigate. Off the top of my head I can find similar concerns to all of your options. Many of your ideas have had technological proofs of concept developed in an academic context stretching back years. They're not widely deployed because the healthcare system is incredibly fragmented with many players who have competing and often misaligned incentives. And there's a ton of regulation layered on top of that: #7, all your disease specific options, and perhaps some versions of #2 and #3 would need to go to the FDA before you could market your technology as solving the problem.
That's not to say your ideas are not good ideas, they absolutely are! But the reason they haven't been deployed is not because we just lack the technology. Those who have successfully deployed technologies in healthcare (for example https://www.virtahealth.com/) have also spent an enormous effort answering the above questions.
For a great book that breaks down a number of issues with tech in healthcare see:
Brand New Day, with its 43,000 members, is probably doing somewhere on the order of $430 million of revenue this year (43k members x $1k in premium per year)
SPAC + dubious product sounds a lot like Nikola. We'll see if this goes the same way. The valuations being thrown around are shocking though. A lot of Kool aid going around in investment right now.
Just wanted to point out that there are good SPAC too. Hyliion, OpenDoor & Virgin Galactic come to mind. If you haven't heard of HYLN, check it out. It's currently in a massive dip due to many people cashing their early SPAC price + many people associating Nikola with HYLN because they're both in the EV truck industry, but HYLN has actually amazing tech, great founder and I've talked to many truckers who cannot wait to retrofit the new engine in their old truck.
OpenDoor and Virgin Galactic both went public through Chamath’s SPACs. It might be a little early to judge if they are good SPACs, we’ll see how they are performing several years from now.
As if nobody in this $2.5 trillion industry has heard about software before.
Healthcare costs and waste are not a technology problem. They are a policy and incentives problem.