What Is Healthcare’s Most Unanswerable Question?

When people tell me I’m funny, I say looks aren’t everything.

Suppose you and I are together at a ballgame—you pick the sport. We are sitting in a large arena.  You are eating something that looks like trail mix, but I can’t identify what trail it came from.  You look at my cheeseburger and remark, “That meat is pink.”  “I told them just to lean the cow against the radiator for a few minutes.”

“The snack bar has croissants that were flown in from Paris this morning.  If you hold one to your ear you can hear the sound of a sidewalk cafe.  For the next hour,” I told her, “I am going to teach you how to be a good consultant.”

“Good.  Do we really need the whole hour?”

For the sake of keeping the math simple, suppose that, including us, there are one thousand people at the game. You have an M.D. and a PhD.  You are a thirty-two-year-old population health professional, you wear sensible shoes, you live with your mother, and you love cats.

For the next few minutes, just think of me as a man of mystery.

You try to impress me with your knowledge of the health of the 1,000 people in the arena. “Do you know…?”

  • 450 of them will have at least one chronic disease
  • 333 of them will have two or more chronic diseases
  • 100 of them will be treated in a hospital this year
  • 20 of them will be readmitted with 30 days of their discharge
  • 10 of them will be readmitted for a reason not tracked by CMS
  • About 200 of them smoke
  • About 300 are obese
  • Roughly 100 have no insurance
  • 10 of them will die within twelve months
  • None of the men are pregnant

“Wow, you know a lot of stuff,” I said. You beamed.  I knew that to make my point, a simple trail of breadcrumbs was not going to work.  I had to make sure the breadcrumbs were croutons.

I scanned the crowd with my binoculars. “Do you see that woman in Section B, row 6, third from the left?” You looked and acknowledged that you did, in fact, see the woman.

“Is she healthy?” I ask you. “Section A, row, 2, seat 1. What about the boy wearing the Make American Great Again baseball cap who is seated next to the man wearing the Lock Her Up t-shirt? Does any of your data tell you if he is healthy?”

“No, but it tells me that the man and his son are idiots.”

“I get up every morning and practice my liberal cliches in the mirror.  Wanna hear one?  Income disparity in this country hasn’t been this bad since the Great Depression.”

I show you my t-shirt.  On it are the words, “I am with Her(b).” You look at me like I am an idiot—that’s okay. I get that look a lot.  You said, “You remind of the type of person who might walk into a 7-Eleven one day and kill everyone inside because the Slurpee machine wasn’t working.”

“Both flavors?” I asked.  That was when you kicked me.  I knew you were thinking that someone ought to send me to a re-education camp.  “Shall I continue?” I asked. “Section A, row 7 seat 4? Section C, first row, the one in the middle?”

“You are not into complete sentence structures, are you?  You have made your point, I think. I do not know the health of a single person here. Was that your point?” You ask.

“I wish it was that simple. What if I told you this about one of the people in this arena? Over the last year, the person’s resting heart rate has increased by fifteen beats per minute. He has gained twenty-five pounds, he does not exercise, he drinks four cans of soda a day, and he eats fast-food more than five times a week.”

You reply, “I would tell him that he should be examined for heart disease.”

“Your diagnosis is correct, doctor. Now, tell me which of the people here am I referring to?”  It was like trying to explain cholesterol to a Big Mac.

“I have no idea.” Of course, you don’t. And that is healthcare’s biggest problem. Nobody who is managing the health of the population knows anything about the current health of anyone in the population.

Nobody can answer this question, “I am healthy?”

And here is the really bad news. The person we were just discussing collects all of that data on a myriad of health apps and wearable devices. And he will continue to track it right up to the moment he has a heart attack. And he will continue to track it because he does not know that he may have heart disease. Neither does anyone else know it. Collecting health data is no more valuable than not collecting health data. Neither is monitoring it.

For example, does anyone know the exact status of your current health beyond whatever information you added to your health history form during your last annual exam? Do they know if you exercise, and if so, how much? Do they know if you drink or smoke, or whether you have gained or lost weight? Does your PCP know if you are experiencing any new symptoms?

  • Your primary care physician does not know these answers.
  • Your payer only knows what claims you are filing, and they have no idea whether the illness or procedure for which you are being treated is being managed effectively
  • Your pharmacy does not know whether the medication they gave you is managing your health
  • And the life sciences firm that manufactured your medication does no even know that it was prescribed to you

Every provider or payer or national pharmacy could answer all of these questions if it wanted to. It could because that data is being collected every day by millions of people in the populations whose health is being managed.

Your firm could collect the data, monitor it, and assess it every day. It could do that with my data and yours. It could notify you and tell you when to be examined and for what to be examined.

To manage the health of the population wouldn’t it be more effective if we knew the health of the people who comprise the population?  Getting healthcare to try a new idea is like teaching a hippo to play the clarinet.  It’s not fun for the hippo, and nobody else wants to play that clarinet after the hippo.

Unless we want to agree that effective population health management is nothing more than having the ability to forecast the health of large numbers of people , for population health to work we must reverse engineer what we are doing.

It doesn’t do to leave the dragon out of your calculations if you live near him.  While there may be value in knowing that twenty percent of the population will have diabetes, the only thing that will get my attention is knowing if I will get diabetes.  I call that me-Health.



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