As we head into a new year full of unknowns and possibilities, it's important to consider not just expectations for the future, but also to revisit past predictions. In this piece, Dr. Steve Schutzer, MTVA Founding Board Member & Co-Founder, Upswing Health, takes a look back at his assessment of the challenges and solutions shaping American healthcare from eight years ago. With the benefit of hindsight, he reflects on what has changed, what has stayed the same, progress made, and the hurdles that have hindered greater transformation.
I was updating my LinkedIn profile recently and came across a short piece I wrote eight years ago – “Walls or Windmills” – referring to an ancient Chinese proverb:
"When the winds of change blow, some build walls, others build windmills."
It was written to express my hopes and concerns about the trajectory of U.S. healthcare in 2017.
I reasoned that our system's reliance on antiquated, anti-competitive regulations and lack of transparency on price and quality hindered progress.
Sure, that made sense.
But, looking back, I have to wonder “What was I thinking?” To my incredulity and chagrin, I was largely wrong having profoundly underestimated the headwinds (walls) we'd face despite the windmills we were building.
Living proof that, in healthcare, what we hold to be true at any moment in time – don’t bet the farm on it!
So, let’s take a look at some of my sagacious predictions and some obvious foibles:
1. Hillarycare, Obamacare, Trumpcare.
I got this one right - it hasn’t mattered. The then $3.3 trillion-dollar annual healthcare spend should have been more than enough to provide quality care for all Americans.
Unfortunately, 8 years later, that number has swelled to $4.8 trillion dollars (that is a 4.8 followed by 11 zeros) in 2023 and still no measurable improvement in health outcomes.
2. True – the solutions haven’t changed.
The solutions to the entrenched and intractable problems that chronically obstruct progress are widely recognized and fundamentally remain the same. Empower healthcare consumers (both plan sponsors and patients) with essential tools to promote free market competition based on the value they will receive for the services they purchase (defined as outcomes that matter to the patient divided by the true cost of delivering the outcomes).
Here are just a few of the tools that have been introduced in the past 8 years:
Price comparison tools or apps that allows users to view and compare prices for medical procedures, diagnostics, and even some medications across providers.
Platforms that provide quality ratings, patient outcomes, and online reviews for all providers and healthcare facilities.
Spending tracker and optimization tools to help patients understand and maximize tax-advantaged health accounts such as HSA/FSAs.
Digital platforms within a health plan that incentivizes patients for choosing high-quality, lower-cost care options (e.g. non-hospital-based imaging centers).
Telemedicine options and virtual-first broad-based specialty networks that provide convenient and immediate access to care at a lower cost than in-person visits.
3. ”Provided with access to credible, adjudicated clinical outcomes information and true cost of care data, today's digitally adept healthcare customers will pave the way to real value.”
But have the more digitally adept healthcare customers really paved the way as we had hoped, and I had predicted?
Maybe, but the results have been mixed at best. Through a combination of consumer-driven cost sensitivity, preventive care, and demand for transparency, digitally adept healthcare consumers have had some influence on spending patterns.
On the positive side, patients today are more informed and involved in their care decisions than ever before.
However, these benefits have not always translated into improved healthcare value.
But why?
Cost Shifting, Not Cost Savings: Consumer-driven models often simply shift financial responsibility to patients without addressing the root causes of healthcare waste and inefficiency. As a result, patients then often forgo necessary care due to out-of-pocket cost concerns, leading to even worse outcomes and higher costs in the long run.
Data Overload Without Insights: While these tools generate vast amounts of data, many fail to translate into actionable information – the practical insights for patients or providers, the ultimate decision-makers. Without clear, comprehensible and trustworthy information about clinical outcomes and their respective costs, the promise of empowering patients remains unfulfilled.
Unequal Access: Consumer-driven healthcare disproportionately benefits those who are financially literate, tech-savvy, and healthier. Vulnerable populations, who stand to gain the most from healthcare reform, often lack the resources or tools to navigate these systems effectively.
4. Has Silicon Valley finally figured it out?
In 2017, I predicted that Silicon Valley would become a dominant force in healthcare, and that prediction, I believe, has largely come to pass. Tech giants like Amazon, Apple, and Google have disrupted many aspects of healthcare, particularly consumer engagement, wellness, and digital health.
However, the promise of Silicon Valley’s seismic financial investments translating into scalable value-based healthcare has not been fully realized, limiting their overall impact on the transformation.
Despite billions in funding, many Silicon Valley initiatives have struggled to address systemic barriers. For example:
Fragmentation of care: While digital tools have proliferated, many have focused on niche areas or single conditions without integrating seamlessly into the broader healthcare ecosystem. In their now iconic 2006 text “Redefining Healthcare,” Professors Porter and Teisberg postulated that providers should be organized into teams specializing in specific medical conditions to manage the entire care cycle for those conditions, allowing for better coordination and improved outcomes. They coined the term “integrated practice units.” Today only a few advanced primary care organizations have actually succeeded in creating this focused condition-based approach to care delivery.
Although progress has been made, health information exchange and interoperability remain stubbornly limited and continue to minimize the potential impact on population health and value-based care which call for a more holistic, coordinated approach.
Lack of focus on patient reported outcomes: Many tech-driven solutions prioritize process and engagement metrics, such as app usage or adherence to digital programs, rather than patient reported outcomes or true cost savings. This misalignment has limited their relevance in value-based care contracts, where measurable improvements in health and cost are paramount and should be the top priority.
Scaling challenges: Solutions often pilot well in controlled environments but struggle to scale across diverse populations or regions. Factors such as varying interstate payer policies, lack of broad provider buy-in, and unique patient demographics continue to run interference and have stalled broader adoption. Despite their successes, tech companies have struggled to scale solutions across the fragmented U.S. healthcare system. One high-profile case in point - Haven, a healthcare venture by Amazon, Berkshire Hathaway, and JPMorgan Chase, disbanded in 2021 after just three years having failed to meet its ambitious and widely publicized goals.
5. In my original piece, I highlighted Ramon Llamas' statement from PatientsLikeMe regarding patient empowerment:
"We cannot continue to depend on the providers of health care to fix our problems. Therefore, I envision health care as a collaboration between patient and provider to maintain, rather than repair, an individual's health and wellness."
Eight years later, this vision has seen some major strides forward, but comprehensive fulfillment remains elusive.
Where Progress Has Been Made:
Greater patient empowerment: Platforms such as PatientsLikeMe and other crowd-sharing initiatives “empower patients through community” inspiring patients to take an active role in their care. PatientsLikeMe now has 850,000 members across 2,800 medical conditions. Patients share their experiences, outcomes, and insights, thereby creating a collective intelligence that has helped many manage their chronic conditions, discover alternative treatment options, and advocate for themselves – in other words, fill in gaps where traditional care has failed to offer solutions.
The growth of these patient communities is evidence that collaboration can occur outside the traditional doctor’s office and will only accelerate fueled by generative AI and platforms such as ChatGPT.
Wellness and preventive care on the rise: Increasing attention to wellness and preventive care, aided by wearables like Fitbit, Apple Watch, and other health-monitoring devices, has enabled patients to track key health metrics. These tools, coupled with telemedicine and digital health coaching, are nudging healthcare closer to proactive and personalized models.
Technology-Enabled Partnerships: Digital platforms have brought providers and patients closer, allowing for shared decision-making through tools like remote monitoring, virtual visits, and shared electronic medical records. These technologies align with the ideal of maintaining good health, rather than merely reacting to illness.
Where the Vision Falls Short:
Incumbent Provider-Centric Systems: Despite patient-centric platforms, the broader healthcare system remains largely provider-driven. Reimbursement models and organizational incentives still prioritize episodic, reactive care for condition management over ongoing wellness and disease prevention. And with a majority of U.S. physicians now being employed, the focus is still on driving higher revenue for their employer rather than better outcomes for their patients.
Data Usage Gaps: While patients generate more health data than ever before, much of it is either siloed or underutilized. Few providers effectively integrate patient-reported data into their care plans, limiting the potential for true collaboration.
Access and Equity Challenges: Collaboration assumes a baseline of access and health literacy that is not universal. Vulnerable populations often lack the resources to engage in these platforms fully, further widening disparities rather than bridging them.
Focus on Patch Work for Illnesses vs. Health maintenance: While technology has facilitated some proactive care, the current system still remains largely reactive and aligned with payment models that incentivize sick care not health care. Chronic disease management programs and wellness initiatives are growing, but they have yet to fully supplant the dominance of acute, episodic care delivery models.
Overall, during the past 8 years, I certainly see more windmills but also some new and reinforced walls (and moats).
It is abundantly clear that technology alone cannot dismantle the silos and misaligned incentives that persist in our system today. Achieving true value-based care requires close collaboration between innovators, policymakers, and care delivery organizations, with a relentless focus on the outcomes that matter to our patients and the true cost of delivering these key performance indicators .
The Optimist - I see immense potential in the continued integration of technology, the promise of GenAI and artificial intelligence in personalizing care, such movements as direct primary care and the slow but steady dismantling of outdated clinical and payment structures.
The Pragmatist - Turning around decades of misaligned incentives will likely unleash a torrent of fierce pushback from legacy incumbents. How do we ensure that the windmills we build are resilient enough to withstand the storms ahead?
That question remains enigmatic so please chime in!
Looking to the future, I’m all in, and still "in it till the end." Through the Moving To Value Alliance, a 501(c)(3) non-profit, and Upswing Health (an MSK population health management company) my week remains consumed by the passion, shared by so many others, to create a better way to keep Americans healthy.