So the question was the role of artificial intelligence.
I just did a paperback version of my book 'cause the book came out two years ago.
So, and somebody asked me what's changed in the last two years.
I would say the physician, the growth in the understanding of physician unhappiness about
their computers has grown a lot.
The entry of Silicon Valley in a big way has grown a lot, but maybe the most profound change
will be the advances in artificial intelligence, machine learning, and deep learning.
And you've probably been learning about this.
There's a very good article in The New Yorker this week about it.
It is profound.
I mean this is no longer hype.
This is real, and if you doubt it – how many of you have Alexa?
Anybody have Alexa at home, the Amazon Echo?
Isn't it unbelievable?
It's, because you think about Siri and how it – Siri is pretty stupid, but Alexa is
pretty smart.
And I talk to her in the morning, and she's my friend.
It feels different, and you can see that this is entering a new phase.
I think it's gonna be quite profound, and I think what we're gonna see is that within
not two years but no more than five the, there will be a biopsy of the chart.
Right now you can barely search the chart, but in a few years as you're typing in or
you're dictating in the chief complaint, it's gonna be searching through the chart
and figuring out the relevant things that you need to understand about the past history
and moving them into your field of view.
I think that you're, we won't have scribes anymore, those of you who use scribes, because
the doctor and patient will have a conversation.
It will be audiotaped or whatever that is.
And it will go into the record not just through voice recognition but in an intelligent way.
It will know this sounds like you're talking about heart failure, and I've gone through
the chart to look through for relevant things, and I didn't hear you ask about wait gain.
Would you like to?
That I think is very real, and I think that's because of the Googles in the world entering
this world.
I don't think Epic or Cerner are likely to have that competency.
Will doctors go away?
I don't think so.
The fields that I think are really gonna be threatened are gonna be the visual recognition
fields: radiology, pathology, dermatology.
I can't see 20 years from now.
That just strikes me as an easier problem than a driverless car.
So I can't see 20 years from now there being a lot of doctors reading x-rays, reading path
slides, looking at skin rashes.
I think for what most internists do, I think the computers will be very helpful adjuncts
to us rather than replacements of us.
One question for an early-stage physician or solo practitioner, how do you see them
– how – what advice would you give for someone trying to work in the hybrid model
of fee for service and value-based care?
Well, first of all for the solo practitioner, God bless you, I hope it lasts.
I almost can't imagine that it can.
I think the needs for infrastructure and support, it's hard for me to believe that a solo
practitioner can possibly pull that together.
People, recognize people have been predicting the death of small practice forever.
But the, if you look at the rates of consolidations, of practices being bought by hospitals, it
does seem to be that very small practices are threatened now.
I don't think I have anything profound to say about that.
I think that we all know the canoe analogy.
One foot is on the dock.
One foot's on the canoe.
The canoe is moving away from the dock, and at some point you gotta jump.
I can tell you from my own hospital day, if we sort of really went all in on value and
kept people out of the hospital and kept everybody healthy and all that, we would go out of business
by next week.
The economic model still does not support that.
On the other hand, we know that if we wait until that canoe moves away from the dock
and it's majority value, if we wait till then to figure out how do we deliver care
that's better, safer, and cheaper, we will go out of business 'cause this is a five-
or 10-year journey to figure out that set of competencies.
So I don't think there's any great answer to that other than to say that this is not
a repeat of the movie in 1995 where there was managed care, value pressure that then
went away.
I can't see any or really any realistic scenario where the value pressure goes away.
And I think if you're not learning the competencies to manage a population, to use data in new
ways, to deliver better care, quality measures, cut your costs, if you're not learning that
competency today, I think you're gonna be dead in three to five years when this becomes
the way we're dominantly paid.
But I think what's interesting is that there are certain primary care groups that have
basically said we're gonna start again and we're now gonna do just value.
So Iora, Oak Street, GENCARE, GENMED, all these different groups exclusively do risks
around MA.
And they do very well, but having the foot on the, in the canoe and on the dock is hard.
Your company is a very interesting example of a company, a company that made the decision
to bet the farm on this, right?
Yep.
So and not everybody did and the company's doing well.
And so you'll see that happening where there are just groups that make this decision that
now is our time.
But I think the dominant practices will say we're gonna live in these worlds for a while,
and the mistake will be to say I'll deal with that value stuff when it becomes 51%
of my practice.
It just takes too learn, too long to learn how to do this, to build the teams, to build
the use of data.
It's a three- to five-year journey at a minimum, so you have to start learning it
now.
It's interesting at Humana.
We have, oh, 60-some-thousand physician groups in value.
And when folks start off with us and they say, "We're fee for service.
We now like to get paid on the upside," we say, "That's great."
And then they saw we did really well there.
We wanna go straight into full risk.
We say, "Yeah, no, not for another four years, because we can predict based on how
you're doing.
You need those four to five years."
So that's your timer, as in five, four to five years.
Four to five years.
And if you come in and say, "I'm ready to take risk right now," we'll say, "Thank
you, but no."
Not with us.
We'll help you, but we've gotta make sure that you're gonna be prepared for success.
And can you predict whether they will be successful in five years?
Yes.
You can see very quickly in terms of how they manage certain things.
And for primary care physicians, for us internists who are dealing with this, it is complicated.
You do need to think about investing in the right strategies early on.
And it's a different mindset.
So for instance, you don't need to write down nine things as you gave an example on
the review of systems because review of systems is irrelevant.
It becomes what is important for the management of that patient.
You're no longer trying to get that level three or four code.
What you're trying to do is prevent the patient from being hospitalized or having
diabetic foot ulcers and things like that.
And where the technology will kick in, and you may be already experimenting with this,
is if you're trying to keep patients well and healthy outside of the hospital or even
the office, you will eventually begin to use sensors, or they'll breathe into their iPhone
in the morning, and they'll be checking their glucose.
And part of the thing we really got wrong is we began to develop some of those technologies,
and then they get beamed to the primary care doctor.
I mean you may have heard Eric Topol speak before.
It was very kind of optimistic about all this.
And it's like, and so the patient will be measuring these 37 different things – their
skin sweat and their mood and their blood pressure and their heart – and it gets beamed
to the primary care doctor who's happy to receive that.
That's a planet I'm not familiar with.
But you're getting new data on 2,000 patients.
That can't work.
There has to be some new layer there that essentially becomes almost air traffic control
who's following a panel of diabetics who are out there through new digital inflows.
And it's tricky.
And that's actually what Humana and these new companies are doing.
So we've got very simple devices.
Because if you believe that more and more healthcare is gonna go into the home, then
that, this'll make sense.
Because if you believe in value, where's the cheapest place for people to get things
done?
It's usually the home.
And if you can get materials to them and then have a center monitoring the air traffic control,
then it puts the primary care physician in this driver's position figuring out what
they need to do.
So that's good.
Do we have time for another question?
Yeah, we actually have, there's a couple questions coming in, and there's like two
common themes.
So to kinda summarize, one question is around physician's role and involvement in the
transformation of healthcare and what can they do to be more involved rather than reciprocating
the change.
And then the second theme of questions is around patient compliance and accountability
and how do we give that back to the patient as well since we're, physicians are gonna
be measured on outcomes.
Both terrific questions.
Getting involved, I think as a profession we've not been great here.
We've, or as individuals, as societies, to some extent we've left some of the quality
measurements to someone else to do it, and we've certainly left a lot of the idea of
system improvement to other people.
That's what an administrator does.
They go to meetings.
I don't do that.
I'm a doctor.
It's a natural attitude, but then what we get are systems that are built that don't
actually work well because you actually need to understand the clinical ecosystem.
So I think it's a refreshing trend to, A, see the societies stepping up to this, to
see physician groups stepping up to this.
Part of this is the value pressure.
They realize that we have to get more involved.
It's now mission critical.
The choosing wisely campaign that I was on the ABIM Foundation that produced that campaign.
That was actually a very noble thing because what we had was basically every specialist
society coming out and saying, here are five things that people do in our profession that
actually don't add value.
I think and part of the reason why it made so much of a wave was people were waiting
for physicians to say that and admit that.
And I think that we sort of lose credibility when we don't own up to the fact that for
a lot of reasons we sometimes do things that are not completely necessary.
So I think we've got to be out there bolder.
We need more people like you who are connectors, who understand medicine and understand business,
understand operations, understand technology.
And I'm actually quite excited by that.
I was a political science major in college, and back then that was, and I went to med
school.
That was really weird.
Now a lot of kids come out and they want to be physicians and technologists or physicians
and business people, physicians and engineers.
And I think in part 'cause they recognize to build better systems, you need clinical
insight but you also need that kind of insight as well.
The issue about patient accountability is tough.
I think we all feel when you're being measured on something and not doing well and the reason
you're not doing well is the patient didn't take their medicines, why am I being held
accountable or blamed?
It's a natural instinct.
And I think patients probably are being given more and more accountability.
If you think about copays and deductibles, more and more of the cost of care is being
moved to patients, which creates some level of accountability.
I guess I'd wanna be careful about not taking that too far, because if the patient is not
adhering to their meds, I actually want some of the accountability on the side of the health
system and the doctor.
Like did you explain that well enough?
Again I will watch my father, who's a pretty bright guy but 86, and the way people describe
his 12 different cardiac meds he was supposed to take, there is no way in a million years
that if I was not there translating he would've understood the first thing about it.
They just didn't do a good job.
And so to say if he hadn't taken it correctly that it's his bad I actually think lets
the health system off the hook.
I think we have to come up with ways that explain it better.
And then there will be times where the patient didn't do what they needed to do or smoked
too much or whatever and we do need to account for that and adjust for that in the way that
we're being measured.
But we shouldn't be left completely off the hook when it comes to patient behavior
'cause some of it is determined or influenced by us.
The VA was the first large system to computerize, and the VA for all of the stuff that it gets
in the press, the VA does a pretty job and delivers, if you look at measures of it, delivers
pretty high quality care at a competitive cost and one that for a lot of veterans is
quite satisfying.
The VA was in the quality and systems improvement business before anybody else.
The VA had a full-fledged completely interoperable electronic health record, 20 years ago.
So I think the VA has been very impressive.
The VA unfortunately becomes a piñata in the public whenever anything goes wrong, and
there's, it's a big system.
There's enough scandals.
It will be very interesting to see what happens under this new administration and this issue.
Basically a number of big systems that built their own computer systems, Harvard Partners
for one, Vanderbilt was another and the VA the third, basically all of them in the last
several years have said we can't afford to do this anymore.
So it's very hard to keep up a computer system when it's this complex.
It'll be interesting to see.
It's gonna be a windfall for whichever company gets the VA's business.
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