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Scott Shreeve, MD

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I'm the CEO of Crossover Health, a patient-centered, membership-based medical group that is redesigning the practice, delivery, and experience of health care. We offer urgent, primary, and online care to our members who can access our technology platform, practice model, and provider network from anywhere and anytime to optimize their health. Email Me



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The Innovators Interview: Conversations with Jason Hwang

Interview (ĭntər-vyū) n.

  1. A conversation, such as one conducted by a reporter, in which facts or statements are elicited from another.
  2. An account or a reproduction of such a conversation.

I have long been a fan of Clay Christensen and his concepts of Disruptive Innovation (DI). I devoured the book and the subsequent follow on books. It resonated with me because of what we were doing at Medsphere so closely aligned with what the principles and concepts in the book. As I have now transitioned more into the personal health space, and begun dabbling in health policy and systematic reform by default, I have come to further appreciate how the notions of DI can and should be applied to health care. I believe by so doing we can harvest the DI fruits of increased access, lowered costs, and improved quality of products/services.

In December, I was fortunate to attend and speak at the WHIT 4.0 conference and hear more about the book and the theory from Dr. Jason Hwang, a co-author and co-conspirator of Clay’s who has embarked on a missionary tour spreading the gospel of DI to the health care industry. Jason has a fascinating background, and one I can certainly identify with as architected his career to pursue his passion of introducing DI to reinvent (or perhaps create?) our health care system. I had the opportunity to catch up with him by phone and share the results of our brief conversation with you below:

S: Jason, great to meet you. Tell me a little bit about your background:

J: I attendd the University of Michigan Medical School and did my internal medicine residency at UC Irvine Medical Center. I tehn spent a year as Chief Resident at UC Irvine and another year working at Kaiser Permanente. While I enjoyed the work and my colleagues, I was left with a sense that I wasn’t doing enough or contributing at the right level to solving some of the issues I was facing in everyday practice. I determined to go to business school and was accepted at Harvard. In addition to working closely with very impressive colleagues, I was privileged to take a course from Clay Christensen. It turned out that he had been toying with the idea of writing a health related book for a long time, and I answered the blast email sent to find students interested in collaborating on the project. Over the next two years, I immersed myself in the research, writing, and revision of the book. During this experience, and with all the interaction we had with health care leaders throughout the world, we quickly realized that our work would not end with the publication. In fact, we feel that the conversation has only begun.

We determined to house our ongoing health care efforts within a think tank structure called Innosight Institute, which also covers other social / public sector issues that can be served by applying DI concepts. I never could have predicted this path that I am now on but am enjoying it thoroughly.

S: How is your organization funded?

J: We are currently supported by grants from sponsors who are interested in expanding our DI work. This grant model has been more readily adopted by the folks working on the education side of Innosight Institute, but we are hopeful that our health care counterparts will catch on now that the book is out.

S: Any interesting insights leading up to publication of the Innovators Prescription?

J: I never could have imagined how much work was involved in writing a book like this. The book actually took much longer than expected because we sought so much feedback from an incredibly wide variety of health care leaders. It was a difficult task to assimilate all the feedback, both pro and con, given the wide variety of perspectives, constraints, and challenges faced by various reviewers. However, this was also one of the most rewarding aspects of writing the book, as it really helped to reshape our thinking and constantly challenged us to refine our DI model. We really wanted to get it right.

Of interest, a few people have been overly focused on the title of this book. We obviously chose the title because we felt it had some shelf appeal and also to stay congruent with the Clay’s past books. We did not intend for the concept of prescription to mean prescriptive, or to assume that an understanding of DI unlocks all the answers. We do, however, feel very strongly that understanding the DI framework can be a useful predictor of what will work, particularly when based on our approach of looking at other industries who are “ahead” of health care in terms of some of the challenges they had to overcome as they sought to increase access, lower costs, and improve the quality of their products and services. The DI framework provides an excellent reference to understand those experiences while enabling us to predict with ever increasing accuracy the impact of potential reform proposals within health care.

S: So what are you doing now to effectively preach the gospel of DI within the health care context?

J: Well, that’s an interesting way to phrase the question, because often I feel like a missionary sharing a message that doesn’t always resonate with people. Over the next 6-12 months we are really focused on getting the notion of DI’s potential contribution to the health care reform conversation squarely out into the public. We want the lay press, the health care press, and most importantly the thought leaders who will be influencing public policy and health care financing to consider how an understanding of the DI framework can contribute to predicting which solutions may provide the most viable options to impact these very complex challenges that face the health care industry.

We did receive feedback that our book did not provide enough detailed solutions. However, the purpose of the book was to help set a framework, develop a common language for discussion, and understand the catalysts or enablers that would allow policy makers to truly enact health care reform. Our focus has always been to understand the root cause of the problem, to understand what jobs need to be done, and how we move from modeling to implementation to scaling the innovation. We believe that spreading the DI framework can facilitate this, after which much smarter people can come up with much better solutions than we could ever have derived for the book.

S: So let’s dive in, what are some of the root causes that you establish in the book?

J: Let me try to outline several of them here in bullet point form:

  • Root Causes
    • We have very outdated business models in how we are providing care. I realize that these have evolved out of necessity, but it is time to rethink the business model so that we can leverage technology enablers and create new value networks to introduce disruptive change within health care.
      • The movement of Intuitive Medicine toward Precision Medicine provides opportunity for new care models. In addition, we need to find business models that emphasize wellness care and long-term management of chronic diseases.
      • Each of these types of care needs to have the right business model addressing the right “job to be done” for each particular patient
      • DI Theory helps us predict the best ways to break apart the currently conflated business models; they have been tested in other industries, and we believe they can be applied to the health care industry
      • The concepts apply and can be extended to business models for Hospitals, Physicians Practices, Payment Systems, Medical Schools, Pharma, etc.
    • Reimbursement Systems lock in our current business models of health care and provide a major impediment to change as entrenched interests do not want to change
      • This is an extremely challenging, longstanding, and near Gordian Knot-like problem.
      • One revenue model for health care that is capable of generating disruptive innovation is the Pre-Paid Health Model delivered through an Integrated Health Systems (Kaiser, Intermountain, Geisinger, etc), which we’ve called in the book Integrated Fixed-Fee Providers
      • Needed reforms include adaptation or repeal of current regulatory constraints, and introducing others that reward health systems that are structured for disruption (like encouraging Kaiser patients to stay within the Kaiser system beyond age 65). Health savings accounts to hold people more accountable for the cost of their behavioral choices, but also to stimulate healthy behaviors.
  • Movement toward Precision Medicine
    • The introduction of new technology into health care has paradoxically introduced ever increasing costs. Most other industries have figured out how to achieve greater value in return for increased spending..
    • As more and more diseases become better understood, the person who can deliver care can change. Work can begin to shift from specialists to generalists to non-physicians and computer-aided algorithms, to self-diagnosis and -management. This movement toward precision medicine gradually obviates the need for specialization and centralization, also allowing for new venues of care with corresponding improvement in results.
    • How to fix chronic disease care
      • 75% of all health care costs are caused by chronic diseases and therefore the opportunity for innovation in this area is potentially very impactful. Facilitated networks can really help drive the behavioral changes required to reduce costs and improve outcomes of chronic diseases. We see groups such as patientslikeme and diabetic support communities as models for how facilitated networks can help patients make lifelong modifications that result in lower costs with better outcomes.
    • Getting The Incentives Aligned is a critical success factor as individuals and organizations always return to their root incentives when care delivery challenges arise. When incentives are not aligned, we observe behaviors that only exacerbate friction and animosity when trying to deliver on the promise of disruptive innovation. We see most promise in incentive alignment through two types of organizations:
      • Fixed Fee Integrated Provider this is well-documented from the Kaiser, Intermountain, and Geisingers of the world. One topic I am starting to research is how an independent hospital or insurer could turn into a successful, integrated health system.
      • Corporate Orchestrators are based on the observation that throughout business history, a company will choose to integrate into a critical activity out of necessity, even when it’s some part of its “core competence.” With health care, we have seen some forward-looking employers taking on an increasing role to ensure the health of their employees in order to reduce costs, stay competitive, and ultimately enhance the delivery of their core products/services.

S: Can you share some specific examples of organizations that have “broken apart” the conflated business models or have begun addressing some of these root causes?

J: I think the best examples, and ones that we highlight frequently, are the Cleveland Clinic and the Mayo Clinic. Essentially the leaders of these organizations have understood the Wickham Skinner’s notion of a “Factory within a Factory.” They allow these focused units, centers of excellence, to develop focused business models that leverage technology and intersecting areas of expertise in novel ways to deliver best outcomes. While they may be co-located within the larger organization, these business units have the necessary autonomy to operate apart from the mothership. These are great examples of organizations disrupting themselves.

S: I think you have been falsely accused of disparaging the medical home – can you clarify your perspective on the Medical Home?

J: Thanks for asking this, as I do want to clarify our perspective. In our evaluation of the medical home, we believe there is clearly a job-to-be-done that most patients require – “help me coordinate my care” – which is important in an increasingly fragmented health care system. But my criticism is mainly targeted at the assumption that this care coordination must be headed up by a physician. For some situations, this job could be fulfilled by a non-physician or even a software program. In other cases, the amount of information required to manage and coordinate care well goes far beyond the realm of a primary care provider. So while we see cases where a primary care coordinator is appropriate, we also see situations where this is overwhelming and counterproductive. The bottom line is that the medical home is simply a label for a “job” that we’ve identified for most patients. Those organizations who are able to deliver a solution that can address this job in a disruptive manner are best suited for long-term success.

S: I was pleased to see you guys reference Care Accountability Organizations or Personal Health Advisory Services as an alternative or augmented perspective to the Medical Home? Can you explain your thoughts on this?

J: Elliot Fisher, MD and the Dartmouth group have advanced this notion of a Care Accountability Organization or as you refer to it at Crossover Health – “Personal Health Advisory Services”. Essentially, these ideas represent what we are talking about in an independent, non-conflicted third party that has the scale, scope, perspective, and aligned incentives to deliver on the “help me coordinate my care” job. This job will become increasingly important as the DI theory indicates that health care will actually become even more fragmented over time.

As I mentioned earlier, most patients will need help to navigate the waters. But this guide could be a doctor, it could be a nurse, it could be a phone based consultation service, or it could be an online physician interaction. For those individuals who are already a part of an integrated fixed-fee organization, it will likely be the health care system itself that provides this service (Kaiser, Intermountain, Geisinger, etc), as they benefit from keeping their patients well. If you are not a part of such a system, coordination of care could come from an independent third party who helps make all the necessary care connections.

S: How does Concierge Medicine fit into your construct?

J: Concierge medicine has both good and bad attributes that make it interesting, but by itself it does not necessarily qualify as a DI. Concierge practices have not fundamentally changed the business model (remains conflated), and the desire to command premium pricing for higher levels of service is the very definition of a sustaining play. There’s nothing wrong with creating a successful sustaining model, but we have to realize that it does little to advance our mission to create a health care system that is affordable and accessible to everyone.

S:  How to do you view self proclaimed innovation competitions, like the upcoming Health X-Prize, as contributing to the accelerating potential disruptions?

J: Well I am a huge fan of the X-Prize and the multiplier effect possible through competition. It creates some interesting incentives, some public interest in rooting for the teams, and unusual non-monetary motivations for participants. It will be something that we will keep our eye on as this type of funding mechanism breaks free of some of the constraints of the typical sponsored investment in the constant search for innovative ideas.

S: Jason, I really appreciate your time and wish we could dive deeper. I will look forward to additional conversations with you and other leaders regarding how DI can and should impact our health care system.

I could have talked with Jason for hours regarding some of these ideas, and also all the interesting individuals he talked with and continues to talk with as part of his ongoing conversations with industry thought leaders. Keep an eye out for him in a city near you.

3 comments on “The Innovators Interview: Conversations with Jason Hwang

  1. goftedahl says:

    I had the opportunity to hear Dr. Christensen and Hwang in Minneapolis, and have read and discussed The Innovator’s Prescription and it’s concepts with many.
    I serve as a chief knowledge officer at the Institute for Clinical Systems Improvement in Minnesota, and resonate with the concepts of DI, challenges and perversities of the present system (if one can call it that). We’ve done work with a depression innovative (DIAMOND) in Minnesota, which has elements of a DI, and while we’ve had outstanding results thus far, the potential for failure within the present constraints of our health care system and its payment methodology highlight many of the issues presented by Drs. Christensen and Hwang.

    I look forward to ongoing conversations and opportunities to continue my learnings into how we can take these fascinating and provocative concepts, and provide concrete examples to support and reinforce, and perhaps enhance the evolution of the model as we move forward.

    1. Thank you for your thoughtful commentary. There is so much great work that has been done in Minnesota – glad to see you are a part of it.

      I really believe we need to create an entirely new value chain outside of the current medical-industrial one that exists today. This is why I am so bullish on the direct practice model (See Going Off the Grid post). Companies like Current Health and HelloHealth are going to do very well.

      I really like your comment about trying to continue to highlight concrete examples of DI. Send me any new ones you are seeing.

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