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The health care innovation bubble☆ Sachin H. Jain

In many ways, it is the best of times for those amongst us who are interested in transforming American health care. For the first time, there is broad recognition of our deep quality problems and the long road ahead to improve on them. The question is no longer whether we should expand access, but how. We have moved on from documenting healthcare disparities—to beginning to work to close them. For the first time, we have health information technology and payment instruments with the ability to support system transformation. Whatever we think about the current state of electronic health record systems, the HITECH Act's meaningful use provisions give us a federal health IT infrastructure where there was none. On the payments side, the Affordable Care Act created a Center for Medicare and Medicaid Innovation with real power to transform how we pay for clinical care in this country. The combination of health IT and new payment models is rocket fuel for the healthcare change-makers among us. Finally, for the first time, we have better talent that is turning its gaze towards changing the health care system. When I started as a student in medical school, I felt unique but also marginalized because my interest was not only in learning medicine, but also in driving change in policy and practice. Today, you cannot walk through the medical school quad or the teaching hospitals without bumping into someone with a big idea to change healthcare. Healthcare hackathons and accelerators are teeming with enthusiasts launching new ventures. There is more human capital being deployed to change healthcare than ever before. And yet I worry that when I walk through most hospitals, clinics, and health systems around the country, the loud noise made by words like “innovation,” “transformation,” and “strategy” is obscuring the powerful murmurs of intransigence that still dominates our health care system. I worry that underneath the smoke of health care innovation, there is no real fire, but individuals motivated less by real change than by profit or worse, recognition. I worry that “pilot” is code for “sorry, I can’t say yes, but I’m too polite to say no.” I worry that rather than this being the single most important moment in the evolution of our country's health care system—it will be remembered as a missed opportunity. I worry that we are living in an “innovation bubble.” There is a disconnect between the conferences I attend, the journals and blogs I read, and the reality of medical practice on the frontlines of

healthcare delivery. There is a “change layer” – the cloud in which visionary ideas about transforming health care resides. But there is also a “reality layer” – the place where most care is delivered. Both are necessary, but there is little mixing between them. So while there is a booming innovation industry – a new startup being created every day, a new app being launched every minute – the actual experience of delivering or receiving care is changing scarcely. In fact, many elements of the change layer—startup companies, innovation centers—are structured to isolate and incubate change. The most charitable view is that new models of patient care must be supported separate from the rest of an unmoving enterprise; that innovative solutions and models are too disruptive and must be protected; that over time, these new innovations that arise from the change layer will trickle into the reality layer. But there is another more cynical view that many elements of the change layer have been created and supported by the incumbents to deliberately kick the can down the road; that those who occupy the change layer are content to float above the hard work of changing crusty old operations in favor of innovation conferences and startup ventures; that much of what is continuously described as “new” is really window-dressing on the same old stuff. When I was a medical student I excitedly read a Boston Globe cover article about a health plan that piloted a program to pay physicians to respond to patient email inquiries. At the time, it felt truly visionary—an opportunity to use technology to incent care delivery in new ways. Ten years later, I sat on a panel with someone from that very health plan where they continued to talk about this pilot as if it were novel — as if there was still something to learn before scaling the payment model. It was truly jarring. As a research fellow, I studied a progressive health system I had admired for a long time. The health system had become externally famous for integrating open access scheduling to enable same day appointments into its primary care practices. When I began to visit the practices within the system, it became clear that the so-called innovation was limited to a few practices among the more than 50 within the system. Most patients waited months for appointments just like they did everywhere else. Working within the pharmaceutical industry, I watched with curiosity as the industry launched countless initiatives to move “beyond the

These perspectives are solely of the author, not the journal or any of the institutions with which he is affiliated. E-mail address: [email protected] Received 26 July 2017; Accepted 9 August 2017 2213-0764/ Published by Elsevier Inc.

Please cite this article as: Jain, S., Healthcare (2017),

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S.H. Jain

system and health plan, I often jokingly say that pilot is a 4-letter word. We need fewer pilots and more will, momentum, and frankly, courage to implement change. Now this view is not without its skeptics. The nation is populated with health care leaders who have lost their jobs and their shirts by pushing a change agenda too far, too fast. But when I put on my clinical hat, there is actually an ethical dimension to our pace—namely that if we take too long to implement changes to health care delivery that we know will benefit patients, we are withholding necessary improvements of care. We must push forward our best new ideas to transform care at scale, because it is the right and ethical thing to do for patients. The real secret in closing the gap between the change and reality layers is in creating a clinical culture where innovation is not viewed as the domain of the few—but as the responsibility of many. The first sign of the beginning of the end for aspirational organizations is when any new idea is instinctively met with the word, “No.” The second sign of the beginning of the end is the creation of the position of chief innovation officer. I say this partly in jest as someone who until recently held that title. Most large healthcare organizations have optimized themselves for the core business of health care delivery, but in so doing have suboptimized themselves for real innovation. Organizations are successful at achieving real innovation by making it the job of frontline staff to implement creative ideas every day—not as part of a special project or initiative. Without this cultural imperative, most innovation would be a tasty side dish, not the main course. This mindset shift requires a culture that enables, allows for, and even rewards a healthy disdain for the status quo. But many organizations and their leaders instinctively hold on to the status quo because it is what made them successful previously. In such a case, no amount of energy or agitation from the change layer will ever find its way into the reality layer. No number of hackathons, patient centered tools, or decision-aids will be infused because the individuals with the keys to the kingdom won’t let you in to change it. We have all the ingredients to make the most of this moment in healthcare. We have the right problem definition, we have the right technologies and payment models, and we have the right talent entering the field. But we also have a gap between what's happening at the change layer and the reality layer that none of us can deny. My hope is that by calling it out, we can begin to have authentic dialog about how we might begin to narrow that gap—and bring these layers together.

pill,” to build services and solutions businesses to enhance patient outcomes only to undercapitalize them and quietly shut down without notice. The industry was unable to sustainably think about a future outside of high margin molecules—just as many hospitals are unable to think of a future without fee-for-service. So what are the obligations of those of us who exist within the change layer? How can we make the change layer more impactful in reality? How can we not waste this special moment in history where so many stars seem to be aligning? One of my mentors in medical school was Jim Kim, previously of Partners in Health, then president of Dartmouth College, and now president of the World Bank. Jim spent much of the past decade arguing that we need a greater focus on the “science of delivery,” studying how interventions are scaled in order to enable and facilitate greater diffusion of innovation to close the gap between best clinical science and best practice. I believe Jim was right – I even worked with a colleague to launch a journal to support the development of this field. Yet, I think a science of delivery is not a replacement for good leadership. We need leaders who define their jobs as closing the gap between the change layer and the reality layer – leaders who aim to converge aspirational vision and the frontlines of clinical care. The science of delivery rather than being a science of “how do we scale,” is really common sense organizational behavior, integrity, and leadership. The fundamental task of the person leading innovation in an organization is not to invent the new idea or develop the new solution—it is to create the environmental conditions such that any new idea will have a fighting chance to survive and thrive. More than anything, we need to adopt and demand a new pace. Somewhere along the way, it became acceptable in healthcare to have change management timelines that stretch from days, to weeks, to months, to years for things that we already know work. Somewhere along the way on the front lines of health care delivery, we convinced ourselves that change is necessarily slow. Having worked in the federal government, academic medicine, and also large corporations, many people are often surprised when I say that the pace of change was fastest in the federal government. The reason for this pace was that there was a clear sense of urgency and a culture of speed and accountability created by our leaders. I would argue that any of us who desires to change health care must not just challenge the system with new ideas, but also with new expectations of pace and scale that engage both the change layer and the reality layer. In my current role as Chief Medical Officer of a delivery


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