Viewpoint

The Self-driving Patient: How Health Care Will Catch Up


Bruce Pyenson
Gillian Woollett

21st century change has yet to really reach health care. Amazon can predict our next purchases, but medical specialists have trouble coordinating our prescriptions. Most people haven’t sent or received a fax in years, but doctors and hospitals still depend on them. So many aspects of our lives and economy are being customized, dematerialized, accelerated.

How will health care catch up? We believe a vanguard of tech-savvy patients will lead the way.

Bruce Pyenson

Bruce Pyenson

But thinking that doctors’ waiting rooms will be the access point to high-tech health stations is like imagining a stagecoach pulled by genetically modified super stallions. Or that stain-free clothes will be made with foot-pedaled sewing machines.

Medical science is the best it has ever been, and the United States continues to lead the world. Yet the speed of care, let alone its improvement, feels glacial, especially when you are sick. Transforming health care isn’t just a matter of removing a few bugs here and there from a glitchy system. More fundamental, root-and-branch change is needed. Just as some communities go straight to cell phones without ever having landlines, we believe some aspects of our health care infrastructure could be entirely replaced with consumer-focused systems that are continuously evolving. That kind of change has the power to eliminate sluggish, wasteful aspects of American health care that add to overhead, encourage redundancy, and preclude access.

Gillian Woollett

Gillian Woollett

Early adopters create ‘NewHealth’

We believe that early adopters of a new kind of health care that we are calling “NewHealth” will push the American health care system in this direction. Patient-focused drug development and “right to try” drugs that are not yet approved are just hints of what this new system offers.

A whole array of technologies could drive large-scale, rapid shared learning. Instantly available smart technology will bring a new level of convenience and accuracy to diagnosis and treatment. And care will improve as providers are forced to respond to patient demands that they provide NewHealth.

Initially, NewHealth may be more expensive. We believe, though, that early adopters will happily pay more because it offers immediate value to them. Arguably, the change is already underway in a minority of patients who have researched innovative solutions and seek out health care providers that will provide them. Examples are patients who insist on peritoneal dialysis or unapproved uses for drugs. And these patients already want to engage with their providers as partners in better and more personal care. Providers who don’t engage may fall by the wayside if their need for deference runs contrary to the progress the patients expect.

A democratizing influence

Across the world, health care availability is variously treated as a right or a privilege depending on one’s place of residence and available resources. Yet we’re always left with the question of how much care is accessible and for whom, how that decision is made, and who pays the bill. Like education, but perhaps even more so, health care can have far-reaching consequences. Differences in the quality of care we receive can alter our lives, so some people are healed or their condition well managed while others suffer illness, life-long disability, or even face death.

Can smart technology help people overcome the otherwise intractable socio-economic determinants of health? Can it bring better care to all, like quality public education has made us all better off? Even though your smart phone cannot transplant a heart, it will be able to signal when you need immediate help. NewHealth can help democratize medical expertise and frame an individual’s medical needs in the context of their real life. Knowing when to ask for additional help through use of the NewHealth tools will bring personalized medicine to millions.

Our health care system wasn’t designed; it started as a house and grew, unsystematically, room by room, floor by floor, into an immense, complicated castle. Some of the original floor tiles are still there, and an observer can pick out how each generation added different bricks to the walls. How the creative disruption of our health care system will unfold is far from certain, but examples of imminent success should inspire and challenge our thinking:

  1. Self-driving cars are here and seem likely to become ubiquitous soon. Can the self-driving patient be far behind? Or are they already here, scattered among the population, with a few patients taking control, owning their own outcomes, and inspiring others by their examples?
  2. Early adopters believe that current smart technology can be used for routine diagnosis, prescribing, and monitoring of many health conditions and that technology can perform those functions smarter, faster, more conveniently, and more consistently than health care professionals can.
  3. Advanced smartphone-enabled diagnostics (e.g. candidiasis in possible HIV patients) are finding a home in the developing world where convenience doesn’t mean saving time and trouble but avoiding arduous, unaffordable journeys to reach care that is priced higher than what many people can afford.

Inertia, regulation will be in the way

But we’re not yet there. NewHealth may be coming, but it hasn’t yet reached the critical mass where it can expedite delivery, link outcomes to interventions, and reduce waste.

And there will be problems and setbacks. Both over- and under-treatment are definite risks of self-guided care. Every new drug is not another thalidomide or penicillin, but experience will broaden our understanding of consequences of different medical choices. Impatient sufferers won’t wait, and early adoption won’t be without its hazards. A death associated with a patient’s misinformed self-directed care is, of course, a death, but perhaps those deaths sting less than any of the 100,000+ annual U.S. deaths today already caused by medical errors.

How can we help NewHealth thrive? Regulators could, of course, support disruptive innovation, just as communications regulators did in the 1980s. Many skilled professionals in health care would welcome such progress, despite what others say are their vested interests. These professionals will welcome and be sought after by early adopters. Other professionals may overtreat self-misguided patients, but their outcomes will be expensive.

A challenge will be to optimize change without forcing patients or providers to violate laws, and regulators will need to protect the less well-informed from charlatans. For sure, some vulnerable patients and others will need­—or want—some pieces of our established, more paternalistic health care; patients won’t soon be performing their own operations. So NewHealth will challenge the health care system from the outside, but it will also force the system to improve, in our estimation. And in our democratic, pluralistic society, we should expect and appreciate that different people will reach different conclusions even when facing the same choices.

NewHealthers: A noticeable minority

We believe that change is inevitable but will be slowed by inertia and regulatory or monopolistic barriers. Some providers will resent less obedient patients, but others will enthusiastically support more individually appropriate solutions and take risks with their patients. It’s likely that the early adopters (most likely the more affluent and educated) will soon become a noticeable minority in some physicians’ offices. Some health care providers and insurers will see the opportunity and evolve to support these individuals. The rest of us should cheer them on, however disruptive they may at first appear—or we will die waiting too.

Bruce Pyenson is a principal and consulting actuary at Milliman in New York City and a MedPAC commissioner. Gillian Woollett is a senior vice president at Avalere in Washington, D.C.