Greetings from the LHH! I submitted my mileage reimbursement yesterday for my internship visits this summer and had a total of 1,610 miles driven to visit all of my students. That’s about 20% less than last year, but we had eight fewer kids, so that makes sense. It was a lot of windshield time, but it was worth it. Getting to meet with the kids at their internships is really a treat - they get so much out of the experience of being in a professional setting, and the preceptors are usually surprised at how bright they are and how much they can actually contribute. The students really mature through their experience and come back dramatically different in the classroom in the fall.
Speaking of the fall, the Traitor Tree in my backyard has already begun to turn. WTH, Tree? Every year it can’t wait to plunge us into winter. Well, we have at least another month of hot weather - September is always hotter than I remember from my childhood (while June is always disappointingly colder).
So this week I wanted to talk about innovation in healthcare. This is inspired by the podcast I released this week with Dr. Bill Hudenko, a psychologist at the Dartmouth Geisel School of Medicine and Dartmouth Health, who is also a mental health technology entrepreneur and the Global Head of Mental Health at K Health (see Listen below). Bill has been working for years on how to use technology to increase access to mental health care, and improve outcomes. You can get the full story by listening to the podcast, but what I want to focus on here is his latest work with K Health.
K Health offers unlimited text-based mental health care (i.e., you text your provider using your phone) for $49/month. Now even if you have health insurance with a decent mental health benefit, if you are seeing a provider a few times a month, you are going to pay more than $49 in co-pays, never mind if you have a provider who is cash-only, which from my observation is an increasing phenomenon. My students spend more than $49/month on iced coffees from Starbucks (let’s not even get into their White Claw budget). In our interview, Bill talks about the fact that there is solid evidence that text-based therapy is as effective as in-person therapy for most conditions. And this $49 fee also includes medication management, which usually involves a separate payment to a psychiatrist. So it’s really an incredible price reduction, and it’s largely due to the use of technological innovation.
The United States is the leader in health technology in the world. But most of that technology is focused on improving quality, rather than reducing cost. The wide diffusion of MRI imaging, or DaVinci robots are two examples of quality-improving technology that results in higher cost. Let me glaze your eyes over with a couple of graphs.
Here’s a simple supply and demand graph, showing the effect of an improvement in the quality of healthcare - probably as the result of technology such as moving from x-ray to MRI, improved antibiotics, or mRNA vaccines. When quality improves for a good or service, it creates more demand for that good or service. I think we could all agree that surgery with anesthesia would be an improvement over surgery without anesthesia. Adding anesthesia doesn’t reduce the cost of surgery - it actually increases the cost. But it sure makes having an amputation done more palatable. Or a lumpectomy, or pretty much any other procedure. An improvement in quality causes the demand curve to shift to the right. Without a fundamental change in how the good or service is provided, what we see is a movement along the supply curve. When we have an increase in demand, we will see both a higher price, and a larger quantity. This is pretty intuitive - when the price people are willing to pay for something goes up, more suppliers are willing to provide it. So generally, improvements in quality result in more healthcare at a higher price. I’m willing to pay more for surgery with anesthesia than for surgery without it. That’s kind of the story of US healthcare - we get more care, and we pay more for it. (Quality improvements are fundamentally good - as long as we don’t outlaw lower quality options because higher quality options are now available. We do a lot of that in American medicine, unfortunately. More on that another day.)
Another way you can get the same effect as I’ve drawn on the graph above is by providing subsidies to the buyers. When we make buying something cheaper - for example by providing government subsidies to health insurance through the PPACA (Obamacare), or through the new Inflation Reduction Act (IRA), we cause the demand curve to shift right. The buyers don’t bear the full cost of the subsidized service - but the suppliers still get the full price. With a subsidy, the buyer pays part of the price, and the government uses taxes to pay the rest. We get more healthcare, but at a higher price. Subsidies aren’t inherently wrong - but we should not pretend that they don’t result in increased total cost to society.
Some improvements in quality can actually drive down the cost of providing care. Improvements in pharmaceuticals have resulted in shorter hospital stays in some cases. In this scenario, we can imagine the hospital providing the service at a lower cost. When providers can reduce their cost (i.e., provide the same procedure, but with fewer bed days - bed days are a real cost to hospitals), this is represented as a right shift of the supply curve. A right shift of the supply curve can be thought of as providers being willing to provide the same service for less money, or more service at the same price. Either way, what you get is more healthcare at a lower cost. We have seen this in services like lasik, contact lenses, and most cosmetic surgery.
Coming back to Bill and his work with text-based therapy - Bill is offering a lower cost solution to mental health care. Text-based mental health care allows for more scale through more efficient use of provider time - it shifts the supply curve to the right, as is shown in the second graph. It also offers the possibility of AI support, which we talk about a bit in the interview as well.
Talking with Bill really made me more hopeful about a real revolution in healthcare than I have been in some time. Most of what I have been watching over the past few years - in terms of consolidation of health systems, for example, or arguments for further subsidies as in the IRA - seems to be rearranging the deck chairs on the Titanic - prices just keep rising because we aren’t fundamentally changing the way we provide care. And I believe we provide really good care in general. There is a reason why rich people around the world come to the US and don’t go to, say Canada or Great Britain for their healthcare, even though their care is cheaper.
So do check out my interview with Bill. I’ve also included a couple of links that are relevant to innovation and I’ll talk about them below.
So with that, willing good for all of you, I present you with the links!
(pic above is the Traitor Tree hanging out in my backyard)
Read
What: Hat Habits, How to Innovate – part three: the Subtraction technique
https://hatrabbits.com/en/subtraction-technique/
Why: So my immediate response to text-based mental health care was it can’t possibly be the same quality as face-to-face care. Bill assures me it is in terms of outcomes. But you could say the same thing about cars. A Ferrari will get me from the LHH to the parking lot at UNH. So would have the Adventure Van (my 17 year-old Honda Odyssey I used to drive). Same outcome. Different experience. So to me, that’s how I think about text-based care. It’s the Honda, or maybe Kia, of mental health. But if you only care about getting from point A to point B, or going from depressed to functional, then the Kia is just fine.
My two favorite books on innovation are Inside the Box: A Proven System of Creativity for Breakthrough Results by Boyd and Goldenberg, and The Innovator’s Dilemma by Christensen. More on the Christensen book in Watch. Inside the Box proposes a series of ways of tools for helping you innovate. One of them is Subtraction, discussed here. The idea is to clearly describe your good or service, and then take away some key characteristic and see what you come up with. Take mental health therapy. What does traditional therapy look like? It’s pretty simple - an office, two chairs, a therapist and a patient talking. What would happen if you took away the office? Remote therapy. This results in an immediate cost reduction - the provider no longer has to pay for an office - so you get the much desired right-shift of the supply curve (the second graph), and therefore lower cost and more visits (more access). What if you then take away the video? Text therapy. Now the patient and provider can engage in asynchronous exchanges. Another right shift, lower cost and more access.
This blog post briefly explains subtraction, but I really recommend Inside the Box if you are interested in this sort of thinking.
Watch
What: VIDEO BOOK SUMMARY, "The Innovator's Dilemma" by Clayton Christensen (4 min)
Why: Here’s a 4-minute summary of The Innovator’s Dilemma, which I also recommend. Christensen popularized the idea of “disruptive innovation”, which has been grossly overused and misused at this point.
In a few words, disruptive innovations are less powerful, and deliver less benefits, but they focus on a specific need for a larger group, and importantly at a lower price point so more people can be served. Text-based therapy is basically all of that. You don’t get the fun of going to a therapist’s office and having her/his undivided attention for an hour, but you do get better access at lower cost, and with much more convenience.
The book is definitely worth reading if you haven’t yet.
Listen
What: Health Leader Forge, Dr. Bill Hudenko, PhD, Global Head of Mental Health at K Health
https://healthleaderforge.blogspot.com/2022/08/dr-bill-hudenko-phd-global-head-of.html
Why: If you made it this far, I won’t waste more of your time. Please give the interview a listen. You can skip to the mid-point if you just want to hear about text-based mental health.
Thanks for reading and see you next week! If you come across any interesting stories, won't you send them my way? I'd love to hear what you think of these suggestions, and I'd love to get suggestions from you. Feel free to drop me a line at mark.bonica@unh.edu , or you can tweet to me at @mbonica .
If you’re looking for a searchable archive, you can see my draft folder here: https://drive.google.com/drive/folders/1jwGLdjsb1WKtgH_2C-_3VvrYCtqLplFO?usp=sharing
Finally, if you find these links interesting, won’t you tell a friend? They can subscribe here: https://markbonica.substack.com/welcome
See you next week!
Mark
“The meaning of life is to find your gift. The purpose of life is to give it away.” – Pablo Picaso