Tuesday, December 31, 2013

ObamaCare 2014:  Tale of Two Americas

Two Americas have emerged in health care reform: states like California, which have embraced ObamaCare, have enthusiastically implemented its key provisions, and are intent on boosting enrollment and ensuring its success; and states like North Carolina, whose political leaders oppose ObamaCare, resist its implementation, reject Medicaid expansion, and hope that the program collapses.

Jonathon Oberlander and Krista Perreira, “Implementing ObamaCare in a Red State – Dispatch from North Carolina,  New England Journal of Medicine, December 26, 2013

2014 will be the story of two Americas  - Blue states versus Red States,   progressive versus conservatives,  inside the Beltway crowds versus outside the Beltway masses, bicoastals versus inlanders,  Obamacare believers versus nonbelievers.

Given these dualities,  President Obama has two choices: one, compromise with his distractors or confront them.  I predict he will choose that latter course by issuing executive orders and staking out his philosophical differences with the GOP.  Bringing in John Podesta to spell out these differences is one signal of this approach. Another is his history of taking unilateral actions, such as ramming ObamaCare down the GOP’s throat,  changing the law 21 times without consulting Congress,  using the IRS to punish his adversaries by denying them tax-exempt status,  repeatedly deceiving the public with claims that could keep their doctor and health plan,  and charging ahead with healthcare.gov to meet a political deadline after being forewarned it was not ready and might fail.

This is a president that takes inordinate pride in his namesake, ObamaCare.  He is not about to change it because of dropping polls showing distrust in his leadership or its lack of workability.  He will campaign on this issue through a national PR effort, raising money from celebrities, exciting his base with his partisan passion, issuing good news stories about Obamacare benefits.  He will try to work around Congress. He will strike out with executive actions. He wlll demean and ridicule Republicans for failing to cooperate.

But there are big Red Lines obstructing his path to November 2014 electoral glory.   Two obstacles are: one,  the Red States with their 30 GOP governors,   their 680 state legislators,   and the 63 Republican House members and Senators -  all elected in the 2012 midterms; and two, the June 2012 Supreme Court decision allowing states to opt out of Medicaid expansion.   These two events imperil the main intention of ObamaCare dream – to provide coverage for the uninsured and underinsuref and to expand Medicaid.. 

But as the proverb says: the road to hell is paved with good intentions.  And as Joseph Epstein points out in “ObamaCare and the Good Intentions Paving Co” WSJ, December 31, 2013), “ ObamaCare is a nearly perfect example of the Good Intentions Paving Co. at work.  A President and the leadership of his party decide what it would be a fine thing to bring universal health insurance to the nation – what a sweet notion, really – except when they enact the law, it turns out to bring in its train confusion, anxiety, probably loss of employment, added personal and public expense, and aggravation all around. “

Now  the nagging  thought of a repeat of the 2010 midterms in the 2014 midterms haunts the Democratic party. For good reasons.  The IRS scandal punishing conservatives,  the horrendous healthcare.gov rollout,  health plan cancellations exceeding enrollments, and skyrocketing premiums and deductibles,   have aroused the Tea Party, mobilized conservatives,  and sunk Obama in the polls.  Only 16 states have embraced Medicaid expansion, 25 have declined,  and 34 have told the federal government:  “You set up our exchanges. We do not believe in them. You explain this confusing, complex, and controversial law.  It’s your law, not ours.”

Or.  in the words of Oberlander and Perreira in their NEJM piece:  “The ACA is a national law, but its implementation varies substantially across the country.  Two  Americas have emerged.”

The botched ObamaCare rollout, Obama’s known deceptions, and widespread health plan cancellations, have intensified opposition to the health law.  This opposition will grow right up to the November midterms,  barring unforeseen developments, such as a booming economy, sudden  public embrace of ObamaCare’s benefits,  and a perfectly functioning healthcare.gov website.  These events could prevent another midterm nightmare. Meanwhile Obama must figure out how to make the ACA work in states whose governments are rooting for working to ensure its failure.   And he must strive to keep the Good Intentions Paving C. from going out of business. 

Tweet:  America is divided into two countries – one, favoring and embracing Obamacare, and two, the other rooting for its failure.

Monday, December 30, 2013

We Can Do Better Than This

There is another and a better world.


 I have composed 3200  blog posts over the last 7 years under the blog title of “Medical Innovation and Health Reform.”  As I write these pieces, I find myself saying, “We can do better than this.”

I define medical innovation as doing things simpler, cheaper, more conveniently, and better.  I define health reform as changing things for the better.

In my opinion, current health reform efforts do not meet these tests.  The health law is too complicated, expensive,  inconvenient, and it  has not improved quality.   

We can make it simpler.   

We can trust patients more by encouraging them to have health savings accounts with high deductibles.  They can choose the care they want up to the level of the deductible, and they can set aside money they do not use for health purposes for retirement and other uses.  We could issue a health savings account  to each citizen  at birth and let them pass it on to their heirs. Patients with “skin in the game” use less care and pay lower premiums.

We can make it less expensive by removing third parties from the doctor-patient equation.   Physicians will tell you dealing with third parties accounts for more than half of their overhead.   That is why doctors going into concierge practices can cut their rates by more than half.    We reduce premiums by cutting the number of regulations with which doctors and hospitals must comply.  

We can render it less expensive by making  prices transparent,  posting them in offices and hospitals and on the Web.   We can let  patients shop across state lines for the best price  and the best listed outcomes.  We can make  all health transactions tax deductible.  We can institute  national tort reform, have health courts pay  for medical injuries and make lawsuit-losers pay,  thereby reducing the number of frivolous lawsuits and the high malpractice rates physicians and hospitals must pay.

We can transfer some decision making and patient support to other health professionals rather than doctors and to patients themselves. Nurse practitioners and physician assistants are effective in treating patients.   Patients already can interpret pregnancy tests, glucose and hemoglobin A1C levels,  lipid results, the meaning of body mass indices, and DNA implications.

We can make care more convenient for patients and doctors.   We can let patients choose their own doctor.   We can let patients choose their own health plan.   

We can encourage patients and doctors to make better use of online information technologies.  

The list of ways to do this is impressive and growing  -  convenient scheduling, prescription renewals,  posting of test results through physician websites; email communication between patients and doctors,  encouraging patients to compose their medical histories through the use of clinical algorithms;  having patients carry their medical histories on cards in their wallets and purses; monitoring patients vital signs,  heart rhythms, an complications  remotely through embedded sensors;   evaluating patients  at home and in remote locations through Skype and similar technologies;  and predicting future diseases and impact of treatment based on a person’s genomic makeup.

Tweet: We can make better use of medical innovations, and we can achieve better health reforms than we are now doing

Sunday, December 29, 2013

Obama’s 2nd Term Hinge of Fate

To depend on or turn on, as in "Everything hinges on his decision."

Hinge, definition

To say that President Obama’s  2nd term hinges on how ObamaCare  turns may be an overstatement.  But not by much.  ObamaCare will dominate the political discourse from now until the November midterms.  It is, at the same time,  Obama's  Achilles Heel and his Great Opportunity.

Already the media are predicting chaos after January 1.  A perfect storm seems to be gathering over the healthcare.gov fiasco, the millions of health plan cancellations,  and the uncertainty and skepticism among the public about what comes next.

What can President Obama do about this perfect storm ?  He can talk of the good things ObamaCare has wrought.  He can launch a PR campaign to persuade the public it is the right thing to do for the public good.   He can mobilize his political and celebrity surrogates to go forth and spread the word.  He can seek to convince the invincibles. He can, in short, talk the good talk and promote the good cause.   But these tactics may not be enough.  Distrust of his role in the health law is simply too deep. 

Obama  can do something else.   He can be humble.  He can say the ACA hasn’t worked out as planned.  He can say mistakes were made -  unilaterally passing the law without a single GOP vote and  not living up to his promises that people could keep their doctors and health plans.   He can apologize for failing to bring down premiums and deductibles.    He can say to contain these costs health plans had to narrow the numbers of doctors and hospitals they could access,  that patients might have to switch doctors, and they might see their benefits cut. 

And he might even follow the example of Winston Churchill in these  dark days of World Ware II when Britain's fate hung in the balance.   He can acknowledge the  confusions, uncertainties, and unforeseen consequences the law has generated. President Obama  csn  straightforwardly  say things might go badly in the short term, in January when the law takes effect and perhaps right up to the November midterms.

In 1942,  when things were going badly for Britain in World War II, with one British defeat after another in the deserts of North Africa and the seas of Southeast Asia,  Churchill called for a Vote of Confidence in the House of Commons to warn the Nation of dark days ahead and coming misfortunes.

Said Churchill:

“There is no worse mistake in public leadership than hold out false hopes soon to be swept away.   The British people can face peril or misfortune with fortitude and buoyancy, but they bitterly resent being deceived  or finding that those responsible for their affairs are they themselves living in a fool’s paradise. I felt it vital not only to my position but to the conduct of the war, to discount future calamities by describing the immediate outlook in the darkest terms.” (Winston Churchill,  The Hinge of Fate, 1950).

Churchill asked for a free debate, for things to be said in plain English.   “No one need be mealy-mouthed, and no one should be chicken-hearted in voting.”

Obama should call for a free debate about the merits and faults of the health law. It has plenty of both.   He should express both sides  in his press conferences and his State of the Union address in January, and he should pull no punches in discussing either the bright and  dark sides of the law.   He should acknowledge that he has made 21 changes in the law to correct its deficiencies, many of which are self-inflicted and poorly thought out.  He should call for full debate and ask for  a Vote of Confidence in the primaries and the General Election in November.      This is too large an issue to be swept under the political rug or to generate false hopes.

Tweet:   The ObamaCare issue will dominate the national political debate between January and November, as it should.

Saturday, December 28, 2013

My Gratitude List for 2013

I’ve got a little list – I’ve got a little list.

Sir William Gilbert (1836-1911), The Mikado

I’ve got a little list of things for which I am thankful.

I am thankful:
 I was born in the U.S. with its long traditions of individual freedoms and independent thought;

·         we have an open society,  where we can openly debate controversial issues without resorting to violence;

·         we can conduct this debate without fear of economic  reprisals or discrimination;

·         we can openly criticize our government without being considered bigoted or prejudiced;

·         we have bottom-up enterprising society that  gives us a resilient and flexible economy capable of rebounding from down cycles and bad government;

·         we can practice our faith and express our beliefs without censorship;

·         we are tolerant society capable of adjusting to new and emerging social and cultural norms;

·         we have a checks and balances political system with a guiding constitution  that prevents one-sided governance or dominance by one political party;

·         we have the ability to correct, modify, and change our laws and even repeal them should they prove to unworkable for the majority of our citizens;

·         we have a high-tech, high touch  medical system that most of our citizens approve of despite its obvious faults – high prices and limited access to the vulnerable, poor, and uninsured among us.

·         we remain a world leader in producing technological innovations that benefit and connect all peoples;

·         we believe,  in spite of our political beliefs, conservative, liberal,  independent,  or libertarian, that a strong social net is needed to protect the disenfranchised, and the rest us should pay to keep that net intact.

Tweet:  As a U.S. citizen,  I am thankful for our freedoms, enterprising spirit,  wealth,  tolerance,  technological excellence, and abundance of choices.

Friday, December 27, 2013

Forecast for 2014

Forewarned forearmed.

Cervantes (1647-1616), DonQuixote de la Mancha

D.C. = Darkness and Confusion

Washington pundit on meaning of D.C. as in Washington, D.C.

George Carlin (1937-2008) once gave this nightly weather forecast:

 "Continued darkness with widely scattered light in the morning." 

 I feel the same way about the Obamacare forecast for 2014:

 Continued darkness until November 2014 followed by widely scattered light for the remainder of President Obama’s lame duck term.

Here is the rest of the forecast.

1.       Darkness and confusion will reign in Washington and in contested Senate and House races until November
2.      Republicans will  rain on Democratic parade by repeatedly airing “ You can keep your doctor and health plan, Period” video clips and by featuring unsubsidized voters who cannot afford new health exchange plans.

3.      GOP will retain House and win Senate by one vote. Six senators in states won by Romney will lose.

4.      Congress will vote to repeal ObamaCare. Obama will veto, and veto will not be overridden.

5.      President Obama’s approval rating will drop into low 30s,  and approval rating of health law will plunge to 25.

6.       Ten million more Americans,  not only in individual, but in big group markets, will lose their coverage.

7.      Ten to twenty million Americans will join Medicaid ranks. Many of these will have hard time finding doctors to care for them because more than 40% of doctors will not accept new Medicaid patients because of low reimbursements and bureaucratic hassles. 

8.     A number of lawsuits will successfully challenge President Obama’s ignoring and unilaterally changing ObamaCare provisions without consulting Congress.

9.       Costs of insurance and deductibles will continue to rise as young fail to meet quota of 2.3 million by March 31,  and death spiral,  higher rates for older citizens, sets in.

10.  More Americans will lose their insurance than will be covered by health exchanges.

11.  Penalties for those who did not buy coverage or who were unable to do so because of healthcare.gov malfunction will not be enforced or will be delayed because it will become a raging controversy.

12.  Democrats will scramble for cover from ObamaCare and will ask for delay or suspension of individual mandate and extension of employer mandate.

13.  Stocks for health plans will plunge as ObamaCare raises expenses and cuts profits.  Congress will be forced to bail plans out to make ObamaCare  viable.

14. There will continue to be clouds and turbulence until Congress presents and passes an alternative plan containing these features universal health tax credits,  competition among health plans and providers across state lines, easily accessible health savings accounts,  price transparency, disruptive innovations,  fewer regulations,  and national tort reform.

Tweet:  The weather forecast for 2014 for ObamaCare is continued Darkness and Confusion followed by scattered light after November elections.

Thursday, December 26, 2013

ObamaCare Legitimacy and Coercion Problems

The care of human life and happiness, and not their destruction us the first and lonely legitimate object of good government.

Thomas Jefferson (1743-1826)

The Obama administration has a problem.  Americans are unhappy with its governance.  Only 30% think the country is headed in the right direction, and only 38% approve of the health care law.  Their main gripes with the health law are denial of personal choice, distrust of big government's competence, and difficulties and frustrations of signing up for health exchange plans.
Government  distrust focuses on competence  - the healthcare.gov fiasco – and coercion - the use and abuse of “mandates”  to force people to buy something they do not want – unaffordable and expensive  health exchange plans  containing  benefits they do not want to subsidize others.

The healthcare.gov rollout fiasco highlights the competence problem.   

How could the government be so incompetent as to  launch an untested website that is so hard to use?  

And how could government be so unfair that it would impose penalties on people who were unable to sign on because of the botched website?  

And what those millions of cancelled policies?  

And what of those unaffordable premiums and soaring deductibles  for the unsubsidized and those promises you could keep your doctor and your health plan?

And those “mandates”?  That’s another kettle of foul smelling fish.  \

How can you force people to buy policies containing benefits they do not want, do not need,  and will never use in order to subsidize other people.  The Obama administration has not sold people that they must participate in the exchanges for collective action for the common good.

As David Brooks wrote in his December 23 NYT column:

“It is pretty clear that the implementation of ObamaCare will set the tone of how Americans think about government for years to come.   There are two large questions to be settled, which you might call competence and coercion?"

In America, with the penchant of its people for individual choice, and given these overt displays of incompetence and mandates imposed from above,  how can you coerce people to do what they don’t want to do,  in the short-term as well as the long-term? 

The Obama administration has responded by backing and filling holes in the law, by loosening, delaying, and suspending objectionable provisions.  And now it has granted “hardship exemptions” to those who cannot even afford bronze health plans,  the cheapest of them all.  Thanks to the Internet, people are used to  personal  and decentralized choices. 

When will the exemptions never end?  When will  people consider the penalties for not signing up be considered legitimate?  Maybe never.  As David Brooks so trenchantly says, “Government lacks the legitimacy to coerce.”

Tweet:   Because of incompetent rollout of healthcare.gov and unpopularity of coerced “mandates,” implementation of ObamaCare will be difficult.

Monday, December 23, 2013

Understanding ObamaCare

A President needs political understanding to run the government, but he may be elected without it.

Harry S. Truman (1884-1972), Memoirs, Volume II, Of Trial and Hope

My E-book, Understanding ObamaCare: Travails of Implementation, Notes of a Health Reform Watcher, will be out in January.

What is the book about?

It is not so much about understanding ObamaCare, but about Obama and his health law  understanding America and its general and healthcare culture.

To wit:

We are not necessarily in this all together collectively.  We are in this separately as individuals as well.

As individuals we rely upon one another, but we rely on ourselves as well. 

We expect to earn our own keep, to make our own choices, to be self-reliant, to cherish common values that got us where we are as a  nation,  to elevate ourselves to the level of our talents,  to realize our ambitions, to pay out of pocket for what we want, and to help each other when in need.

We are in this to enjoy our individual freedoms, to lead our lives as we see fit,  to follow our own North Start, rather than to be under national surveillance or marching orders.

We are a diverse, pluralistic people, and we expect to be treated as such. 

Our medical system is diverse not uniform, and its caregivers and receivers are heterogeneous not homogeneous.  One size does not fit all. 

We cannot be standardized.  

Patients and doctors move to different drummers, and each is perfectly capable of making medically intelligent decisions.

We are an independent. not a dependent people.

We do not like to watched or be lectured to about what we can and cannot do. We do not like too many rules and regulations.

We are entrepreneurial and enterprising.  

We like elbow and head  room to rise above the common herd. 

Given that room, we believe one person raises the other up – to a higher level of personal, public, and national achievement.

We are a people of genius – a land where Steve Jobs, Bill Gates, Warren Buffett, and Oprah Winfrey can rise to the top of wealth, power, and influence.

We are a free-wheeling democracy, not a sclerotic welfare state.  

We believe people should be able to speak their minds without being labeled as extremists or as politically incorrect.

We believe people should be able to pick their own doctors and their own health plans, or no health plan at all, and take their own medicine, even if that medicine is ineffective and does not meet federal standards.

We believe in specialized excellence and well as generalized compassion -  in being the best and getting the best.

We are a bottom-up.  not a top-down society. Every region of the country and every state makes its own choices of what it wants and what is best for its fellow citizens,  what institutions if supports, and what its people need..

We believe in actions, not words, in results, no rhetoric, in excellence, not in control.

These days Americans are not fond of the word "mandate," perhaps because it rhymes with "dictate" and perhaps because we are increasingly distrustful of Big Government.

Tweet:   Understanding Obamacare  begins with understanding American culture and what it stands for.

On Health Law’s Latest Tweak

A tweak, according to my dictionary, is a jerk, a pinch, or a twitch, often of one’s nose or ear.

Tweak Definition

The Obama administration’s latest tweak,  compelling insurers to offer “bare bones” coverage to those with cancelled plans has AHIP (American Health Insurance Plans) rattled. 

Says Robert Zirkelbach,  spokesperson for America’s health insurance plans, “ This type of last minute change will cause tremendous instability in the marketplace and confusion and disruption for consumers.”  

Karen Ignani,  AHIP president, is unhappy.  She and her group, tried to kill the law when it was being debated. And since its passage,  they have built up hopes the ACA’s new enrollees will reap billions of dollars in new policies from the individual mandate.   

Now she ruefully notes, individuals have “ a path around the mandate.”  This latest tweak could cause AHIP to lose billions if it causes few people to sign up for ObamaCare.  The industry  feels it  may be  victim of a flawed law  that has gone off the rails in ways they predicted it might.

The “catastrophic bare bones”plan is merely the latest twitch
Of 20 of this year's  tweaks in the multilayered ACA sandwich.
Having first opposed and then supported the ACA, can  AHIP now take a principled  stand,
When unexpected changes like these may be more than their profit structure can withstand?
What happens if fewer enrollees are there in January  to post a check,
Does AHIP then just become the caboose in the ObamaCare train wreck?

Tweet:   As the WSJ December 23 headline says, “Health Deadline Rattle Industry: Rule Changes Poses Test for Insurers.”

Friday, December 20, 2013

Another Day, Another Individual Mandate Delay

Delay is preferable to error.

Thomas Jefferson (1743-1826), Letter to George Washington

Yesterday the Obama administration issued another change,  its 21st, in its health care law.    This change gives a “catastrophic exemption “ to those whose plans have been cancelled for failure to meet federal standards and who cannot afford a government plan. People will now be able to keep their “bare bones” plans.   This is in response to public outrage over plan cancellations for 6 million Americans and higher premiums and deductibles for replacement plans.

Some are calling this latest federal action a “Hail Mary”pass  to save ObamaCare and its unpopular individual mandate.   

This “catastrophic exemption” raises a fundamental question; Is ObamaCare an unworkable failure, a rolling disaster,  a cataclysmic catastrophe,  and merely the latest in a string of strategic mistakes?

These mistakes include:  going whole hog on reform rather than approaching it incrementally,  arrogantly stiff-arming the GOP rather than asking for their input into the specifics of the law,  and changing the law 21 times through “executive orders” through improvisational delays rather than consulting with Congress.

ObamaCare may not yet be a catastrophe,  but it’s getting there when its various provisions,  heretofore abstract theories become concrete realities.    The American people do not like what they see, and they are responding by not signing up for health exchanges and by expressing their disappointment in countless polls.   

 The issues in question  are mainly three: one distrust because of broken  government promises, two, uncertainty about future costs and access to health plans and doctors; and three, concern about government incompetence in rolling out healthcare.gov.

Why not  back off, Mr. President, and admit you made some mistakes in your path to reform?   

Why not delay ObamaCare for a year?   

Why not consider the obvious options – retaining coverage for pre-existing illnesses and young adults under their parents’ plans, modifying the individual mandate to fit the needs of the young and others,  expanding Medicaid under the individual state’s direction,  selling plans across state lines,  tax credits for all, health savings accounts for all,  and national tort reform?

Tweet:   ObamaCare is in trouble,  as shown by government changing it 21 times,  e.g.  “catastrophic exemptions” for those who can’t afford it.

Thursday, December 19, 2013

Health Care Inefficiency: Is There a Cure?

Curing Health Care: Six Prescriptions for What Ails the Industry

HBS Alumni Directory Bulletin,  December 2013

Given the complexity and resistance to change of the U.S. health system, is there a cure for its complexity?   And, if there is, will the cure by politically, consumer, patient, physician, or managerially driven?

I do not know. But Regina Herzlinger,  a professor at Harvard Business School,  has an idea who does. 

In her 1997 book, Who Killed HealthCare: America’s $2 Trillion Medical Problem and the Consumer-Driven Cure, she asserts only consumers can cure the system.  We cannot, she says, depend on health-insurers, general hospitals, employers, the U.S. Congress, or academics,  to remake health care.

I thought of professor Herzlinger when I read an eight-page section of the December issue of the HBS Alumni Bulletin entitled “Curing Health Care: Six Prescriptions of What Ails the Industry.”

Who will prescribe the cure?  Will it take consumers or outside experts in managing complex social systems? 

Maybe it will require imaginative people asking, not how to change what is, but what could be.   Maybe the present forces at work are like the proverbial ostrich.   They can run, but they can’t soar – innovate sufficiently with large enough ideas  to reach a practical solution.

In any event, here’s a quick rundown on Harvard Business School alumni and faculty members prescriptions for cure.

·         The first prescription, “Free the Data!” features the work of Jonathon Bush (MBA 1997).    Bush is CEO of athenahealth, a $42 million firm in Watertown, Massachusetts with a 30% annual growth rate.  His company sells cloud-based software.  The software helps physicians communicate and share information.  It tracks and manages test results; aids patients in making appointments, and seeing test results; and assists physicians in improving collections.    His firm rises above the common IT herd, by, among other things, allowing physician EHRs to talk to other EHRs and to do so without installing  in-office EHR systems.
·         The second prescription, “Build a Killer App, “ describes the work of Halle Tecco (MBA 2011) at Rock Health, a San Francisco-based company that organizes an annual  Health Innovation Summit Conference and offers aspiring entrepreneurs free-access in “The digital start-up space.”  The root idea is to deliver health care at the lowest possible cost in innovative ways.   How this can be achieved, given the burdensome handicaps imposed by government regulation, s challenges would-be health entrepreneurs.   Rock Health’s approach is the classic Silicon  Valley  solution  - bring like-minded entrepreneurs together;  let them socialize, compare notes, and collaborate, and in the process, evolve innovative answers to tangled thorny problems.
·         The third prescription,  “Measuring Health Care’s Real Costs, “ rests on the work of HBS professor Bob Kaplan.   It concerns his work at MD Anderson in Houston, where he has applied his concept of “Time-driving activity-based costing (TBABC) to real time cancer care.  TBABC identifies the time of people and equipment needed to perform a service and to reduce time and cost, for example,  to perform a test, schedule a procedure, and see the results. Here the idea is that there always room for improvement when an outsider with a critical eye looks a complex situations, improves  and  lowers cost, and measures results to provee the point..
·         The fourth prescription,  “Making Medicine Personal,” involves the work of Gregory Stock (MBA 1987).  Stock speaks of preventing disease and improving outcomes through the proactive use of simple  genetic markers, e.g., DNA in saliva and buccal mucosa scrapping, to identify environment factors such as mercury in dental fillings or in certain fish.   By using available techniques to identify toxins and their effects, Stock feels we may be just at the beginning of a biomedical revolution through use of personal genetic markets.  “Things are about to catch fire,” says Stock, “It’s a virtuous cycle where more access brings more knowledge and value.”
·         The fifth prescription, “Leveraging Human Nature,” concerns the work of Nava Ashral, HBS associate professor.    In Zambia, this behavioral economist has investigated how people’s behavior in buying condoms  has slowed the HIV epidemic in that country.   She found hair dressers sold twice at many condoms are anybody else.     She feels studying behavior patterns at the community level   may be more productive in bringing about  and improving outcomes than costs of care and medically-induced changes.  She and her colleagues strive to get people to use what they need and to buy what they need in the normal course of their day-to-day lives. 
·         The sixth prescription, “Integrate Preventive Care and Payment,”  relates the activities and highlights the idea of Seth Blackley (MBA 2007),  Frank Williams (MBA 1977), Harvard alumnus Tom Peterson, all backed by the UPMC Health Plan and by David Bradley (MBA 1977),  Bradley is founder and  chairman of the Advisory Board in Washington, D.C.  Together they participated in and helped found and further the mission of Evolent Health – to bring together people, processes, and technologies to create a provider-lead, clinician-driven  system focusing on preventive care.   Evolent  seeks to change the fundamental  nature of health care payment- by intervening in a more holistic way before patients reach the emergency room or the physicians office or are hospitalized.   The believe they can achieve this goal through “full-care teams” and health care coaches instructing patients what to do short of seeing health care professionals.   Evolent is now working in 15 markets, soon to expand to 30 or 40 markets.   TPG Growth, a venture capital firm, recently invested $110 million in Evolent.  Says Blackley, “Working in health care right now is like joining Google in 1999,  We’re on the cusp of a reinvention of a huge sector of the economy.”