1. Creative Destruction:
What Doctors Must Know To Thrive in the Brave New World
of American Healthcare
Yuri Kruman
10/14/15

2. Bio / Approach
 B.A. in Neuroscience (UPenn)
 Ph.D. coursework in neuroscience (NYU)
 J.D. from Yeshiva University (Cardozo School of Law)
 Law: helped defend physician from lawsuit by insurance company
 Finance: project manager in banks, hedge funds
 Health Tech: co-founded MoreSpinach, Inc. (Health Insurance),
Finance/Operations at Maxwell Health (Benefits Admin SaaS),
Product Management at Liazon (Benefits Admin SaaS), Doctor
Acquisition at Baby Doctor (Pediatrics-on-Demand app, launching
this week)

3. Overview
 Medicine is Business
 Legacy Thinking in the Medical Profession
 Current Trends in Healthcare Delivery
 The ACA for Docs – Burden or Boon?
 Personalized Medicine – The Future or Myth?
 Where Tech is Taking Medicine
 Thar’s Gold in Them (Data) Hills!
 In An Ideal World…
 Takeaways for Doctors and Med Students

4. Medicine is Business
 Effects of ObamaCare – Kaiser Study on Effects of ObamaCare
on the Medical Profession
 Malpractice insurance, admin costs are only increasing
 Consolidation of insurance companies (fewer plans available,
prices will rise)
 Increased costs for claim reimbursement, higher procedure prices,
lower reimbursement rates
 Consolidation of hospital systems (more streamlined care, but
more expensive)
 The cost of price transparency for procedures – market forces
will lead to increased competition, lower prices and
commoditization of healthcare

5. Legacy Thinking in the
Medical Profession
 Business as Usual while Rome Burns
 Guild mentality and over-regulation, as in the legal profession (also in the
process of being creatively destroyed)
 Medical Paternalism (avg. of 17 years training before practice)
 Ex: The AMA lobbied the Obama Administration to prevent patients from
accessing their own genomics data.
 90% of physicians surveyed expressed discomfort with using genomics data in their
diagnoses and to determine treatment
 Slow adoption of EHRs, technology, experimental and alternative
medicines – chronically behind the curve of science and technology
 Shifting healthcare landscape means every doctor is either a savvy
entrepreneur or an hourly wage worker

6. Current Trends in
Healthcare Delivery
 Only 30% of doctors remain in private practice today – getting lower by the
day
 Health systems hold all the power of scale and leverage over physicians
 Malpractice insurance and overhead admin costs rising
 Claims reimbursed at lower rates with ACA’s Medicare provisions
 Fewer people entering the profession
 Nearly half of physicians said they would not advise a young person to pursue a
career in primary care.
 Barriers to Entry = Death by Acronym: ACA, EHR, MU, PCMH, PQRS, MOC, ACOs,
PPO, HIPAA, etc.
 Central actors: Health system CEOs, politicians, NOT doctors or patients
 Keys to the equation: cost containment, effective treatment direction by health
insurers and politicians
 Smartphone as primary vehicle of healthcare delivery, doctor-patient
communication
 Telemedicine and on-demand medicine becoming more prevalent – without

7. Current Trends in
Healthcare Delivery
 Biggest population serviced: retiring Baby Boomers (also end of life care)
 ER-ization of Medicine: Per a May 2015 poll by the American College of
Emergency Physicians (ACEP), 75% of emergency physicians report that
emergency visits are going up.
 This represents a significant increase from just one year ago when less than half
reported increases. Rather than trying to keep people out of emergency departments,
policymakers need to recognize the value of this model of medicine that people want
and clearly need.
 CityMD and other local ER centers have popped up like mushrooms all over NYC in
the last 5 years
 Specialization = Survival –> death of the GP
 Competition with Dr. Google – everyone’s an instant expert
 Price transparency tools gaining ground – market forces taking root
 Specialized concierge services, including medical tourism

8. The ACA for Docs – Burden or
Boon?
 Physicians’ opinions of the law: highly polarized, but not reflecting
actual effect on practice
 Kaiser Family Foundation / Commonwealth Fund Study (June 2015):
 many providers reported seeing an increased number of patients since the
coverage expansions went into effect, but not an accompanying compromise in
quality of care.
 large majority of primary care providers are satisfied with their medical practice,
but a substantial percentage of physicians expressed pessimism about the
future of primary care
 many providers feel that the amount of time they have with each patient and the
time they spend on insurance administration issues have gotten worse.
 reported rate of new patient acceptance among primary care physicians has
declined slightly (89% to 83%), but the share accepting new Medicaid patients
remains about the same at 50 percent.
 Most providers said their ability to provide high-quality care to all patients has not
changed since January 2014 whether or not they have experienced increases in
their Medicaid or newly insured patient populations
 a large majority of primary care providers— Democrats and Republicans alike—

9. Personalized Medicine –
The Future or Myth?
 Eric Topol: population health is on its way out in favor of
personalized medicine
 Wearables/Biosensors – soon-to-be ubiquitous, but often
inaccurate and a privacy nightmare
 Everything from FitBits to diagnostic diapers (SmartDiaper) – everything
will be monitored to death and increase anxiety among upper middle
class
 Affordable Diagnostics: genomic testing (23andMe), blood testing
(Theranos) microbiome testing (uBiome) – still huge privacy
concerns re: data
 1% + Tech Elite vs. everyone else – huge gap in availability and
information due to cost
 Will this gap remain or disappear with economies of scale,

10. Where Tech is Taking
Medicine
 MOBILE – smartphone as the new center of gravity in diagnosis,
adherence, communication
 Optimizing sleep, blood glucose and other critical health habits through apps
 Secure communication between doctor and patient
 Secure patient data storage, sharing on social media
 Smartphone detection of skin and other cancers, other diseases (Mobile ODT,
SkinVision, MoleScope, CellScope, others)
 Wearables – FitBit, Jawbone, etc.
 Questionable accuracy of data; only a matter of time before standards are
established.
 Question as to the real value of this data beyond the basics.
 Genomic and microbiome diagnostics - 23andMe, uBiome, etc. –
endless diagnostic and preventive uses
 Preventive Dentistry – catching signs of chronic disease years before
they develop
 Longevity - Blue Zones, Calico – mimicking diets and lifestyles of long-

11. Where Tech is Taking
Medicine
 Crowd-sourcing diagnoses - CrowdMed - helping solve
entrenched medical mysteries
 3-D Printing: organs, tissues, prosthetics on demand
 Medication adherence tools – AdhereTech, etc.
 Telemedicine – Teladoc, HealthTap, MDLive
 On-Demand Medicine – Baby Doctor, Pager, Heal, PediaQ
 Improved claims software – Virtual Benefits Administrator, Plexis
Payer Platforms, etc. – automatic claims processing, lowering
overhead costs and errors
 Care pricing transparency tools - Castlight Health, Zakipoint
Health – enterprise health spend optimization; Symbiosis Health –
consumer out-of-pocket spend optimization

12. Thar’s Gold in them Hills (of
Data)
 Ex: Penn Signals - tools for building predictive applications based on
historical data, as well as real-time data in Penn Med’s EHR system
 Ex2: NIH’s “BD2K” (Big Data to Knowledge) initiative - allows physicians
to analyze patient data and vast healthcare histories databanks to
determine which patients may be at greater risk of developing conditions
such as diabetes or heart disease
 Ex3: State of Indiana: the state government is analyzing population data
to prioritize funding for the most effective programs, including those that
reduce infant mortality rates
 Biggest concern: patient data security (from hackers, scammers,
fraudsters, etc.)
 Crowdsourcing Epidemiological Data – Citizen Science, crowdsourced
studies (ex: Cell Slider: sharing images from tumors with the general
public, enabling them to score tumor markers independently through an
internet-based interface.)
 Predictive Analytics – Google searches as harbinger for epidemics;

13. In An Ideal World…

14. Takeaways – What Do I
Need To Know?
 For now: the more things change, the more they stay the same (day
to day).
 Legacy Thinking => Out of Business; Be Flexible or Become
Obsolete
 Don’t worry too much about ObamaCare (unless you’re in private
practice)
 Tale of Two Medicines – Elites vs. Everyone Else – Care and
Delivery Diverging
 Specialize or Die! – The real money and prestige come with more
training
 Get Social (but don’t socialize) with patients!