An Immodest Proposal

By Mike Farahbakhshian

Editor’s Note: In this month’s article, Mike Farahbakhshian lets his position as a thought leader in the Health IT community go to his head. Mad with power, he decides to single-handedly use the promise of the “gig economy” to solve the problem of affordable health insurance. He’s insisted we print this. Reading time: 7 minutes. Suggested drink pairing: Four Loko, as much as required until this sounds like a good idea.

Ladies and Gentlemen, The Future

Our current fee-for-service healthcare system is so 20th century. Much like fax machines, Styrofoam fast-food containers, and making eye contact with other people instead of our phones, we Millenials reject this system. We are the future and our new ideas are the best ideas. We know this, because a Pepsi commercial told us so.

Take That, Oppressive Corporations! Brought to You by Pepsico (NYSE: PEP)

One aspect of the new economy is the “gig economy.” Instead of a highly regulated market dominated by a few players, whose employees are overworked and underpaid, we have a… highly deregulated market dominated by a few players, whose 1099 contractors are overworked and underpaid. Plus: apps!

(Mental note: Build time machine. Go back in time to the early 80’s. Show Tip O’Neill the Uber App. Profit as deregulation is completely unopposed.)

So, why couldn’t this work for health care?

Everything Old is New Again

If you think about it, for most of human history, health care was performed as part of a “gig economy.” You’d go to the barber, and casually mention that you had an abscessed tooth or a compound fracture. If the barber felt up to it, he’d take the gig. Perhaps he’d yank out a few teeth. Or, if you had the abscessed tooth instead of the fracture, he’d apply leeches.

And he will still shame you for not flossing.

It was good times, and sometimes it’s good to reject the mechanized, Weberian hierarchy of 20th century life and return to basics.

That’s why I present to you the new app that would revolutionize healthcare: Doctr.

Doctr works by allowing you to search for nearby providers. You list your problem and are anonymized; providers can signal their readiness to treat you, and you can swipe left to say “no thanks” or right for “let’s meet at the nearest Starbucks with Wi-Fi and you can examine me in the bathroom.”


Rather than being beholden to health networks, providers can become part of a true community of care: they can directly engage with the patient. Isn’t that what they complain about? Not enough time with the patient, and too much time dealing with healthcare administration? Complain no more, for Doctr allows a direct interaction with the patient. That interaction can become a long-term relationship, the one both patients and providers crave, so long as the doctor gets 4 or more stars as part of their ratings. This incentivizes customer service.

As patients, why do you want a doctor providing bad customer service? I’m an American, damn it: I want the best health care in the world, not some pompous jerk telling me to quit drinking my customary gallon a day of Mountain Dew because of fake-news bogeymen like “metabolic syndrome” or “stomach ulcers.” With Doctr, I can give this provider the two stars he or she deserves and get the second, validating opinion I so desperately need.

Plus, with Doctr, your health record will be stored in the cloud using cutting-edge HIPAA-compliant, FIPS-140-2 encryption, which means that it will only be viewable to you, the provider looking at your current gig, the NSA, and the Russian mafia. No more meddling insurance companies worrying about pre-existing conditions: with Doctr, all your conditions are pre-existing.

We will anonymize your information and sell your health conditions to advertisers to provide targeted advertising, but no human will look at this information. So if you start receiving ads for combination toenail fungus/erectile dysfunction medicines, only our customized, cloud-based AI will judge you.

This Sounds Great: But How Do I Pay?

I’m glad you asked. The “gig economy” isn’t alone: the Robin to its Batman is “crowdsourcing.” With crowdsourcing, I can appeal to the Internet at large to have them pay for my ideas. While often associated with content creation, crowdsourcing has been used to seek an injection of funds to pay debts, and healthcare bills. While often compared to venture capital, crowdsourcing is actually very much like the insurance industry: many people pay into a pool, and that pool pays out in the case of horrific accidents, like your “Fifty Shades of Grey/Minions” crossover fan-film.

So, if a doctor wants to be paid for his or her service as a “gig doctor,” you will need to find that money somehow. Medical costs can rack up quickly, especially when you factor in paying damages to the Starbucks for wheeling in the MRI and unplugging their milk frother to run it.

The logical solution would be a crowdsourcing app to pay medical bills, but we are left with two fundamental questions:

  1. Why should anyone pay to help you?
  2. What will incentivize you to pay for anyone else?
Picture Unrelated.

The insurance industry currently works on the principle that low-risk people (young, healthy Millenials) pay into the pool over their life and that high-risk people (the elderly, the sickly, etc.) receive the benefits when needed. To discourage fraud, waste, and abuse, there are a Byzantine array of protective mechanisms, such as premiums, individual mandates, and approval of certain treatments over others due to cost-benefit analysis. However, this cost-benefit analysis has a perverse incentive: to benefit the insurance industry, not the patient. As such the actuarial business is a grim industry; one where cold numbers overrule emotion, and where profit trumps the desire for a healthy citizenry.

What if there were a solid, ethical incentive to pay into the system, and also for others to pay for you?

I’m glad you asked. I present to you this incentive, in app form: Tontinely.

Tontinely works on the principle of a tontine: everyone pays in, and the last person left alive receives the full payout. A portion of every dollar you contribute to another person’s healthcare gets put into a tontine. This encourages paying for other people’s health care. The more you pay, the more you get over time, compounded with interest.


Every time you receive health care funds via Tontinely, your payout is reduced: this eliminates unnecessary expenditures for hypochondriacs. Yet, there is a strong incentive to receive health care when you need it, because if you die, you don’t get your sweet, sweet tontine payout.

To ensure Tontinely funds are only used for healthcare, the app will use secure funds transfer using Bitcoin-based blockchains directly between the Tontinely app cloud and the Doctr app cloud: no pesky middlemen like insurance payers, banks, or credit cards. The transactions are encrypted and anonymized. Once again, control returns to the patient: transactions are only visible to you, your gig-doctor, the NSA, and the Russian Mafia. And that’s the way we at Tontinely like it.

Finally, we at the Tontinely development team have listened to the feedback of you, the beta testers. We have put in biometrics and location-aware Near Field Communications functionality, similar to Apple or Android pay. This discourages murdering other Tontinely users to cash in: if you are around another Tontinely user and their vitals cease, your Tontinely payout is reduced.

(Providers on Doctr are exempt).

Fixing Healthcare Is Not Swift

Okay, okay, I give: for those few of you that have been skimming this halfheartedly: this is satire. Yet through this reductio ad absurdum thought exercise, I hope I’ve conveyed a few key things. First, the insurance industry is layered with multiple complexities, and is a tontine in and of itself: except in this case, the beneficiaries are the insurers themselves. This perverse incentive needs to be resolved in the long run.

Although Tontinely is entirely a product of my caffeine-fueled imagination, I was able to spitball a few controls that encourage contribution and discourage fraud, waste, and abuse: and I’m not an expert in health care or insurance by a long shot. Whatever your politics may be, I think we can all agree that we need more thought on how to encourage voluntary contribution into insurance pools, and ensure that the money is used to actually provide better outcomes to patients.

Second, the fee-for-service model in use today is very much like a lower-tech Tinder. Part of the absurdity of Doctr is that it seems like something that can actually come to fruition in our lifetimes. It doesn’t matter how much tech is layered onto the provision of care: unless we switch to value-based reimbursements, health care will be cheapened into a dating app: the love triangle will be between your pathology, the provider, and the health care network.

There’s still a lot of debate over Fee-For-Service versus Value-Based Care: there are still proponents who believe that the Fee-For-Service model actually lowers costs due to competition: niche medical industries, such as cosmetic surgery, LASIK, dentistry, and veterinary care, are given in examples. Moreover, the move from Fee-For-Service to Value-Based Healthcare incentivizes providers to move to Accountable Care Organizations (ACOs) and hospital networks. Without proper incentives that are installed by design, like actually well-thought-out versions of the controls I put in place to prevent the abuse of Tontinely, an ACO can perpetuate the same problems we see in health care today.

I personally believe the shift to Value-Based Care is the right thing to do. Yet the health care and insurance industries have serious dysfunctions that must be resolved before we are truly able to have Value-Based Care done right.

Who will step up to the challenge?

Who will take this gig?

 

 

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