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Perfection In PowerPointThe Innovator’s Prescription: A Disruptive Solution for Health Careby Clayton M. Christensen, Jerome H. Grossman, and Jason Hwang (New York: McGraw-Hill, 2009), 441 pages, $32.95
In an era of ever fuller disclosure, I feel compelled in my review of a health care business book by a Harvard Business School (HBS) professor and his colleagues to disclose my own association with the institution that has produced so many of the nation’s investment bankers, strategy consultants, and CEOs: in the mid-1980s I tended bar for many of the professional programs offered at the HBS for corporation executives from around the country. I never had the privilege of studying the curriculum, but as the bow-tied townie armed with the most dangerous drug in the room, I bore witness to the extracurriculars: lots of smartly dressed people all nodding in agreement, sketching on cocktail napkins, and congratulating each other for being in each other’s presence. So you can imagine my surprise twenty-five years later to learn—after two public companies, two CEO jobs, a graduate business degree from Johns Hopkins, membership on several corporate boards, and two health care business books of my own—that the answer to health care’s woes appears to be this: tear down the corporate health care establishment. Or, more genteelly, "disrupt" it. Clayton Christensen first applied the term "disruptive" to health care in the 1990s, when he apparently discovered that angioplasty was cheaper and easier than bypass surgery, and he has been applying it ever since, most recently in the form of The Innovator’s Prescription. The book is 441 pages of postmodern business jargon, bubble charts, and marketplace anecdote, swirled into a menacing-sounding methodology and ladled across the entire U.S. health care system. Although the book excavates several fascinating nuggets about wrenching changes in other industries, it attempts to force each into Christensen’s franchise-in-progress, "disruption theory." A bewildering amalgamation of high business concept, market evangelism, and wishful thinking, the book lacks disciplined data on what patients actually demand and health care actually supplies. It is also willfully at odds with what occurs every day in the actual corporate marketplace. To wit, the same day I was reading the authors’ argument for the inevitable integration of health care business functions, thanks to the pressure of today’s market disconnections (p. xxxi), WellPoint was announcing the spinoff of its pharmacy benefits management company to ExpressScripts. The authors may believe they are lighting the way to a brave new world of corporate health care, but much of their analysis is oddly nostalgic—a reminder of the good old days (circa 1995) when every health care merger, no matter how big, made perfect sense—at least to those who papered it. Like its predecessor health care business panaceae from those boom days, The Innovator’s Prescription offers up a vocabulary for a utopian health care system in perfect alignment with a magically functional marketplace. Sick patients go to retail clinics for primary care; primary care physicians are doing much of the work of specialists, in practices now called "solution shops," aided by telemedicine and clinical decision-support software; specialists collaborate through Web communities and are paid for outcomes, not procedures; hospitals have deconstructed themselves into "solution shops" or "value-added processors," depending on what the authors need them to be; the chronically ill are managed by call centers and each other through "facilitated networks"; the uninsured get health savings accounts (seriously); and the whole thing works because every American has control of his or her own portable electronic medical record. Poof! A bunch of market-driven miracles, all rendered flawlessly in, well, PowerPoint. Many of the authors’ ideas about how health care ought to work do not last across adjacent chapters or pages: "financial supermarkets" failed because they tried to sell too many consumer financial products at once, and yet a few lines later, the authors recommend that "companies like Fidelity Investments" also add health savings accounts to their portfolio of—uh—financial consumer products (p. 253). And throughout the book, the authors vilify today’s primary care practices and general hospitals as "dinosaurs" for trying to be all things to all patients, while holding out as the example of a health care organization that can really disrupt the status quo with innovation—Kaiser Permanente. Best of all, the authors claim that consumers will happily compile and circulate their health risk assessment scores in search of a good health insurance deal, adjusting their risk behavior in real time to changes in their premiums in an unfettered marketplace where payers reward full disclosure and everyone assembles and shares their online personal health record with their employer (pp. 142, 175). Who is going to make all of this happen? Who is going to disrupt health care? Christensen and colleagues contend that government is too big, clumsy, bureaucratic, political, and conflicted to innovate. Rather, the disruption miracle will be driven by two stakeholders: large vertically integrated payer/providers (Kaiser again), and large corporate employers. This idea is so powerful that it shows up on the pundit circuit at least every three years, best tracked by the terms "direct contracting," "re-engineering," "benchmarking," "six sigma," "Bridges to Excellence," "Leapfrog Group," and "pay-for-performance." The idea actually dates back to the 1980s, when large employers started herding people into HMOs (like Kaiser, which has been around since the 1930s), and small employers started forming "purchasing coalitions" to fix their local health systems—or at least to create organizations dedicated to talking about fixing their local health care systems. In fact, there are fifty-eight coalitions spread across thirty-four states, according to the National Business Coalition on Health—the "coalition of coalitions" formed a decade ago. I am unsure how to reconcile the authors’ enthusiasm for employers’ revolutionizing the health system with their concurrent belief that the system is such a mess twenty-plus years after employers first got on the problem. The takeaway, as they say in business school, is this: if you feel that your health care organization is on the verge of being disrupted by an angry mob of employers, you should follow what may be the real "innovators’ prescription": hire Christensen’s consulting firm, Innosight LLC (which, in Christensen’s own words, is "disrupting the innovation and strategy consulting business"). There it is on page 32, in a list of other companies that changed the world, nestled between Google and Kodak. Perhaps it is the self-aggrandizement the authors seem to share with the ballooning employer-fix-it crowd, but when I encountered this perennial theory in The Innovator’s Prescription, I finally realized that everything I learned as a bartender at HBS was true: things do work out perfectly when we all nod in agreement, sketch it out on cocktail napkins, and congratulate each other for being in each other’s presence.
J.D. Kleinke (jdk{at}mttaboros.com) is a medical economist, an author, and the chief executive officer of Mount Tabor, a health care information technology company in Portland, Oregon.
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