On my first day as a “cow” (or junior) at United States Military Academy at West Point, I learned a lesson that has stayed with me my entire life and contributes to the lens through which I consider all business issues. During my time at West Point, all cadets were required to take SS307, “Introduction to International Relations.” As I was a pre-med math/science guy, I walked into the first day of this class having no idea what we would be learning, much less expecting to learn anything that would become part of my intellectual bedrock. I was dead wrong in the first 15 minutes of that class.
Because I was alphabetically first in the class of about 20 students, I assumed the job of “section marcher” on the first day, meaning I sat in the first chair and was responsible for taking attendance and giving a report to the professor as the clock struck exactly 1 p.m. Once I did that, the professor said simply, “Take seats. Pay attention.”
He casually strolled over to his desk, ceremoniously pulled out a green squirt gun modelled after a Colt .45, and held it up for the whole class to see. He then came back over to my desk and announced he was giving me a loaded squirt gun, that I would be the only cadet given a weapon and I could do whatever my instincts told me to do. “This is strange,” I thought. I looked around the room and saw both interest and suspicion in my classmates’ eyes, then back at the professor (whose face suggested nefarious intent) and my course of action became clear. I began emptying the gun’s contents into the uniforms of anyone in range. (Note to the reader: This was West Point in 1986, not Berkeley in 2017.) After about 10 seconds of behaving like the Joker in a Batman movie, the professor stopped me and announced he was changing the game. He went back to his desk and produced another squirt gun. He gave this squirt gun to another cadet across the room from me (who had been out of range and remained dry) and again stepped back to observe.
No one knew any of this was going to happen and so no one had a plan; but, the action developed quickly and silently. The other armed cadet and I looked at each other and, without saying a word, conspired to victimize every cadet without a weapon, but to leave each other alone. The Monroe Doctrine was instantly re-invented; my side of the classroom was my hemisphere and his side of the classroom was his. At the moment, it was completely intuitive, but in retrospect it speaks deeply about the universality and timelessness of human behavior.
The professor continued this pattern until there were five guns in play, at which point, it became a free-for-all of squirt gun aggression, with everyone getting soaked — the unarmed cadets most of all. The squirt gun exercise was, of course, a metaphor for the conduct of nations and the nuclear arms race that was of significant concern in the mid-1980s. There were many lessons, but the biggest one I remember was “If you don’t have a ‘squirt gun’ in the real world, you are going to be a perpetual victim.”
Now flash forward to my life as a private practice orthopedic surgeon. Once I got my feet on the ground clinically and was able to start paying attention to the business operations, I began to see immediate parallels to the world of international relations. There are many independent entities in play in our local market: orthopedic practices; referral sources; payers; patients; hospitals; urgent care facilities; etc. Each of these entities is aggressively pursuing its own strategy to maximize its outcome in the market. It is the Wild West, but the cavalry isn’t riding to our rescue if we get in trouble. All of these entities are competing for scarce resources, defining “value” as the outcomes they seek and “costs” as the means to achieve value. One entity’s value is another entity’s cost, with perspective and conclusions depending entirely on each player’s position — a point that is continually neglected in the national discourse on health care.
Health care landscape
Until a few years ago, the system was stable. A type of détente existed, which was comfortable for surgeons. However, the last decade has seen the development of new instability, marked by an arms race that will determine the health care landscape for the foreseeable future. A new weapon has been introduced, deceptively marketed and quizzically subsidized.
What is the weapon in this new arms race? What is the “squirt gun” that is changing the balance of power and the conduct of health care? The answer may initially be surprising. Just think about it. What are commercial and government payers using to drive their costs and surgeons’ revenue down?
The answer is big data. Big data refers to the ability of modern computer networks to automatically analyze and reach deeply hidden conclusions about millions of interrelated data points at speeds unattainable by humans. That is what the push for electronic health records (EHRs) was really about. EHRs convert disorganized narrative data requiring prohibitively expensive human analysis into discriminant, highly organized data that computers can pool and analyze instantly. Patients have the big data weapon, too. They now use websites that grade categories of surgeons to help decide where to seek an appointment. Soon, they will be able to comparatively grade costs vs. outcomes. And hospital systems? These use big data to measure and compare surgeons across the nation to decide how much to pay for call, how much OR time is allocated and how much help to provide in the OR. As a surgeon, I am starting to feel like the unfortunate cadet in that first SS307 class who was never given a squirt gun. Surgeons are the soaking wet, perpetual victims in this arms race.
Power of big data
As soon as possible, all surgeons need to put the power of big data on our sides, if for no other reason than to restore balance to a complex health care ecosystem that needs us to thrive and maintain independence. Just as patients, payers and hospitals use big data to dictate their terms to us, we need big data to help us understand where we are failing to exert our will at the point of sale based on the value we deliver.
As a surgeon, do you think your hourly employees at the appointment desk or in the billing office can manually, and in real time, figure out how to protect your interests against these automated weapons wielded by the consumers of your work? Further, do you think your employees are motivated enough to even engage in the struggle? Think of payers as North Korea, hospitals as Russia and patients as the European Union. Think of surgeons at present not as the United States, but as Mexico — a bit player on the international stage that always under capitalizes on the value its citizens contribute to world productivity.
Personally, I would rather play the game as the United States — well-armed, respected, feared and able to dictate terms from the friendly end of a gun barrel. If you would also rather play this game as the United States, you need to put big data on your side. Big data can be used to predict the value of all requested encounters before appointments are assigned, track the long- and short-term reimbursement behaviors of individual payers and plans, and determine the optimal allocation of clinic personnel to create maximal productivity or optimally care for bundled patients, among thousands of other uses.
Realize that, like a squirt gun, big data is agnostic of its handler. It will work for whoever holds it. It can be used by the holder to accomplish the goals of the holder’s organization at the expense of competing interests. The arms race is on, but most surgeons remain blissfully naïve, clinging to their beloved quarterly reports rendered through manual calculations.
“Political power grows out of the barrel of a gun,”– Mao Zedong, 1927
John “Jay” Crawford, MD, is a partner at Knoxville Orthopaedic Clinic and founder of nextDoc Solutions, a software company that builds custom apps for orthopedic surgery practices. His primary interest is helping private-practice orthopedic surgeons discover and implement strategies to ensure robust and sustainable business performance in a consumer-driven health care environment.