Disrupted: American healthcare has reached its tipping point

American healthcare has reached a tipping point. Look no further for proof than the insiders and outsiders who are linking up to disrupt the long-stagnant, cost-ridden industry that's eating up nearly a fifth of the nation's gross domestic product.

"It's important to keep in mind that the bulk of healthcare problems—and costs—stem from lifestyle behaviors and social circumstances," Michael Dowling, CEO of Northwell Health, said in an email responding to questions about the Amazon-JPMorgan-Berkshire venture. "I would like to see some of these companies go into poor neighborhoods and try to figure out how to address health issues stemming from poverty, lack of jobs and all the negative social circumstances that contribute to chronic illness, substance abuse and health disparities in this country. That's the biggest challenge. "

Healthcare innovation has moved notoriously slowly over the past few decades. To wit, there are still providers that rely on paper medical records. Consumers still don't have ready access to their data and doctor's notes. And despite all the talk about the benefits of paying for value over volume of services, most of the healthcare system is mired in a fee-for-service mode.

Part of this is explained by the heavy regulation surrounding the healthcare industry. It's also because the industry spends a significant amount of time assessing the risk to the patient with each change it makes, said Hal Wolf, CEO of the Healthcare Information and Management Systems Society.

Because of HIPAA laws, there's little portability in healthcare and no continuity of data if a patient switches insurance plans. Hospitals, physician offices and clinics use different EHR systems that don't speak to each other, payers use different claims processing systems, and care is known to be fragmented, said Joshua Raskin, analyst with Nephron Research.

"Banking is way ahead of healthcare and is one of the first industries to be so consumerized, bringing services into your phone," Wolf said.

While there have been endless attempts to upend the healthcare business model and lower costs, the success stories are few and far between. The stumbles offer cautionary tales for the latest forays aiming to disrupt the system.

In partnering with providers and EHR vendors to put patient records on the iPhone, Apple was channeling Microsoft HealthVault and Google Health, which were launched in 2007 and 2008, respectively. Those companies looked to give consumers control over their personal health records and make them the interoperability agent.

Arming patients with their own data gives them the power to take control of their health and care experience, which is what Apple is hoping happens. But in the past, consumer appetite and functionality haven't been there, experts said. And neither Microsoft or Google could muster enough critical mass to drive change. Google Health was abandoned in 2011.

Previously, AT&T, HP and IBM Corp. tried to drive efficiencies through health information systems dedicated to logistics, materials, billing and revenue cycle management, but couldn't pull it off. Walmart had also been rumored to be planning a venture that would leverage its vast distribution network to make a dent in the healthcare supply chain, but it never came to fruition.

"My sense is that this can't just be done through technology. These companies have to use their influence and market power to change behavior of not just employees, but payers and providers," Runyon said.

There have been several employer coalitions that combined to put pressure on providers. The Pacific Business Group on Health created a narrow network of high-quality providers that its member employers contract with directly for certain services, such as hip and knee replacements.

Just two years ago, the Health Transformation Alliance, a coalition of now more than 40 employers, formed to leverage members' combined heft to secure better pharmacy contracts. Members include some of the largest U.S. companies, including American Express, Coca-Cola Co., hospital system HCA, and IBM. The alliance this year also began contracting with healthcare providers in three metropolitan areas—Phoenix, Chicago and Dallas-Fort Worth—to care for employees with diabetes, hip and knee replacements and lower back pain. The group is looking to expand the program to new states in 2019.

In several high-profile cases, employers have leveraged scale to contract directly with a health provider for all of their employees' health needs, ultimately cutting out the insurance company.

"Some of our best breakthrough solutions over the years have come from employers who are paying many of the bills for our current non-system of care," said Dr. Mark Keroack, CEO of Massachusetts-based Baystate Health. It's worth noting, he said, that Kaiser Permanente grew out of industrial healthcare models.

With few details available, it's unclear just how Amazon and partners plan to tackle healthcare costs, but the companies said they would initially focus on technology solutions to provide employees and their families "simplified, high-quality and transparent healthcare at a reasonable cost."

The companies seem to be focused on lowering the cost of care primarily for their own employees, but successful solutions could be rolled out to the entire population in the future. It's unknown if they will simply self-fund employee benefits together, or if they will build out their own insurance operation.

Still, observers have reason to believe this latest coalition could be successful, if for no other reason than they have the financial resources and technical expertise to make something happen.

Any high-cost, high-margin business has to be worried about the partnership, said John Driscoll, CEO of health benefit-management company CareCentrix. Health insurance brokerage companies and the supply chain stand out as targets.

Brokerage firms make a better margin on services than the health plans they sell, which makes them vulnerable, Driscoll said. And in the supply chain, there are many layers of costs between manufacturing equipment and supplies and their delivery. Amazon could upend those by collapsing different distribution regimes.

"The excess prices in the U.S. system are a function of a lack of transparency and people not getting the care they need in the lowest-cost setting," Driscoll said. "The dream team of Amazon, Berkshire and JPMorgan can immediately bring value in terms of transparency, not just with price but availability of services. Still, they have to partner with players in post-acute world to shift care out of hospitals and nursing homes and empower consumers with data to know what options there are."

Others doubt that with just around 1 million employees scattered around the nation that the companies have enough heft in one place to negotiate better rates from providers.

Raskin said it's all about employer benefit design. "The consortium will find that beating up on the health insurers is probably not the answer. Their margins are at the low end of the healthcare industry," he said.

That means using incentives to prod employees toward high-quality, lower-cost care. Transparency in price and quality data, which has long been hard to come by, is finally starting to emerge.

Amazon "can use its technology to steer patients to proper sites of care in real time," said Andreas Mang, chief operating and innovation officer at the Blackstone Group's Equity Healthcare, which has helped set up custom health benefits for 52 companies.

As employers and consumers become armed with more data about how care quality, safety and prices vary, employers should use cost incentives to eliminate access to inappropriate and unnecessary care, and eliminate network healthcare providers that are outliers, said Suzanne Delbanco, executive director for the Catalyst for Payment Reform, a not-for-profit group that mainly represents employers.

But there's resistance "in giving up provider choice involved in narrowing provider networks, which you'd do better with a low-wage workforce," said Paul Ginsburg, director of the Center for Health Policy at the Brookings Institution and director of public policy at the USC Schaeffer Center for Health Policy and Economics.

While the new Amazon-JPMorgan-Berkshire Hathaway entity is unlikely to have enough of a concentration of employees in any one market to shift the cost paradigm, the consortium could follow the Pacific Business Group on Health's model and negotiate deals with certain high-quality providers to deliver specialty care to employees, Delbanco said.

"I fantasize that we'll decide to build some provider systems that are not subject to the current market power imbalance and where there can be real accounting for the actual cost of care and the efficiency of which it is delivered," she said, adding that the group has 34 large employers working with health plans to tie half of their insurance benefit payments to performance metrics. And seven years ago, Catalyst for Payment Reform had two employers that wanted to implement reference pricing. Now, the practice is far more common and is further driving conversations around transparency.

"You can't overestimate the difficulty of doing this," Kaufman said of the attempt by Amazon and partners to tackle growing healthcare costs. "But when you put three organizations together, (given) the quality of those organizations and, especially with Amazon in the mix, it would be a mistake to underestimate their abilities."