One Step Forward, Two Steps Back
One Step Forward, Two Steps Back
Last week, the sudden shutdown of Forward — a one-time unicorn that raised more than $650 million — sent shockwaves through the health tech world. Forward promised to revolutionize health care with AI-powered, clinician-lite CarePods. Ultimately, Forward became, as Jay Parkinson aptly put it, “a $400M mistake in understanding the demand…something investors would want, but not something those outside the bubble would want.” Instead of rehashing Forward’s demise, let’s step back and explore why innovators keep missing the point in health care.
I watch a lot of NFL football on Sundays — it’s my time to unplug, recharge, relax, and let my mind rest. Thanks to RedZone’s constant switching between games, I know the teams, players, strategies, and stats. But knowing the game from the couch doesn’t mean I could coach it. My brief, unsuccessful stint as a junior high backup lineman ended 35 years ago. If I tried to coach or manage an NFL team today, I’d fail spectacularly. Health care is no different. Limited experience, imperfect knowledge, and overconfidence in your solutions won’t guarantee success in complex, high-stakes environments.
This may seem like a roundabout way to explain the Dunning-Kruger effect, but it’s especially pronounced in health care. Ideas like food as medicine, primary care in retail stores, and AI-powered docs-in-a-box sound promising in theory. Yet understanding the realities of our health care system reveals why they’ve struggled to gain traction. Medicine is not practiced in an idealized vacuum, and it can defeat the most well-thought-out, well-intentioned, common-sense solutions.
Google found this out the hard way when it tried to roll out AI-powered retinal scans in Thailand. Great results in the lab — not so great results in the clinical setting. Retail giants like Walmart and CVS faced the same disconnect. Who wouldn’t want the convenience of primary care in a pseudo-vertically integrated retail setting? Patients, as it turns out. In a recently published RCT, an intensive “food-as-medicine” program failed to improve glycemic control in patients with diabetes. And now we have Forward, “a $400 million mistake in understanding the demand.” These ideas work in theory but crumble when they meet the paradoxes of our health care system — one that demands flexibility, nuance, and adaptation.
My second patient of a busy week walked into clinic on Monday with a several-weeks-old broken hip. Yes, he walked in on a broken hip. His case wasn’t simple—he had a complex medical history with an ongoing workup. He didn’t need AI, fancy tech tools, or health care where he picks up his prescriptions. He needed a coordinated care process capable of managing his complex situation quickly, safely, and effectively. Thanks to the hard work of a multidisciplinary team, the patient underwent a successful hip replacement.
Complex cases and patients like this are increasingly the norm, not the exception. I practice in the suburbs outside a major metropolitan area. My patient population is diverse and comes from across the socioeconomic spectrum. I see everyone from dual-eligible patients to wealthy hospital donors. Their priorities, challenges, and expectations can be vastly different, but there are common threads.
Experience has taught me how to balance evidence-based, reproducible, high-value care with the subtleties and nuances of tailoring care to the individual. It’s a constant process in evolution that is informed by years of front-line experience. Health care is messy and unpredictable. Decisions are rarely black and white. There is no substitute for firsthand knowledge. Yet many people building the future of health care lack the perspective that only comes from living these moments.
Many clinicians in health care leadership roles have medical degrees but don’t have real-world experience. While they understand the science of medicine, they often lack the lived experience of seeing patients and navigating the chaos of clinical environments. They’re trying to run an NFL team with only junior high football experience. Entrepreneurs without clinical backgrounds make assumptions about how health care should work. They may have the best intentions, but their solutions often fail because they oversimplify, misunderstand, or misidentify the problems.
This isn’t to say only practicing clinicians should lead or innovate health care. Some of the best NFL coaches and GMs never played professional football. But they spent years on the sidelines and in locker rooms learning from mentors and understanding the nuances and complexities of the game from the inside. The same applies to health care. Leadership and innovation without front-line experience risks missing the intricacies that make or break a system. Assumptions replace understanding, and solutions fail, often spectacularly.
If you’re building in health care, my advice is simple: Get out of the bubble and onto the front lines. Experience the complexity of academic hospitals, the pressures of private practice, the diversity of urban clinics, and the resourcefulness of rural hospitals. Every setting teaches a unique lesson, and together, they reveal the full picture of what health care truly needs.
Health care is too complex, too nuanced, and too personal to be revolutionized from a distance. The best solutions don’t come from boardrooms or Silicon Valley brainstorming sessions — they come from understanding the messy, unpredictable realities of patient care. Whether you’re an entrepreneur, policymaker, or health care leader, the most valuable perspective is forged on the front lines. Spend time in the clinic, the hospital, or the operating room. See the challenges, the triumphs, and the humanity of health care up close. Because just like in the NFL, to win you have to understand the game.
Small Incisions
Physician Payment Reform In Medicare: Putting The Pieces Together (Health Affairs)
One of the better-written pieces on ACOs, MSSPs, APMs, and primary care payment reform. ACOs make sense in theory and may be the most viable version of VBC. The article nicely outlines current challenges and potential solutions. Still, it seems like we’re not there yet. ACOs and newer CMS models (like TEAM and Making Care Primary) incentivize PCPs to take more ownership of specialty care by reducing referrals, coordinating more post-acute care, and providing steerage to ‘in-network’ specialists. Do we want PCPs bogged down trying to deliver and coordinate specialty and post-procedural care, or do we want to free them to focus more on preventive care, patient education, and chronic care management?
Lincare has a pattern of fraud and violated probation agreements with the government multiple times. Such actions should have led to the ‘death penalty,’ excluding the company from Medicare participation and effectively killing their business. As it turns out, if, like Lincare, you’re too big to fail, HHS just keeps slapping you on the wrist. The victims in these cases are elderly patients and taxpayers. The government’s inability to stop outright fraud and unwillingness to solve the issue should be cause for concern, especially for anyone clamoring for more government-run health care. The billions of dollars wasted here could be used to … say … not cut physician reimbursement again next year. (For fun, Google ‘doctors jailed for Medicare fraud.’)
Capitalism is the path to value-based care (Healio)
An insightful article arguing that not only have existing value-based care models failed to achieve their goals, but they’ve also actually made things worse. The hidden downsides of these programs — forced consolidation, doctor shortages, rationing of high-acuity care — are rarely considered. The focus remains on reducing utilization, for better or worse. The solution: care delivery that relies on competition, innovation, transparency, and efficiency. We don’t need clinically irrelevant metrics, ratchet mechanisms, and convoluted payment models. True VBC is providing high-quality, cost-effective, evidence-based care. We’ve tried these other models with unsatisfying results. Maybe it’s time to give good ol’ free-market competition a try.
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
I am so glad someone finally explained AI in Healthcare this way. I had so many doubts about the thousands of things that can go wrong with an AI health care revolution. I still like the LIVE physician who can actually look in my ear with an otoscope, place a stethoscope on my sternum when I have median lobe pneumonia, and check my tonsils with the flat , wooden tongue depressor!!