An Operating System for Healthcare Dreamers

It’s time to jump off the sidelines. I’m tired of writing about the ills of American healthcare, but not doing enough to fix them. Nobody likes an armchair intellectual.

To that end, I’m announcing today that I’ve officially joined Mishe Health as Head of Quality and Value. If you haven’t heard of Mishe yet, you soon will. Think Amazon and Visa, but specifically for healthcare. Mishe is rewriting the rules on behalf of bewildered patients, disempowered physicians, and exploited employers. Our system has too many rent-seeking interlopers. Mishe is the reboot you’ve daydreamed about… but assumed would never come to pass.

In case you’re curious, I’m not leaving clinical medicine. I’m keeping my day job as a practicing neurosurgeon. But I refuse to be a passive cog in the machine, begrudgingly accepting the incessant crescendo of indignities that we all face as front-line physicians. A patient of mine, who I’ll call Alice, made this painfully clear.

Back pain was making Alice miserable. She had become a ghost… a shell of her former self. Alice had once been a proud, hyper-competent ICU nurse, but now she didn’t know who or what she was anymore. The pain had stolen away her identity. Her kids couldn’t recognize her.

Physical therapy didn’t help. Injections didn’t help. Opioids took the edge off, but she was scared of an addiction. Chiropractic adjustments didn’t help. Massages felt good for a day, but were too expensive. Acupuncture didn’t help. And so the only option left was surgery.

A spinal fusion? A disc replacement operation? She was barely 40… was this really happening? She couldn’t stomach any of these options. And that’s when Alice and I met. I told her that I suspected an annular tear - a painful rent in the outer lining of her intervertebral disc. I offered her an endoscopic, outpatient procedure to fix it, but I warned her that it might get denied by her insurance.

I was right. The procedure didn’t fit into the archaic and oft-arbitrary rulebook of most commercial payers, even though it was much less expensive and risky than traditional surgical options. I attempted a “peer-to-peer” to overturn the denial, but it didn’t work. I appealed the second denial, and was rebuffed again.

That’s where the story ends. There’s no happy ending. We don’t have a celebratory selfie from her post-operative visit, because I never had the chance to help her. She faded away into that sea of quiet desperation, betrayed by a healthcare system she’d worked in for years.

Why do we let this happen? Why do I let this happen? She was my patient. She put her trust and faith in me. What angers me is not just the nonsensical insurance denial, but the demoralizing labyrinth of disappointment she’d been forced to navigate beforehand. She spent years in a purgatory of non-surgical interventions that didn’t help, trying one thing after another, and then doubling back to try them again. She was a nurse - someone well-versed in healthcare, and she still fell victim to this fragmented, disjointed, and chaotic maze. No one was there to suggest a comprehensive care pathway. No one took full accountability for her care journey. No one took full ownership of her back pain.

Stories like this can unsettle you. I like to think of myself as an academic physician… a surgeon-scientist. I pat myself on the back when I publish research on value-based care, predictive modeling of outcomes, cost analytics, and innovative procedures. In the Discussion sections of all these publications, I love to write about the future of healthcare and how some new framework or insight will make a difference. What is the point?

When I think about Alice, I feel a tinge of embarrassment. Most of this research occupies a theoretical world of abstractions and self-aggrandizement. I don’t see it making a difference for her. These publications collect dust on PubMed, while real people struggle in the real world.

Meanwhile, Marc Andreessen famously claimed that “Software is eating the world.” I’m a techno-optimist, but he said those words 14 years ago. When is software going to fix healthcare? I’m not talking about electronic medical records, ambient AI scribes for clinic notes, or chatbots for medical advice. I’m talking about a fundamental re-tooling of infrastructure and incentives, powered by software and transparency, that can change the story for people like Alice. I seriously doubt that true innovation of this kind will happen through health systems or major payers. The software industry, on the other hand, has a way of rebooting industries. Uber, Netflix, Amazon, Salesforce… where is this energy in healthcare?

I should disclose that I’m biased. As a medical student, I took a year off and moved to the Bay Area to research medical applications of machine learning and AI. Silicon Valley was intoxicating. I drank the Kool-Aid. I began to view entrepreneurs and startups as agents of change, and I wanted in.

When I left the Bay area, my father warned me: “Don’t forget all this and become just another white-coated cog in the machine. Bottle up this feeling and take it with you.” Fast forward a decade, and I remembered those words. I’d become a practicing neurosurgeon, with an ambitious research program, but it wasn’t enough. I was stuck in a trap of RVU maximization and podium presentations, but the Alices of the world were no better for it. So I spent a couple years exploring the ecosystem of healthcare startups.

I came across some interesting companies. Some were promoting price transparency, while others wanted to get serious about hospital quality. Some had niches in the musculoskeletal space, while others were directed at self-insured employers. But nothing pulled me in. It felt like all these efforts were just nibbling around the edges. Everything was a point solution. Where was the software-powered moonshot? Where was the attempt to reimagine the entire game board?

That’s when I met Sidney Haitoff, the co-founder of Mishe Health, in early 2024. I’ll never forget that first conversation. I showed him my attempts at mapping patients’ (convoluted) journeys, assessing the appropriateness of treatments, and measuring the true value of care… and his eyes lit up. He said: “This is exactly what we want to enable with Mishe.”

He showed me how Mishe’s cloud-based software infrastructure cuts out all of the middlemen - the “layers of payers”, as he calls them. He showed me how Mishe directly connects patients, employers, and providers. He showed me how Mishe combines clinical data from electronic medical records, financial/claims data from employers and practices, and direct inputs from patients. He showed me how AI agents and humans-in-the-loop would off-load the burden of care navigation, communication, and coordination. And with that, I was hooked, and we got to work.

We started by identifying high-yield outcome metrics for major classes of conditions, and baking those metrics into the natural flow of healthcare transactions. Suddenly, true quality tracking is friction-less and scalable. We then dove into the evidence-based guidelines for those conditions and asked a simple question. What if you could score a patient’s healthcare journey against the “gold standard” care pathway suggested in the peer-reviewed literature? It’s taken months, but the process is now in place. The implications are dizzying.

With Mishe, an employer can now quantify the appropriateness of the care pathways of its employees. Patients will be able to numerically compare health systems based on the appropriateness of the care pathways that matter most. This is what Alice and everyone like her deserves. This is what we all deserve. Patients deserve to be guided to the right treatment at the right time by the right person. They deserve transparency around outcomes and costs, so they can make decisions about elective treatments on their own terms. Self-insured employers deserve to know what they’re paying for, and they deserve the right to take charge of their health plans without getting hoodwinked by some third party. Physicians deserve to be paid fairly for their work, and we deserve the opportunity to charge what we want, as long as the market will bear it. And we deserve the autonomy to choose the treatment we feel is correct, not the one some commercial insurer tells us is correct.

That last one really gets me. Everyday, insurance companies deny authorization for countless treatments that patients desperately need. They also arbitrarily under-reimburse (or don’t cover at all) innovative procedures that can be life-changing. I’m sick and tired of this. That’s why I’ve worked with Mishe’s clinical advisory board to identify unique, high-value treatment pathways that are commonly blocked by Medicare Advantage and major commercial carriers. We’ve started contracting with jumbo employers to steer patients to these superior pathways, such that physicians get reimbursed in a manner that is commensurate with the value provided. What a novel concept for healthcare - value capture that matches value creation!

It all sounds idealistic and lofty, but I don’t see anything wrong with that. A famous man once decreed: “Some men see things as they are and ask, ‘Why?’ I dream of things that never were and ask, ‘Why not?”

I’ve dreamt of a Consumer Reports for specialty care, where patients can choose hospitals and physicians based on the costs and outcomes that matter specifically to them. We’re building this at Mishe. I’ve dreamt of an “App Store” for condition-based bundled payments. We’re building this at Mishe. I’ve dreamt of a “developer platform”, akin to GitHub, where specialists can assemble integrated practice units “in the cloud” that aren’t bound by the walls of a health system. We’re building this at Mishe. I’ve dreamt of a world where health systems aren’t ranked by the arbitrary whims of US News and World Report, but based on their ability to steer patients along evidence-based care pathways. We’ve enabled this at Mishe. And I’ve dreamt of a world where those evidence-based care pathways serve as “shared baseline protocols”, which are then iterated on through continuous improvement loops (thank you, Brent James). I’ve dreamt of a Learning Healthcare System.

It’s a heady feeling when you realize that something is a once-in-a-generation instrument for actualizing concepts you’ve kept hidden in your mind (or in the Discussion sections of research papers). That’s what Mishe Health is to me. It’s the operating system (OS) for healthcare dreamers.

OS1 (Payer Platform) is the transactional infrastructure: same-day cash payments for providers, and lower costs for employers by cutting out the interlopers. Physicians do what they think is right, with accountability and transparency. Mishe OS1 is live and available today.

OS2 (Provider Platform) is the healthcare infrastructure: a shoppable marketplace with visible outcomes and costs, where competition is based on evidence and value. Quality is taken seriously and patient journeys are tracked and measured. Patients can finally choose treatment pathways with their eyes wide open, in collaboration with physicians who are accountable for results.

OS3 (Patient Platform) is the wellness infrastructure: gamification of lifestyle modification, wearables galore, and a better-late-than-never shift from “sick care” to true health.

That’s the roadmap - three phases for Mishe Health. It sounds like a long road, but we must realize that the status quo is frustrating at best and toxic at worst. Everywhere I go, my physician colleagues lament the inexorable slide towards lower reimbursement, less autonomy, and commoditization of care. Patients know that the system is only getting worse and more expensive. It’s not enough to physicians like me to publish research or treat “one patient at a time” anymore, as important as that is. There’s a fine line between inaction and complicity.

Mishe could have helped Alice. It could have bypassed the insurance denial and brokered a direct contract between myself and her employer. I would have gotten paid instantaneously for doing the procedure I knew was right, Alice would have finally gotten the relief she desperately needed, and her employer would have gotten a valuable employee back at minimal expense. Mishe could also have scored all the health systems in her area with respect to their care pathways (or lack thereof) for back pain, allowing her to choose wisely and avoid the trap of expensive, ineffectual treatments.

Alice was one of those patients that “got away”. No more. I’m excited to officially join Mishe Health and help architect the future of healthcare. If our work this past year is any indication, it’s going to be an amazing ride. We’ve brokered direct-to-employer contracts that bypass silly insurance denials. We’re arranging appropriate payment rates for high-value, but historically under-reimbursed, surgical treatments. We’ve designed evidence-based care pathways for employers. And soon we’ll be demonstrating to them exactly how much money they’re saving while keeping their workforces healthy.

This is how you build a enable a true free market for healthcare… where competition is based on value and not volume. The solutions will not come from Washington DC or the incumbents. It’s time to get off the sidelines and create the world we want.

(See my recent essays here on MS for a deeper look at the frameworks we’re building.)