The Great Decoupling | Navigating Healthcare’s Shift to DTC & Autonomous Care

Session Focus

Lamas framed the session as an audit of the future: what inside the hospital is designed for obsolescence, what genuinely has to remain, and what care can look like in five to ten years. She noted the stakes plainly. Even 5 to 10 percent of care leaving the hospital would completely disrupt the current system.

She also noted the irony of an ICU physician moderating a panel about care leaving the hospital, since the ICU may be the last place where hospital-based delivery is unavoidable.

Closing the Gap Between Evidence and Practice

AJ Blood MD described work aimed at a specific failure: guideline-directed targets for cardiometabolic disease are consistently underachieved, and the reason is the delivery model rather than the science.

His approach uses AI to determine the right treatment for the right patient at the right time, delivered through team-based care that is decentralized and asynchronous. The point is not to rely on the one-on-one time in an annual visit to adjust medication, diet or lifestyle.

The gap he is attacking runs between what evidence-based medicine establishes and what actually happens in practice. He was explicit that this gap exists at Brigham and Women’s as much as in rural settings, though engagement and access are lower in rural care.

The Case That Change Comes From Outside

Calum MacRae MD, PhD, a cardiologist and geneticist who has run an innovation center and started three companies including an early-stage fully agentic physician, gave the panel’s most contrarian read.

Asked what changes inside healthcare in two to five years, his answer was nothing. He identified three fundamental barriers.

The business model. There are no alternative funding sources short of out-of-pocket spending, which he believes is where change will originate.

The workflow. His phrase: almost everybody is digitizing the 18th century.

The people. In his assessment, clinicians are not interested in changing their workflow, and no physician will be displaced from their current position.

He described his own view as radical, and said it comes from having run a cardiovascular division. Ultimately, he argued, we are the problem with any dynamic change.

That leads him to expect change at the edges, funded directly by patients and consumers, in the space prior to healthcare. He pointed to direct-to-consumer lab and imaging companies as the visible leading edge. Healthcare gets disrupted, in his framing, by people supplying it outside the existing system and outside existing business models.

His point about scale was the sharpest. Medicine is by design an intensely local pursuit, because that is the business model, and everybody loves their little shop. He cited the COVID conversion to virtual visits as evidence: physicians defended the in-person encounter almost fanatically, then the entire field converted in a week after a decade of moving one percent at a time.

His warning about the consequence: because institutions will still be allocating assets and planning the next clinic and imaging center, the shift will arrive as a shock, and one day the demand will simply not be there.

The Case for Transforming From Within

Holly Maloney presented the opposing strategy, noting she is the only panelist without an MD.

General Catalyst set a decade-long transformation thesis roughly ten years ago and concluded that enduring change required partnering deeply with incumbents rather than building outside the ecosystem. That produced about 35 health system partnerships, representing a mid-teens percentage of care delivery in the country.

That work surfaced the priorities and challenges and produced a view of what a transformation stack could look like for a health system. But the firm found that making recommendations and generating momentum was not the same as driving decision making and budget allocation. To do that, it had to own the asset.

In October of last year the firm closed on the acquisition of Summa Health in Akron, Ohio, through its health assurance transformation company. General Catalyst is now investor, partner and operator simultaneously.

She described being in the early innings at Summa, with early signals around freeing capacity and a north star of always-on care deliverable within two hours.

Her synthesis split the difference with MacRae. She agreed most innovation over the next several years will happen outside, while arguing that integration work can keep existing systems from being fully left behind.

A Long View on Timelines

Ian Tong MD said the two to five year question is hard for him because he expected all of this to happen long ago.

Roughly 13 years ago he left Stanford as a clinical assistant professor to join Doctor On Demand, an early-stage telemedicine company. Two things drove the decision: he judged the system unsustainable for the reasons MacRae listed, and he could see in his colleagues’ faces that they would not sustain the model either.

He framed the choice as whether to be the frog in the pot boiling along with everyone else, or to step outside and try to affect greater change, better patient outcomes, and more sustainable and joyful careers for colleagues.

His early career was at the VA, which had a robust telemedicine program. It became obvious to him that industry would leapfrog that infrastructure once hardwired visits became possible on mobile devices, which is what his company then built.

His retrospective observation is that if the country were building a healthcare system today, it would probably start all virtual, designing patient engagement, data collection and integration from the beginning rather than accumulating snippets of history across individual EHRs.

At Foresite Labs he now works on machine learning disease risk prediction. He noted the firm’s history of incubating machine learning companies, including Xaira in drug discovery and Prometheus, its first company outside healthcare, a physical AI company.

Key Takeaways

1. A 5 to 10 percent shift of care would destabilize the hospital business model, which is what makes the audit urgent.

2. The barriers are structural, not technical. Business model, workflow and professional resistance were named ahead of any technology gap.

3. COVID proved the field can change fast when forced. A decade of one percent progress on virtual visits completed in a week.

4. Consumer spending is the likely funding source for change, through direct-to-consumer labs, imaging and pre-healthcare services.

5. Ownership beats advice for driving transformation. General Catalyst acquired a health system after concluding recommendations were not enough.

6. Disruption will arrive as a shock. Institutions planning the next clinic may find the demand simply absent.