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I was an innocent bystander in 1998, happily ensconced in the study of innovation at the Harvard Business School when Professor Elizabeth Armstrong of the Harvard Medical School changed my career with an irresistible invitation: "Everyone else is trying to solve the problems of expensive, inaccessible health care by studying health care. I'd bet that if you stood aside the industry and examined it through the lenses of your research on innovation, you'd be able to see things that others can't see." A short while later Dr. Jerry Grossman, then a Fellow at Harvard's Kennedy School of Government, made the same invitation. Jerry was a physician, had been CEO of one of Boston's major hospitals, founder of a leading health benefits plan, chairman of the Federal Reserve Bank of Boston, and a director of several of America's leading health-care companies. I decided if men and women of this stature saw potential in this approach to one of the world's most vexing problems, I ought to accept their invitation.

My concern a decade ago was whether my research on innovation and management was insightful and robust enough that it would help us understand the root causes of this industry's problems. That challenge proved to be simple, however, when compared with the unfathomable, interdependent technological and economic complexity of the health-care enterprise. Wrapping my brain around the whole of it took 3.1416× more time, and 10× more intellectual energy than I had imagined it could. Making health care affordable and accessible is a challenge of monstrous proportions—far beyond the most intractable of the problems I had previously tried to study.

Too often scholars succumb to complexity of this sort by offering simplistic solutions to incorrectly defined problems. We have been determined not to do this—but instead to wrestle with and boil down the complexity in order to distill from it the essence of the problems—so that we could recommend solutions that would address them at their root. My colleagues and I wrote my previous books ourselves, and generally vetted them only with a small group of advisors and critics before publishing them to the world. But that approach wouldn't work here. Over a hundred friends have helped us do this. These include leaders of medical schools, some of the world's most respected scientists, administrators of great hospitals and health-care companies, practicing physicians and nurses, irreverent, free-thinking and risk-taking entrepreneurs and investors, large and small employers and insurers, and insightful analysts. They have patiently taught us, allowed us to stress-test our ideas against their experience, and helped us conceptually take apart and then reconstruct the industry so that we could understand how the pieces have worked together in the past, and how they must do so in the future. We have listed below the names of many of those who have helped us in these ways. We hope they can see their imprint on this work and that each can feel our gratitude for their selfless service to us and to this Cause.

Jerry Grossman passed away nine years into this decade-long project. It's impossible to describe the marvelous workings of Jerry's mind. He helped us see connections across each element of the system from perspectives that only his divergent mind could take. That a man of his scope and stature would join with me in this enterprise has been an extraordinary honor. Though he is no longer with us, I know that he still lives, and I hope this book brings honor to him and his wonderful family. His daughter Kate has worked with us to be sure her father's mind and voice have been reflected and preserved herein as faithfully as possible. Jason Hwang, MD-MBA, is one of the best students I've ever had at the Harvard Business School. I am deeply grateful that he would step away from his intended career to stay with me after graduation to wrestle these problems to the ground. He beat them up again and again until they confessed the truth. Jason is a true genius, a patient and perceptive colleague. I love working with him.

My son Matt Christensen, my wife Christine, and my Innosight colleagues Matt Eyring and Steve Wunker—each of whom understands my research on innovation better than I do—pored over and poked holes in every paragraph of this book. My friends Lewis Hassell, Gilbert Tang, Jason Sanders, and Jeremy Friese—all of them busy medical doctors—did the same, as did Tom Armstrong, one of Boston's leading venture capitalists. The published version of this book is vastly improved over the drafts that they worked on, because of their help. I am grateful to Lisa Stone and JaNeece Thacker for keeping us organized; to Danny Stern and Whitney Johnson for creating so many opportunities for us to present our ideas to audiences that could help us sharpen them better; and to Mary Glenn, our editor at McGraw-Hill, for so patiently and so competently whipping our work into shape. Our children Ann, Michael, and Katie prepared the index of this book, and patiently let me talk through with them each piece of the logic. Our son Spencer, currently a missionary in Taiwan, has helped me immeasurably with his prayers. I am grateful to my family for the light and richness they bring to my life.

My teaching colleagues at the Harvard Business School—Steve Kaufman, Willy Shih, and Ray Gilmartin—have sharpened our body of understanding about innovation far beyond the limits of my own perspective and experience. I love working with and supporting them.

Dr. Ronald Arky has helped me live free of the complications of Type I diabetes for nearly 30 years. Dr. Michael Kjelsberg saved my life when a clot completely blocked the left anterior descending artery in my heart. Dr. James Karlson sewed my shattered elbow together with Kevlar, rendering my arm fully functional instead of useless. Dr. Sherleen Chen brought brightness and clarity to my right eye, which otherwise would now be blind. Drs. Callie Taffe and Charles Blatt keep me tuned up. The nurses, technicians, and support staff behind these experts are miracle workers, too. These all have preserved, extended, and enriched my life. I thank them. I dedicate this work to Dr. Jerry Grossman and to these wonderful doctors and caregivers who have preserved my life and my abilities far beyond what nature otherwise would have allowed. I hope that through this book, in some small measure I might repay them, by freeing their abilities from the limits that the health-care system within which they work has often imposed. May God bless each of them, and all of those who are engaged in this vast effort to preserve and enrich the lives of mankind.

 

Clayton M. Christensen

Boston, Massachusetts

 

• • •

I've been leading up to this book for 42 years. In 1966, fresh from my medical training, I took a job at Massachusetts General Hospital (MGH) where I divided my time between the Laboratory of Computer Science and the practice of internal medicine. At the lab, I developed an automated medical record for the brand new Harvard Community Health Plan, an early HMO. Along with other young physicians, with the wise mentoring of John Stoeckle, we started a group practice, and I began managing more and more outpatient functions at the MGH. With others from the lab, I founded a software company called Medical Information Technology (commonly known as MEDITECH), which serves health-care organizations worldwide. By 1970, I was set on my career path of combining the art of hospital management with the new information technologies rapidly coming into use.

After 13 years at the MGH, I moved across town to the New England Medical Center (now known as Tufts Medical Center), where I became president and CEO. Here, with the support of an innovative board and leadership team, I found the perfect place to meld my interest in technology and health-care delivery. The Medical Center gave me unlimited opportunities to test and apply many of my theories about how high-quality health care could be delivered more efficiently using information technology and systems engineering.

During my years as hospital president, I became involved with three other organizations that vastly deepened my understanding of management, technology, and health-care delivery systems. In 1980, thanks to Howard Cox, I was asked to join the board of the Stryker Corporation, a Fortune 500 medical device company. During my 28 years at Stryker, I learned an immense amount working alongside its wise and innovative leader, John Brown. In 1984, I was elected to the Institute of Medicine of the National Academy of Sciences, and over the next 24 years, I had the privilege of serving on numerous committees both at the Institute of Medicine and the National Academy of Engineering. I owe a huge debt to the leaders and staff of the National Academies, and especially to Proctor Reid. Finally, in 1990, I was asked to join the board of the Federal Reserve Bank of Boston, and then to serve as its chair. Both Cathy Minehan and Lynn Browne taught me a great deal of what I know about economics and the constructive role of good regulation.

After retiring from hospital management, I joined the Harvard Kennedy School as the Director of the Health Care Delivery Policy Program (HCDP). I am grateful to the people at the Harvard Kennedy School who gave me the intellectual space to develop my ideas of how health care can be transformed in the United States: Joseph Nye, David Ellwood, John Ruggie, Jack Donahue, and Scott Leland. I offer a deep thanks to each HCDP member and guest speaker, for the spirited and rigorous discussions we had over the years. I especially thank Karen Tracy, Karen Eggleston, and Cara Helfner, without whom the work of HCDP would not have gone so well or so smoothly. Many of the ideas developed through the HCDP Program have found their expression in this book.

During my tenure at the Harvard Kennedy School, I continued to enjoy other opportunities to explore how health care could or should be conducted throughout the United States. In particular, I highly valued my time on the board of the Mayo Clinic, where many innovations in health-care delivery are already in place, and extend my appreciation to Mayo's President & CEO, Denis Cortese, and his colleagues, who allowed me to wade through their data and systems for the last five years. I also am grateful for my collaboration with Alain Enthoven, which most recently included work on a report for the Committee for Economic Development.

While the thoughts that go into this project started forming over four decades ago, the seed for this book specifically began to grow when, after I arrived at the Harvard Kennedy School, I met Clay Christensen. One of my greatest joys comes from the opportunity to collaborate with great thinkers from other fields to further inform and develop my research and thoughts on the medical-care industry, and I was excited to have the chance to examine health-care delivery systems through Clay's lens of disruptive innovation. Through Clay, I met Jason Hwang. He has been invaluable to this book: developing and melding first drafts; culling research, reports, and real-world examples to support our theories; and managing the daunting editorial process.

In addition to the partnership and collaboration of my co-authors, it would not have been possible to produce this book without the generous and able help of many people. I'm grateful to a wonderful cohort of friends and colleagues who provided us with carefully considered, thoughtful feedback which helped clarify our writing and ideas. Denis Cortese, Proctor Reid, and Gordon Vineyard all read multiple chapters, provided extensive notes, and were invaluable sounding boards. In addition, I am indebted to John Brown, for his review of our medical devices chapter; Jon Kingsdale, for his passionate thoughts on reimbursement; and Karen Eggleston, for her astute comments on our chronic disease chapter. I owe all the readers a debt of gratitude for their willingness to help make this project as articulate, well-reasoned, and coherent as possible. I also offer sincere thanks to Cara Helfner, whose many hours of research and work on the endnotes helped ensure clarity and credibility; and to Whitney Johnson and Lisa Stone for all their help coordinating the endorsements.

I offer very special thanks to Karen Tracy, who has worked alongside me for 29 years with good humor and patience, keeping me organized and on track throughout my adventures in health care. I have been fortunate to work with someone as wise and sensible as Karen, who has been the calm in the eye of the storm throughout our many years together.

Over a 42-year career, I was lucky to be given many opportunities to serve—in hospitals, government, the corporate world, think tanks, banking, and academia. In all of these settings, I have been blessed with colleagues, those named here and many others, who constantly challenged my thinking and helped me develop, amend, and revise my ideas. To every one of them, I am extremely grateful.

My deepest thanks go to my family: my youngest daughter, Amelia, for being a fellow risk taker and for sharing my sense of adventure; my middle daughter, Kate, who shepherded this book through to publication in its final months, acting as my voice and representative; and my oldest daughter, Elizabeth, for her willingness to take intellectual journeys with me as I explored disparate disciplines and sectors in search of new approaches to transforming the health-care system.

Finally, I would like to thank my wife, Barbara, for her role in this book. From our very first date, in the summer of 1966, we debated about various models of health-care delivery systems from our disparate political perspectives. For the next 42 years, we refined one another's ideas, became better thinkers from challenging one another, and had lots of fun in the process. Together we raised our three wonderful daughters, and we are unabashedly proud that the interest and passion for public policy that has animated our lives and careers is living on in each of them.

 

Jerome H. Grossman, M.D.

Cambridge, Massachusetts

 

• • •

After reluctantly leaving clinical practice behind to attend Harvard Business School in 2004, I could never have anticipated the path that my career subsequently took. In the summer of 2006, I was generously given a most-unexpected opportunity to work with two of the brightest, most talented individuals I have ever had the great fortune to know. It was as though two Oscar-winning actors had just handed me an all-access pass to the studio lot, together with an assignment to help them compose a movie script whose first act was already being reviewed by critics everywhere. The process of researching and writing The Innovator's Prescription was an experience that was alternately terrifying and exhilarating—a constant, ex post critique of everything about a health-care system that I had grown to love, combined with a forward-looking compulsion to make it everything that it could be.

I shared my two-and-a-half-year journey of reflection and exposition with two wonderful, illustrious co-authors, Clayton Christensen and Jerome Grossman. When I enrolled in Clay's class as a second-year business school student, little did I know that we would soon form a collaboration to try to change the health-care system. What I realized very quickly, however, was that Clay's ideas would forever have a profound effect on the way I approach problems and their solutions—in work and in life. My respect and admiration for Clay have only grown since then, and I am distinctly privileged to have had the chance to work with such an honorable, giving gentleman.

Unfortunately, Jerry was called away from this earth far too soon. His passing was a tragic and immense loss for all of us, yet the impact he left behind was immeasurable. He influenced not just health care, but public education, finance, and everything he touched. Jerry was instrumental in opening doors that I never even knew existed, and, in the writing of this book, he often served as the yang to Clay's yin. Clay and I did everything in our power to ensure that this book would be remembered as Jerry's Ninth Symphony, leaving his tremendous legacy intact and allowing him, much as in life, the final word.

I owe tremendous gratitude to the same individuals already thanked by my colleagues, and there are several others who warrant special acknowledgment. Kate Sutliff, Jerry's daughter, ably stepped in to help us complete her father's work during a time of great sorrow. Mary Glenn, Danny Stern, and their respective teams at McGraw-Hill and Stern + Associates expertly guided us along this immense undertaking. Whitney Johnson was the ball of energy that frequently re-energized and re-focused the team. Bern Shen served as the calm voice of impartiality, providing reasoned counsel whenever needed. Lisa Stone, JaNeece Thacker, and Karen Tracy managed to inject stability when there seemed to be nothing but chaos and always made certain things got done. My colleagues at Innosight LLC, including Mark Johnson, Scott Anthony, Matt Eyring, and Steve Wunker, served both as sources and sounding boards for our ideas. And I offer a special thanks to Michael Horn, who co-founded Innosight Institute with me and, in the process of toiling as a fellow starving writer on his own book Disrupting Class, became a trustworthy and valued friend.

Finally, I must thank the people who helped guide me at the head of this winding but worthwhile path: my teachers, colleagues, and patients at the University of Michigan Medical School and University of California, Irvine Medical Center; my physician friends who continue to struggle to deliver perfect results in an imperfect system; and, of course, my family, whose love and support always ensured that I had a working compass and a running start.

 

Jason Hwang, M.D.

Cambridge, Massachusetts

 

• • •

The authors would like to thank the following individuals for their contribution and support.

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Arshad Ahmed Valerie Fleishman Steve Neeleman
Mara Aspinall Steven Fransblow Chris O'Connell
Charlie Baker Erez Gavish Reed Quinn
JoAnn Becker Ray Gilmartin Saquib Rahim
Nancy Barrand Ginger Graham Noah Roberts
Keith Batchelder Andy Grove Mary Kate Scott
David Bjorkman Richard Hamermesh Michael Segal
Richard Bohmer Aviad Haramati Jay Silverstein
Kevin Bolen Lucie Heinzerling Kanwarjit Singh
Chris Boyce Michael Howe Mark Smith
Bruce Bradley Dennis Hunter David Snow
Joe Camaratta Brent James Steven Spear
Chris Coburn John Kaegi Michael Stapley
Delos Cosgrove John Kenagy Peter Stebbins
Deborah Danoff Wolfgang Kleitmann David Sundahl
Ricky Da Silva Raju Kucherlapati Paul Tarini
Keith Dionne Margaret Laws Ferris Taylor
Ken Dobler Jeff Levin-Scherz Joe Turk
Bruce Donoff Armando Luna Janice Uhlig
Nathan Estruth Marie Mackey Nick Valeriani
Colin Evans Mike Mahoney Thomas Viggiano
Robert Falcone Nita Maihle Bill Weldon
Lynn Feldman Joseph Martin Linda Hall Whitman
Stephen Field Michael McGranaghan Woody Woodburn
Elliott Fisher Ed Miller Leslie Yee

Partial support for the production of this book was provided by the California HealthCare Foundation. Information about the Foundation is available at www.chcf.org.

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