MOONSHOT: “You keep using that word. I do not think it means what you think it means”

As the former Chief Medical Officer of a national primary care network and ACO, I was regularly contacted by entrepreneurs who had no doubt that their (product, service, invention or Big Idea) was exactly what my organization needed to (increase revenue, improve quality, engage patients, add value, reduce costs). From my own entrepreneurial experience, I recognize, and empathize with, their vision and passion. However, there was a dangerous pattern in their patter: first, a presumption of our ignorance: having made their magical discovery, they would inadvertently discount the depth of our experience and insights. Second, the fallacy of profundity: the assumption that solving a relatively narrow problem would have transformational effect on our organization, or the system at large.

These feelings came back to me recently when I saw an announcement of a new “Moonshot Investing” program to be announced later this month at the annual JP Morgan Healthcare Conference in San Francisco.

For those who may not know, there is a parallel world of healthcare, separate from those who provide patient care, ringed by angel investors, private equity firms and venture capitalists. Inventors and entrepreneurs configure their prototypes and plans and, like ligands seeking a receptor, approach its boundary. If they connect, the entrepreneurs are translocated into the startup universe (or scale-up universe, for established companies seeking growth) where their business DNA is activated, and their operational phenotype matured until they are ready to be actively transported into the marketplace. Most entrepreneurs require multiple attempts before they find the right receptor; many never make a match.

For 30+ years the invitation-only JP Morgan Healthcare Conference (JPM) has been a major node in this universe. Along the way, a parallel ecosystem sprung up; thousands come to San Francisco at the same time as JPM with no intent to attend, but to share the ferver. This is where the Moonshot Investing announcement is taking place

I have great respect for startup culture and know many for whom the supportive nature of the start-up community has been mission-critical in getting their company off the ground. However, using the theme of “Moonshots” has revealed what might be fatal flaw — and a dangerous risk — associated with startup culture.

The Moonshot Analogy is used when people want to allude to the overwhelming ambition and sheer audacity of a goal. Moonshots are previously-considered impossible missions, undertaken with some risk of failure, in order to deliver unprecedented results.

Among the 80+ companies heretofore designated as “moonshots” there were some with great potential to contribute to quality of care and quality of health. The problem is that there is no audacity among them. There is nothing that could genuinely called a “moonshot”, even if taken collectively. Do we really need another health coach? Is that app really transformational?

Most of these companies developed elegant solutions to problems that are actually grounded in design flaws in our current system. Others reflect medicine’s reductionist nature, with the hope that attacking the pieces might heal the whole. And while entrepreneurs should be lauded for their spirit, aligning startup culture with moonshot-level transformation ends up making them look like they are wearing the Emperor’s New Clothes.

There’s an apocryphal story about President John Kennedy visiting NASA and asking a janitor what he was doing; he responded, “I’m helping put a man on the moon”. True or not, this story reflects the underlying spirit of a “moonshot”: alignment among diverse stakeholders towards a singular vision.

Moonshots are transcendent. A moonshot makes you want to sacrifice your career to be part of something bigger than yourself. A moonshot is about creating something that, as artist Walter Sickert has said, “makes it impossible for those who follow to ever act as if it has not existed.”

With this, the “start-up” movement may have gone too far, encouraging passionate, innovative people to leave the healthcare talent pool to focus on their own ideas, even when they might make a bigger contribution by bringing their insights to a greater movement.

A moonshot requires coordinated innovation in service of the Big Goal. A more accurate application of the Moonshot Mentality would have investors using their money to convince many of the smart, passionate and energetic entrepreneurs to reconsider their own ventures and contribute to one that could achieve a level of change otherwise impossible without them.

New ideas are not necessary for a moonshot; people imagined space travel for eons before we finally lifted off. A moonshot should not necessarily have an immediate economic return and contribute far beyond its immediate achievement.

In 1977 Dr. George Engel raised the specter of reductionism in medicine and advocated for a more inclusive scientific model, if, as Dr. Engel wrote, “physicians in the future are to apply the same scientific rigor to the approach and understanding of patients and their care as they customarily apply to the diagnosis and treatment of disease”. His recommendations were prescient, yet we have done little substantive towards their realization. Much of what we consider innovation today would be superfluous if we had taken Dr. Engels advice to incorporate behavioral dimensions and social factors into our model for care. Let’s not fall into the reductionist trap that diminishes the concept and impact of a moonshot. It can’t just be about creating a critical mass of good ideas against a problem, it should be something that seems almost, well,…inconceivable!

Physician-leader; health strategist; Chief Medical Officer; founded www.unioninaction.org; author: Care Evolution; former public-health official