Virginia Postrel, now a writer from The Atlantic Monthly, made a lasting impression in one of her articles from a prior publication. At a time when inflationary pressures in healthcare are running at 3 times the national inflation rate, and demand continues to grow, it is only too apparent that there are no easy fixes to any healthcare system. How we define health care is imperative to finding the solution.
Health care isn't a single good, nor, like food, is it easily defined in terms of a minimum to sustain life. Studying other countries' supposedly universal systems only demonstrates how fraught the concept of "health care" is: one bundle of services in British Columbia and a less-generous one in Nova Scotia, one in England and another in Scotland, one in New Zealand before the election and another afterwards. Arguably the U.S. already has universal care, in the sense that everyone can get some care-if only from an emergency room-for some things, and that citizens (a critical word in this context) without money are covered by Medicaid. The real issue is how you define "health care." What gets included is a matter not only of medicine and economics but of culture and politics.
Tuesday, March 31, 2009
Monday, March 30, 2009
BC should embrace "Disruptive Innovation" in healthcare
In a healthcare system that is funded with public dollars, a status quo approach (meaning we continue to allocate resources at the same rate as we always have), is not sustainable. We simply have to look for better ways to do more for the people for whom our system is there to provide care.
In the last few years, BC has implemented some new ideas in healthcare, such the OASIS joint replacement program at UBC Hospital which has created a specialized care model including patient education, highly trained joint replacement nurses and support teams, and specialized post-operative care. The program has contributed to reducing province-wide wait lists for joint replacement, and more importantly, has helped patients get back to health quickly and efficiently.
It seems, however, that there is room for even more new ideas in healthcare in BC – ones that would put us at the forefront of quality patient care and appropriate return on the $13 billion invested annually by the government in keeping BC healthy.
The concept of innovative, and potentially disruptive, changes in how “healthcare is organized, paid for, and delivered”[1] was suggested by Jerome Grossman of the Harvard/Kennedy School Health Care Delivery Program just a month before he died last year. He based this upon the concept of disruptive innovation, first introduced by Clay Christensen in 1997, whereby it is believed that consumers will seek out suppliers/providers who offer a level of transparency, convenience of delivery, and costs that represent value. A novel concept in any healthcare system, to be sure.
In fact today’s healthcare model is based upon a fragmented care, fee-for-service model, whereby physicians and surgeons are paid for process, not outcomes. This removes the incentives for doctors to be proactive in managing wellness, not disease, and further provides an incentive to see as many patients as they possibly can. To be fair, this is not to say that doctors are doing unnecessary procedures; it is to say though, that there is no motivation to do things any more efficiently.
Christensen identified two requisite conditions for disruptive innovation: technology enablers and a disruptive business model that can profitably delivery these routine solutions to customers in affordable and convenient ways.[2] Grossman suggests that improved diagnostics and therapies, along with advances in information and communication technologies, have created the framework for disruptive innovation.[3] The BC healthcare system is committing millions of dollars to eHealth technologies in order to connect the disparate systems that exist today. This is step one in the process of disruptive innovation in BC.
With the technology in place, next there must be the development and implementation of ideas that contribute to doing things differently. We’ve dabbled in pay-for-performance to decongest the emergency room. We’ve put specialist doctors on salary in some hospitals to retain them and meet the demand for on-call services. We’ve opened diagnostic imaging facilities in their off-hours to expand capacity.
Perhaps these concepts from other markets have already been considered, but certainly they warrant another look:
- The wellness model of healthcare moves the burden of accountability to the patient; what about investing in wellness and disease prevention, and providing financial incentives to patients who meet certain targets.
- Providing incentives for physicians to support and use a wellness model – including diet and fitness assessments. Paying doctors to oversee wellness makes more sense than waiting for them to treat disease. Wellness management tools are already available, including web-based patient records which allow a patient to track their own progress (like they track their bank account), and communicate electronically with doctors. This model is already available in BC, however only to this extent in the private sector.
- With the shortage of family doctors, what about allowing people that meet certain criteria the opportunity to go directly to specialists? In other countries, this has worked, and has succeeded in shortening the time to specialist, as well as placing patients in control of their medical process. Within this model, Nurse Practitioners may provide a compliment to specialist care, and certain specialists may be given an expansion in scope of practice.
British Columbians should not fear disruptive innovation. It won’t choke the publicly funded system; in the short term, it may create changes that disrupt the normal routine of healthcare and in the long term, it will allow for a robust and self-sustaining system. As a strong and resilient population, BC needs to lead the way through disruptive change if it intends to continue its publicly funded healthcare delivery system into the future.
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