Sunday, June 25, 2006

Baby Boomers and the Tipping Point in Healthcare

There They Go Again

It's easy to blame it on the Baby Boomers but a more accurate way to see it is to say there exists a critical mass of people entering the Healthcare System. This critical mass of people with healthcare needs is one of the major factors stressing the current traditional platform for delivering healthcare and transforming it into a new platform for delivering healthcare. The traditional platform for delivering healthcare has been through the Patient-Physician relationship. There was a time when this platform was a superb way to deliver essentially all healthcare services. In fact much of the success of the modern Healthcare System is due to the strength of this relationship and that is exactly why it is difficult to believe it could be replaced. I don't just think it could be replaced; I think it is being replaced. So what exactly do the Baby Boomers have to do with the Patient-Physician relationship and a tipping point in healthcare?

The Straw That Broke The Camel's Back

Baby Boomers are a large cohort of our population that is moving through our culture and influencing everything they contact. They are the people born between 1946 and 1964 and currently living in the United States. The first of them will turn 65 years old in five years and they are expected to double the size of this age group in the next 25 years. One of the great results of our Healthcare System is that people are living longer and healthier lives. While people may be living longer and healthier lives they still must live with many of the chronic health problems that have yet to be eliminated. Fifty years ago we did not have many treatments for these types of health problems but now we do and people expect to have access to the full range of healthcare services available to treat them. There is nothing magical about the age of 65 or being labeled a Baby Boomer. The simple observation remains: We have a large cohort of individuals entering an age when chronic health problems begin to occur at an accelerated rate. This, coupled with the size of this group, is one of the main factors creating a strain on the system. What we keep referring to as a "Healthcare Crisis" is really the outward manifestation of a system that is stressed and undergoing a transformation. As the first wave of Baby Boomers passed the age when health problems accelerate, the tipping point was reached, and the "Healthcare Crisis" officially began. But this wasn't the only factor.


As I mentioned before the fundamental platform for delivering healthcare information and services has been through the Patient-Physician relationship. The physician was the gatekeeper to the information and the provider of services. Twentieth century healthcare produced an enormous amount of information in addition to a wide range of services. The traditional platform has reached the point of diminishing returns on its ability to provide access to the supply of all the available information and services. It is not a matter of training more doctors. The problem is that doctors are human and humans have their limits. As the supply of information and services grew physicians needed to develop ways in which to manage this increasing supply. In the early part of the twentieth century this was accomplished by improving the training of physicians. As information and services continued to grow physicians began to specialize. Instead of mastering all that medicine offered we mastered smaller and smaller parts of it. While this allowed for the continued growth of information and services it also created an increasingly fragmented process for delivering healthcare. We can train more doctors but this will only create further specialization and fragmentation of the delivery platform. The delivery platform must be a common interface for the patient and be capable of coordinating the delivery of all available information and services. This can't be done with humans alone. With the accelerating demand this will require a new type of platform.


Not only is the traditional platform currently incapable of delivering all the information and services but the demand, in the form of a large cohort in need of those services, is growing beyond the capacity to deliver them as well. I don't think of this as the demise of the Patient-Physician relationship but I do see this as the demise of the physician as the central and only delivery vehicle of our Healthcare System. This is evident in the tremendous growth of non-traditional forms of healthcare delivery in the last few years. With each passing day the ranks of non-physician providers continues to swell. Patients will continue to seek out the services that only physicians can supply but it is very clear that they won't hesitate to obtain all other services from non-physicians if the price is more affordable and the service more convenient. This is also evident in the explosive growth of information on the internet. People will continue to seek out any and all sources of information and have no intention of limiting their access to healthcare information by waiting for a doctor's appointment. So what will the delivery platform for an emerging paradigm of our Healthcare System look like in the future?

And The Ability to Deliver

My best guess is it will be some form of information technology interface. It will need to have access to all of the best available and up to date information and range of services. It must be available at all times. What form this interface takes is anyone's guess but I suspect its earliest form already exists as simply as a computer connected to the internet. In time its capabilities will grow and it will take on new forms. It will coordinate each individuals care and provide what information and services it can provide. Those services that it can't perform will be done first by non-physician providers if they are capable of providing those services. When they are unable then it will be the physicians who provide the services. The gatekeeper will be the information technology interface whose information and limited services will also be available to providers to augment their ability to deliver what services they are trained to provide. Whatever form it takes it must also be very affordable. There are currently 3.3 workers for each social security beneficiary but in 2031 it is estimated there will only be 2.1. When we add in the existing and newly added Medicare benefits this will place an enormous tax burden on the workers in the United States. It is not a matter of saying the costs of our Healthcare System should come down, they must and will come down. It may seem like it's going to be Baby Boomer hell but I am more optimistic. We will find a solution. It may not look anything like the system the Boomers grew up with but if we are to continue to provide the needed information and services it is going to probably take on a completely different form from what we have now. Baby Boomers will continue to shape and influence the world they live in but as I said in yesterday's post it may "be in ways none of us ever imagined or possibly even intended."

Saturday, June 24, 2006

Resuscitation Centers: More Disruptive Innovation Theory for Hospitals

Just a Thought

Maybe what we need more of are "Resuscitation Centers" and not more "Centers of Excellence" focusing on the presumably narrowly defined needs of Trauma, Cardiac or Stroke patients. It is becoming more apparent that the sooner a life-threatening disease process is discovered and treatment initiated the better a patient does. This has been shown repeatedly in the treatment of trauma patients with severe injuries, cardiac patients with acute myocardial infarction, and in patients with an acute embolic stroke. Over the last several years it has also been shown that patients with severe sepsis also benefit from early goal directed therapy beginning in the emergency department and continuing on into the intensive care unit. The common theme for all these treatment plans is early identification of the disease process and aggressive evidence based interventions. The problem is that many of these treatment plans occur in multiple areas of the hospital and can involve multiple specialists.

Focused Care

Physicians tend to focus and segregate based on specialty. By doing so hospital administrators tend to narrow the focus of a hospital toward those specialties and create what are now known as "Centers of Excellence". This can be seen in the development of a controversial type of center known as "Specialty Hospitals". The advantage of these hospitals is that patients with a very specific disease process can seek treatment at facilities that specialize in the care of that type of disease. Many of these "Specialty Hospital" facilities primarily serve patients with insurance who need elective or semi-elective procedures. The patients with the more emergent needs who may or may not have insurance are often directed to tertiary care centers. Many of these tertiary care centers have continued to become more focused experts in the management of disease processes that present in an emergent fashion. They have also attracted individuals who specialize in the treatment of these types of diseases (trauma, heart attack, stroke). As these specialists came into contact with one another on a more frequent basis it became more important to coordinate care. This focused type of coordinated care led to the development of Trauma, Cardiac and Stroke Centers. It is these types of Centers of Excellence that have made it possible to improve the outcomes of patients with complex and life-threatening problems. So with all this high quality care why do we now need Resuscitative Centers?

It's Those Damn Baby Boomers

To put it simply, baby boomers are a large cohort of our population and they are getting older and living longer. Despite all the progress that has been made in healthcare over the last one hundred years, advanced age brings with it health problems and a critical mass of baby boomer health problems is beginning to come center-stage in our healthcare system. In my specialty of Trauma Surgery this continues to be a worse problem with each passing year. We're seeing an increasing amount of older trauma patients who have multiple health problems to manage in addition to their injuries. Because of the associated co-morbid conditions that tend to come with aging the mortality for those over the age of sixty-five is double that of a younger person with the same injuries. Years ago while I was a fellow in Trauma Surgery and Surgical Critical Care at Shock Trauma one of my colleagues suggested the day may come when we will need Geriatric Trauma Centers much like we have Pediatric Trauma Centers today. I think he was closer to the truth than many of us wished to believe.

The Need for a Hybrid System

There certainly is a growing need for the involvement of physicians more attuned to the special needs of the geriatric population who become victims of a traumatic incident. Trauma tends to be a disease process that is seen in a younger and healthier population. (It is the number one cause of death of those between the ages of one and forty-four.) As our population ages there comes with it the development of chronic health problems. It is these chronic health problems (coronary artery disease, asthma, diabetes, hypertension, etc.) which become complicating factors in the management of injured elderly patients. A hybrid system of care is evolving where specialists not used to being routinely involved in the care of trauma patients are more frequently called upon to take part. Many of these specialists (Cardiologists, Pulmonologists, Neurologists, Medical Intensivists) are crossing over from their own Centers of Excellence to join in the management of elderly trauma patients. In doing so we are evolving a new cluster of coordinated care.

Resuscitation Teams

They all have something in common. Within there own specialties they are experts in the ever developing field of resuscitation. Trauma Surgeons like to take credit for this field beginning with Dr. R Adams Cowley's famous claim of a "Golden Hour" in the early management of severely injured trauma patients. What this refers to is that severely injured trauma patients must be identified and aggressively treated as early as possible to improve their survival. This is demonstrating to be true for all emergent life-threatening problems. It may be that what we really need are "Resuscitation Centers" that have mastered the convergence of team members from the multiple "Centers of Excellence". Recently hospitals have been adopting the concept of "rapid response teams". These are small dedicated teams that can be called quickly to the bedside of a patient before they get into serious trouble. I think a more developed and highly skilled form of this will one day be present in all major hospitals. It will come in the form of a "resuscitation team" that will respond to all patients with an emergent life-threatening disease process anywhere in the hospital, including the emergency department.

Radical Sustaining Innovation

So why do I refer to disruptive innovation theory? In a previous blog I commented on the need for disruptive innovation at Trauma Centers for a different reason. In that post I discussed the observation that two-thirds of the trauma patients in the National Trauma DataBase have injuries that would be considered minor by conventional scoring systems. In addition, almost half of those patients were treated at Level 1 Trauma Centers which tend to be the most resource intensive hospitals in the country. I suggested this means we need a low-end disruptive innovation in the form of "Minor Trauma Centers" that utilize mid-level providers supported by algorithm based evaluation and treatment plans. In the words of Clayton M. Christensen, it would be a model that "targets overshot customers with a lower-cost business model". What I'm suggesting today is an idea that works at a more complex end of the spectrum. This fits the model of a radical sustaining innovation.

Convergence of Expertise

A sustaining innovation is an innovation that typically moves a company in an incremental fashion "along the dimensions that customers have historically valued". "Radical sustaining innovations are at the complex end of the continuum". According to Christensen, they "tend to be very complicated and expensive." They are opportunities that are available to companies that must "control large swaths of an industry's value chain". The advantage is that it provides companies the ability to "dramatically change their relative competitive positions in a market-place". The challenge is coordinating and integrating the multiple players involved in the various legacy systems represented by the "Centers of Excellence". The concept of resuscitation crosses multiple specialty service lines but appears to be emerging as a central theme in the management of acutely ill and injured patients with life-threatening diseases. A "Resuscitation Center" would have "Resuscitation Teams" that cross specialty service lines and focus on that period of time from the patient's arrival until that time when the life-threatening disease process is controlled. Specialists (Acute Care Surgeons, Intensivists, Cardiologists, Pulmonologists, Neurologists, etc.) could be team leaders or team members lending a specific level of expertise based on their training, experience and comfort level with the patient's specific problems. The radical difference is that a patient would no longer be seen by a group of independently functioning consultants focusing on a different physiological system but rather by a multi-specialty team focusing on the whole patient. This kind of team play may not be possible among baby boomers but may be necessary and inevitable among those who take care of us as we get older. It is becoming apparent to me that even as we baby boomers get older we continue to change the world in ways none of us ever imagined or possibly even intended.