Trial and Error
The mechanisms by which we will transition from an established platform for delivering health care (Patient-Physician relationship) to an emerging platform for delivering health care (Patient-Information Technology relationship) are not new. They are just new to patients and physicians within the context of their current relationship. Both groups are moving outside their comfort zones to test the alternatives that are becoming available. Learning through trial and error is in the nature of human beings. As we learn, we incorporate new information and blend it into the existing network of information. Moving from one paradigm to another happens the same way. It is gradual right up until the time it isn't and then it becomes obvious to everyone. The transition has already begun. The change is already happening at the most fundamental level. This is in the nature of the Patient-Physician relationship. It has become a Patient-Provider relationship and even the nature of the Provider is changing.
Non-Physician Providers
There are more sources of Providers available today than ever before, and many of those sources are becoming more readily acceptable (Retail Clinics, Chiropractors, Nurse Practitioners, Physician Assistants, Advanced Practice Nurses, Medical Spas). The Internet and television have also become valuable sources of health care related information (Google, Pub Med, Web MD, Dr. Gupta). Many of these options are based on ideas created by physicians but this is not true for all of them. Physicians are also breaking out of their mold. Not only are they offering alternative methods of accessing health care information but they are developing the fundamental concepts for the basis of these information warehouses. Often this comes in the form of protocols and guidelines but it can also be in the form of an IT based evaluation. When the established paradigm for delivering health care was at its peak it was the physicians who were the primary gatekeepers of this type of information. Patients could only access this storehouse of information and services directly through contact with a physician. Times are changing and people no longer have to do this. So why is this?
What People Want
It is no secret that people want three things from the health care system. They are access, quality and low cost. Physicians are slowly beginning to realize this and are struggling to achieve these "customer demands". As they do this they must compete at a different level. They must use alternative methods of delivering health care services and they must begin to deliver them using the older established platform for delivering health care. This traditional platform for delivering health care is relatively slow to perform in this on-demand world we live. So how do we transition from the established platform (Patient-Physician) to the emerging platform (Patient-IT based Provider)? It will be through a series of surrogates.
Surrogate Providers
Surrogate Providers come in two forms. One is human the other is technology based. Access to medically related information is the starting point for both types. The human form is represented by the non-physician providers of health care. Examples include Nurse Practitioners and Physician Assistants. In recent years we have seen the growth of Nurse Practitioners and Physician Assistants who are also providing needed information and services. They do it with improved access and lower cost. Some may argue that the quality is not up to par with that of physicians but the people paying for these services tell us something different. The growth of the retail based clinics such as Minute Clinic demonstrates that people approve of them and think they are of value. The Nurse Practitioners and Physician Assistants who staff them use an algorithm base artificial intelligence to guide their decision making. As retail based clinics expand they will confront greater competition to deliver more services, maintain access, improve quality and drive cost down even further. In time even the Nurse Practitioners and Physician Assistants will find they have competition.
Built To Last
It is the other form of non-physician provider that will be the main form of competition. This is the information technology based provider. Currently it is in its most immature state of existence. As technology improves and medical information systems become more advanced they will begin to compete with the human forms of providers. Initially they will augment and support human providers but in time as people begin to trust IT based support they will seek out the IT based provider. An IT based provider will be available 24/7. It will have all available information regarding the patient, their health related problem and its treatment. It will constantly be up to date. It will cost substantially less than any of the current forms of providers. The day will come when we will have virtual reality environments that will simulate a Physician for those who wish to interact with a visual entity. What is amazing is that I think it will ultimately be physicians who usher in this era. Why is that you say?
Self Interest & Survival
There are two reasons. The first is because it will deliver a better Health Care System. That is Health Care System 2.0. It will deliver better quality care, with improved access to care and at a lower cost. The second reason is because physicians will see it as in their best interest. Retail based clinics are a form of low end disruptive innovation. As they mature they will carve out more and more of the role that physicians have traditionally maintained. This is, as distributors of medical advice and as gatekeepers of the health care system. The IT based providers will in time act as a disruptive innovation and carve out more and more of the retail based clinics territory. Both of these entities have and will continue to have limitations. Each of these types of providers have algorithms that have exit points. These are decision nodes that refer the patient to a physician or other human provider for a specialty service. It will be in the best interest of physicians to position themselves as the natural selection for those referrals. For most physician specialists it will be immaterial who refers them patients. It won't matter if the gatekeeper and referral source is human or IT based. For the patient with an IT based provider they will know instantly who is the closest physician specialist, what is their availability, how much will they cost and how do they compare with other specialists in their field of expertise. In order to compete physicians will need to participate in systems that will optimize their access, cost and quality of care. Everybody keeps clamoring for transparency in our Health Care System. The only transparency that will be needed is that related to access, cost and quality. Beyond that anything goes in Health Care System 2.0.
Showing posts with label paradigm shift. Show all posts
Showing posts with label paradigm shift. Show all posts
Saturday, February 24, 2007
Sunday, February 11, 2007
Health Care System 2.0
The Time Is Now
Everyone agrees that our health care system is in need of serious reform. Some go so far as to say we need to transform our health care system. I have some different ideas on this subject. I don't think we need to look to the future for the transformation of our health care system. I think it is happening right now. This is it. This is what it looks like and feels like. We seem to think it is going to be some type of pleasant experience. It's not. It is this way because we must simultaneously dismantle the model upon which the established paradigm of delivering health care is built and replace it with a new model upon which the emerging paradigm of delivering health care will become established. It must do this and continue to deliver health care to our society. It is not an easy task to do but I believe this process has already begun.
The Gatekeeper
The established paradigm of delivering health care is based on the classic patient-physician relationship. Let's call this paradigm Health Care System 1.0 to borrow a software version analogy. What we have witnessed over the last forty years has been an unprecedented attack on this relationship. Much of it has focused on the role of the physician as the primary gatekeeper to the health care system's vast resources. Most if not all major consultations, prescription medications, in-patient and out-patient treatments and operations were accessed by first going through a physician. If you need anything available in Health Care System 1.0 you must first be granted access by a doctor. In version 1.0 this made sense. The doctors education and training was an essential element needed to direct the patient toward the best available resource. It was the doctors experience with version 1.0 that helped guide the patient through this complex-adaptive system. So where is the evidence that this relationship is under attack or even strained?
Under Pressure
The patient-physician relationship is experiencing multiple sources of pressure. Reimbursements for physician services continue to be cut or at least not increase in a manner to keep up with the cost of living. The rise in medical liability rates has also created a pressure by increasing practice expenses. This means that each patient contact results in reduced net payment to the physician and an increased exposure to medical liability risk. In order to maintain the same level of income a physician must gravitate toward contacts with either reduced risk or improved reimbursement per contact. In addition, insurance companies want a greater say in what treatments a patient may undergo or what medications they may be prescribed. This increases the "hassle factor" for physicians struggling to match allowable treatments and medications with what they believe to be the standard of care. What is slowly happening is the role of the physician as gatekeeper is being stripped away. The combined effect of decreased reimbursement, increased expense, increased medical liability risk and outside sources directing medical care is passively conspiring to remove physicians from this role. Hear me out, I said remove physicians from this role, not entirely remove physicians from the Health Care System. So who or what will assume this role?
Design Specifications for Gatekeeper 2.0
Clayton Christensen touched on this in his recent book, Seeing What's Next. I referenced this source in a previous blog addressing disruptive innovation and trauma centers but it's worth repeating because it really focuses on how this process is currently progressing. He summarized this in the chapter titled "Healing the 800-Pound Gorilla".
1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Non market forces affect the market for innovation by influencing industry players motivation and ability.
I believe as we get better at defining the rules and integrate them into our growing network of information technology these will become the protocols and pathways used by the less-skilled people. This is already in place for mid-levels practicing with Minute Clinic. The protocols and pathways will need to be stored in a platform that can access the information at all times. The artificial intelligence built into this platform will guide the mid-level and eventually even less-skilled people through the maze once only entrusted to a physician. It will need to do this in a way that improves health care access to the patient, at a lower cost with "as good as" results. Minute Clinic and its copycats are already doing this for relatively minor health problems. As they get better at this process they will inevitably migrate up the value chain.
Summer Is Coming
So am I for it or against it? I am neither. I see it as inevitable. It would be like asking me if I am for or against the coming summer. Since I live in Phoenix, Arizona it would be like asking me if I endorse one hundred and fifteen degrees in the shade? I don't really endorse it one way or another I just prepare for it if I plan on being here in the summer months. Between now and then the average daily temperature will slowly rise. It doesn't happen all at once but a little bit at a time. I see the coming of Health Care System 2.0 the same way. I guess in some ways I endorse it because I hope it really will deliver on the promise of an improved Health Care System. Either way, just like the coming summer, I plan on preparing for it by adapting to the daily changes.
Everyone agrees that our health care system is in need of serious reform. Some go so far as to say we need to transform our health care system. I have some different ideas on this subject. I don't think we need to look to the future for the transformation of our health care system. I think it is happening right now. This is it. This is what it looks like and feels like. We seem to think it is going to be some type of pleasant experience. It's not. It is this way because we must simultaneously dismantle the model upon which the established paradigm of delivering health care is built and replace it with a new model upon which the emerging paradigm of delivering health care will become established. It must do this and continue to deliver health care to our society. It is not an easy task to do but I believe this process has already begun.
The Gatekeeper
The established paradigm of delivering health care is based on the classic patient-physician relationship. Let's call this paradigm Health Care System 1.0 to borrow a software version analogy. What we have witnessed over the last forty years has been an unprecedented attack on this relationship. Much of it has focused on the role of the physician as the primary gatekeeper to the health care system's vast resources. Most if not all major consultations, prescription medications, in-patient and out-patient treatments and operations were accessed by first going through a physician. If you need anything available in Health Care System 1.0 you must first be granted access by a doctor. In version 1.0 this made sense. The doctors education and training was an essential element needed to direct the patient toward the best available resource. It was the doctors experience with version 1.0 that helped guide the patient through this complex-adaptive system. So where is the evidence that this relationship is under attack or even strained?
Under Pressure
The patient-physician relationship is experiencing multiple sources of pressure. Reimbursements for physician services continue to be cut or at least not increase in a manner to keep up with the cost of living. The rise in medical liability rates has also created a pressure by increasing practice expenses. This means that each patient contact results in reduced net payment to the physician and an increased exposure to medical liability risk. In order to maintain the same level of income a physician must gravitate toward contacts with either reduced risk or improved reimbursement per contact. In addition, insurance companies want a greater say in what treatments a patient may undergo or what medications they may be prescribed. This increases the "hassle factor" for physicians struggling to match allowable treatments and medications with what they believe to be the standard of care. What is slowly happening is the role of the physician as gatekeeper is being stripped away. The combined effect of decreased reimbursement, increased expense, increased medical liability risk and outside sources directing medical care is passively conspiring to remove physicians from this role. Hear me out, I said remove physicians from this role, not entirely remove physicians from the Health Care System. So who or what will assume this role?
Design Specifications for Gatekeeper 2.0
Clayton Christensen touched on this in his recent book, Seeing What's Next. I referenced this source in a previous blog addressing disruptive innovation and trauma centers but it's worth repeating because it really focuses on how this process is currently progressing. He summarized this in the chapter titled "Healing the 800-Pound Gorilla".
1) Scientific progress leads to better categorization and the development of rules guiding prevention and treatment.
2) Those rules open the door for less-skilled people to do what previously required deep expertise.
3) Non market forces affect the market for innovation by influencing industry players motivation and ability.
I believe as we get better at defining the rules and integrate them into our growing network of information technology these will become the protocols and pathways used by the less-skilled people. This is already in place for mid-levels practicing with Minute Clinic. The protocols and pathways will need to be stored in a platform that can access the information at all times. The artificial intelligence built into this platform will guide the mid-level and eventually even less-skilled people through the maze once only entrusted to a physician. It will need to do this in a way that improves health care access to the patient, at a lower cost with "as good as" results. Minute Clinic and its copycats are already doing this for relatively minor health problems. As they get better at this process they will inevitably migrate up the value chain.
Summer Is Coming
So am I for it or against it? I am neither. I see it as inevitable. It would be like asking me if I am for or against the coming summer. Since I live in Phoenix, Arizona it would be like asking me if I endorse one hundred and fifteen degrees in the shade? I don't really endorse it one way or another I just prepare for it if I plan on being here in the summer months. Between now and then the average daily temperature will slowly rise. It doesn't happen all at once but a little bit at a time. I see the coming of Health Care System 2.0 the same way. I guess in some ways I endorse it because I hope it really will deliver on the promise of an improved Health Care System. Either way, just like the coming summer, I plan on preparing for it by adapting to the daily changes.
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