How will healthcare be distributed in the future? In ways that bear only some resemblance to the way it is distributed today.
The changes will be driven by the new economics of healthcare embedded in the “volume to value” movement, based as it is on “provider-sponsored risk,” the basic, obvious and yet startlingly opaque logic that you deliver what you are paid to deliver — so if you are paid differently you will deliver differently. If you are paid fee-for-service, you will deliver it in ways that derive the maximum of fees for the maximum of services. If you are paid based on being at risk in one way or another for the health of the patient, you will find and invent and evolve the most efficient ways to deliver the health.
We are right at the beginning of this change. Let’s examine it.
What way of distributing care is best for health? Care should be easily and widely available, especially in an emergency or crisis. When we need it, we should have easy access to the best that medicine has to offer. The rest of the time, care should be seamlessly woven into our lives, expertly helping us prevent or manage disease and fine tune our own body systems. And it should not bankrupt us. It should never force us to choose between buying our cancer drugs and paying the rent or buying food for our children.
The fee-for-service system encourages, indeed demands, that healthcare organizations provide care in some kind of opposite-land construct, making it scarce, hard to access both physically and financially, based entirely on episodic care delivered only face-to-face with the individual clinician in the clinician’s preferred place of business.
Risk drives change
Now providers are taking on risk in a hundred different ways, from bundled payments to accountable care organizations to risk-based employer and Medicaid contracts. All of these encourage and in some ways demand that providers flip the scenario, bringing as much care as possible closer to the patient, with more seamless help as constant as is helpful, with greater support for those who especially need it, and at lower cost not only to the patient but to the payer.
This movement to provider-sponsored risk is not over. In fact it is likely just beginning. The end point will likely be that most people in most situations will covered by comprehensive capitated insurance, with their medical needs provided by large regional provider networks that can provide seamless care from the preventive community level, retail, urgent, and primary level through chronic and acute management, post-acute and the full array of specialized services. Despite their comprehensiveness, the demand for efficient, lower-cost quality care will mean that these largely-capitated regional systems must also have the flexibility to offer their patients contracted services elsewhere for specific types of major care, such as cancer care, joint replacement, and cardiovascular services.
Ecology of touch points
Healthcare distribution will change on every axis: time, place, frequency, and manner. The care at the basic and chronic level will be provided through a wide variety of touch points, including primary medical homes; on-site clinics at work, school, or in elder living facilities; pop-up clinics at churches; retail care in big-box stores, urgent care at the mall; house calls for “super users” and immediate discharges; and a web of sensors for those who need it, including “Internet of things” in the home environment, the toilet, the mirror, the television; health watches, contact lenses, smart patches, and implants — all tuned not just to provide the individual with their own information, but to tie them into their family caregivers and to the clinicians with whom they have a trusted relationship, their doctor or nurse practitioner and the system’s electronic health records.
These constant digital connections can support the trusted personal relationship with the clinician and the system. They cannot effectively initiate or replace that connection. Automation and artificial intelligence can be powerful in improving effective and efficient healthcare, but they can never substitute for the core relationship with the clinician.
The shape of these changes will be driven by multiple parameters:
- The broad drive for practical, effective health management for whole populations
- The narrow need to target extra help to the “super users” with multiple chronic problems and frequent emergency department visits, as well as specific high-use groups such as mothers with young children
- The deep economic value in both cases of moving closer to the customer and earlier in the disease cycle, as well as strongly connecting not only with the patient but with the patient’s home caregiver, their child, parent, spouse, or close friend.
- The development of rapid, effective, constant technologies for connecting the customer to the system over chronic care cycles
- The effective need to build all of these along lines of trusted person to person connections.
Trust: The engine of efficiency
The last of these is critical to notice. In all this change, the least understood engine of efficiency and effectiveness is trust. Particularly in population health management, prevention, and primary care, the real trust and cooperation of the patient and the patient’s family is a critical element. The business model doesn’t work without it.
As we are building out these new networks and touch points, many strategists are madly reaching for tactics that actually reduce the person-to-person human element. It doesn’t work. The experience of multiple pilot programs and repeated studies show that prevention or population health management by robo-call, or call centers with scripts, or text message nags, simply does not work. People do not change their lives and habits based on a message or call from a stranger.
As we move forward under the goad of risk-based payment systems, systems will quickly discover what does work, and building and strengthening trusted person-to-person relationships will become a foundational part of the new shape of healthcare.
First published in the 40th Anniversary Edition of Modern Healthcare, July 9, 2016
And how are you proposing to do this without more primary care doctors? (Which means, essentially, more FPs, since most IMs go into hospitalist or subspecialty practice, and most midlevels go into specialty practice because the pay is better?)
Just to meet current needs projected forward to 2025, we need ~50,000 more FPs, while the number is projected to go DOWN by the same number over that time.
We can’t go on paying FPs half what we pay other specialists and expect anything but tragedy and high costs. Primary care saves money while saving lives.
“As we are building out these new networks and touch points, many strategists are madly reaching for tactics that actually reduce the person-to-person human element. It doesn’t work. The experience of multiple pilot programs and repeated studies show that prevention or population health management by robo-call, or call centers with scripts, or text message nags, simply does not work. People do not change their lives and habits based on a message or call from a stranger.”
I agree with you, Dr. Liepmann. Or let’s say I agree, and…
Obviously, saying we need more trusted human contact means we need more trusted humans. However, there are multiple pieces to that, and they add up to: Saying that there are not enough primary care physicians does not mean we can’t have a system with more trusted human contact for those who need it.
Several points:
o Workflow: Much physician time is currently wasted through arguing with insurance companies, difficult EHRs, and so on. If we could streamline the workflows of physicians so that they are spending more of their time on real doctoring, that could well be the equivalent of having, say, 25% more doctors — and the doctors would be happier and even working fewer hours while covering more patients.
o Value: As you say, “Primary care saves money while saving lives.” As healthcare organizations realize that economic logic, that will increase the value of primary care physicians in the marketplace, which means they will be paid more, which will attract more physicians to primary care.
o Nurses: The trusted contact doesn’t have to be with MDs. In fact, at the first and most constant level of contact, nurses and nurse practitioners are probably the more efficient choice. We should be using them more effectively.
o Teams: Much of this work is more effectively done in teams, as has been demonstrated repeatedly.
o Tech: Once established, as I mentioned above, the constant trusted contact can be maintained more effectively with less drain on physician hours through the thoughtful use of new technologies.
There is so much waste and ineffectiveness in the way we currently do things that I believe we can rebuild the system to give patients more trusted person-to-person contact while primary physicians actually make more (reflecting their greater value) while working the same or fewer hours.
I cannot agree with you more on the matter of trust. For healthcare practitioners establishing trust is the number one requirement for providing efficient and appropriate care. As a physical therapist I make it a point to take the time to listen to the patient’s story, the problems they experience and their expectations from the physical therapy I will be providing. It is astonishing how much pertinent information I glean from this that is not in the medical record, including –but not limited to- omissions of previous diagnoses & medications and crucial gaps in the patient’s knowledge about their health conditions. Having this information allows me to incorporate and address these issues as appropriate in my plan of care or refer back to and consult with the physician. In addition, I spend a significant amount of time on my actual evaluation, making sure that the patient understands the logic (based on the physical testing) of my treatment hypothesis and differentials. When the patient understands the logic of the treatment plan and its goals, her/his compliance will be exponentially higher and therefore the treatment more effective in less time with fewer healthcare dollars used. To me, those are the mechanics of building the trust elements of making the patient feel heard, showing provider competence and promoting patient understanding and therefore increasing self-efficacy and self-determination.
It saddens me that, given the choices that have to be made within the economic constraints that reality imposes, the current payer logic seems to be focused on increasing the burden of documentation over actual time spent caring for the patient in order to be effective and build that needed trust. For the practitioners it means lower job satisfaction and higher rates of burnout due to the inability to fully make use of the high level clinical skills that they have worked so hard to acquire. Call me crazy, but it seems to me that it is those clinical skills that will make our system more effective and efficient, not the growing stacks of paperwork. For the patient it means high levels of confusion, dis-empowerment, dissatisfaction and less then optimal outcomes. For society it means spending twice as much per capita as other advanced nations, but with middle of the road outcomes.