It’s easy to be enthusiastic about the future of healthcare. We have seen the emergence of breakthrough scientific discoveries, new technologies and evolving healthcare payment models. Chief among these are: genomics driven precision medicine, DNA editing (CRISPR), artificial intelligence (IBM Watson/decision algorithms), health-related mobile apps (all 165,000 of them), biosensor wearables (1,300 debuted at CES 2016), accountable care organizations and bundled payments. But has this “healthcare revolution” transformed the health of our society? Disappointingly, not yet. We spend more on healthcare than any other developed country (17% of GDP) as we face steadily rising costs and overall inefficiency.
AN OBSOLETE HEALTHCARE SYSTEM
So what’s the problem? In short, it’s ‘the system.’ The U.S. healthcare system is obsolete; an outdated 20th century legacy, designed for healthcare providers (not patients) with payment for volume and profitability of services (not patient outcomes). The U.S. healthcare system actually generates more revenue and profit (for providers) by failing to deliver what patients need; healthcare value. Value must be the key metric for evaluating progress in healthcare. Healthcare should and must be about what patients need and not solely about what healthcare providers do.
The pace of change has been historically slow in the healthcare field—more of an evolution rather than a disruptive revolution. While this may be the nature of scientific discovery, it need not apply to healthcare system reform.
As a healthcare entrepreneur, I recognize that designing a healthcare system for the 21st century requires dreaming big, taking risks and pure grit. So I applaud the recent surge of startups and ‘moonshot’ initiatives designed to prevent/cure diseases and deliver higher quality, more cost effective healthcare. I also recognize that many of these initial efforts will either struggle to have immediate impact or downright fail.
The pace of change has been historically slow in the healthcare field—more of an evolution rather than a disruptive revolution. While this may be the nature of scientific discovery, it need not apply to healthcare system reform. Failure to accelerate progress will have catastrophic consequences and contribute to already alarming health trends like increasing obesity and diabetes rates, cardiovascular disease and the rising number of new cancer cases.
On a more optimistic note, many of the elements of a value-driven healthcare system have already been developed. One area in which a value-driven system could be more rapidly implemented would be to address the social determinants of health by making public health actionable in the context of primary care and family medicine.
One example of this is the ‘upstreamist’ approach described by primary care physician, Dr. Rishi Manchando in his 2014 TED talk. “We simply need a healthcare system that moves beyond just looking at the symptoms that bring people into clinics, but instead actually is able to look and improve health where it begins.”
To illustrate his point, Dr. Manchado presented a female patient from Los Angeles with chronic headaches. She was seen in a local emergency department, underwent a battery of tests (all normal), prescribed pain medication and told to return if her symptoms recurred. They did recur, many times. After being referred to several specialists, undergoing two CAT scans, a lumbar puncture and multiple blood tests at a cost of thousands of dollars, the patient was still sick.
Quite simply, the U.S. healthcare system was not designed to deliver value based care and doesn’t pay for it—at least not yet.
When she came to Dr. Manchando’s clinic, his medical assistant asked about her housing conditions (routine part of the upstreamist medical history). Her apartment had water leaks, roaches and mold, leading Dr. Manchando to the upstream cause of the patient’s headaches: allergy and sinusitis. The treatment? Short-term antihistamines, decongestants and a referral to the right specialists for a long-term cure. Not an allergist or otolaryngologist but rather an experienced community health-worker and public interest lawyer. The apartment was fixed, the source of allergy removed, and the woman returned to a healthier life.
Her medical bill for the total cure was a fraction of the cost of her initial encounter with the healthcare system. The cure also had positive outcomes for her children and other apartment tenants, saving the healthcare system future dollars.
Over the years, the social determinants of health have been largely disconnected from the healthcare system and from the primary care medical practice. So the obvious question is why upstreamism is not medical guideline practice? Quite simply, the U.S. healthcare system was not designed to deliver value based care and doesn’t pay for it—at least not yet.
MAKING A DIFFERENCE IN THE NEXT FIVE YEARS
Redesigning healthcare may sound formidable. However, based on the technologies, tools and policy insights gained over the last decade, I believe the design and implementation of a value based healthcare system is achievable within the next five years.
I remain optimistic because of the increasing number of passionate and empowered patients, healthcare providers, administrators, policy makers and entrepreneurs who are committed to making a difference.
The critical elements of such a system are: accountable multidisciplinary teams that can deliver high quality care at scale and manage costs, a payment system based on patient outcomes and an efficient IT platform to facilitate healthcare coordination. Over the past few years, some progress has been made in each of these areas. Notable examples include Accountable Health Communities, Integrated Delivery Networks (Intermountain Healthcare and Geisinger Health System) and startups such as Aledade, Iora Health, Healthify. However, the timeframes for achieving impact are slow and scalability continues to be a major challenge.
A CALL TO ARMS
Accelerating the progress for reimagining and redesigning healthcare can be accomplished by acting more like an entrepreneur and incorporating best practices adapted from successful, agile startups. Redesigning healthcare will require a patient-centric approach with the right balance of healthcare expertise and entrepreneurial talent, tolerance for ambiguity, and implementing a fast-cycle iterative design and development process to rapidly test assumptions and solve problems.
Despite the challenges of redesigning healthcare, I remain optimistic because of the increasing number of passionate and empowered patients, healthcare providers, administrators, policy makers and entrepreneurs who are committed to making a difference.
We have a unique opportunity to bring these motivated change-makers together with a shared sense of urgency to collaborate on building a value based healthcare system. So what are we waiting for….our future depends on getting the future of healthcare right. Right now!