Breaking Healthcare

Most mornings, you can find my son creating LEGO designs from the ideas he imagines in his head. Last week’s design: a tall, all white robot, with cannons for arms and armored chest plate. My son proudly carried his delicate masterpiece down our wooden staircase when it toppled out of his hands, crashing into pieces on the floor below. His bottom lip began to quiver as tears welled up in his eyes.

I hugged him and said I’m sorry that happened. He looked up at me and knew what I was going to say next because we’ve been here many times before. “That’s the wonderful thing about LEGOs,” he smiled. “We can rebuild it.” 

And he did.

Working in healthcare, there are days when I would like to drop the entire system down a long wooden staircase and see it break. Let the pieces fall. Then rebuild it, taking what we know today and implement the ideas that feel out of reach in our current system.  

Here are three things I would change in a future system.    

Allow people to qualify for care before they get sick or have a serious event

The current system is built to react to illness. This can mean you must have a serious health event to qualify for some types of care. In the case of home health, patients usually receive this type of care after a hospitalization, nursing home stay, or acute exacerbation of an illness. The hospitalization or emergency department visit triggers in-home nursing and therapy, when this type of care in advance could have prevented those emergencies altogether. Current eligibility criteria require patients to be sick before they can get the help. It’s backwards.

This is especially frustrating knowing we have the ability to use existing data and predictive analysis to create alerts that can inform individuals, caregivers, and their providers that they may be needing care. 

Every system is perfectly designed to get the results it gets. Our healthcare system is currently designed to react when a person needs care, not prevent the person from needing care at all.

Designed differently, we can get different results. Fortunately, value-based care is taking us in a new direction, that values preventative care. As old restrictions fall away, healthcare providers can begin to provide care in new ways. The hopeful result? Empower people to be proactive about their healthcare. 

If the healthcare system encourages a more proactive approach, more people would opt to see providers in advance of something bad happening (stroke, diabetes). This behavior can build stronger relationships with primary care and drive a better understanding of each person’s individual overall health and risks.  

With a more proactive healthcare system, we as people would be more proactive to take care of ourselves.

Share data across provider networks

In person-centered healthcare, the information – and data – must follow that person. However, we have a healthcare system where data resides with the provider, not the patient. According to one study, the typical Medicare beneficiary sees seven different doctors from an average of four different practices. On the high end, some beneficiaries with particularly complex conditions will see 16 or more providers from 11 different practices. Add to this the fact that patients also receive care from home health, rehab facilities, behavioral health, or urgent care centers, each of which have their own medical records. 

Most providers recognize the value of the information they are missing when they can’t see data related to a patient’s care. I once had a hospitalist tell me the one piece of information he would love to have when seeing a patient is the clinical note and med list from the last home health visit. This lack of information slows care down, increases duplicative costs, and can even cause harm to the patient as the missing information is critical to making the right treatment decisions.  

The challenges of data sharing go further than the point-of-care. Owners of data can be highly protective of the information and restrict access to it from others if they feel threatened. One example I encountered is the ability to gain access to Prescription Drug Monitoring Data to be used in an effort to study the opioid crisis. Despite the urgency of the situation and widespread recognition of the problem, providers were resistant to releasing the information out of fear of how it will be used. 

Technology exists to connect disparate data sources and provide access to the right people at the right time. Providers using software such as PatientPing get alerts when their patient is in the emergency department or sees another provider outside of their practice. This helps facilitate care coordination and can lead to better care outcomes at lower costs. Implementing these data bridges and designing data infrastructure around the patient is necessary to achieve savings and quality.

Make pricing transparent to the consumer

It is an economic principle; perfect information is essential to competition. In a truly patient-centered healthcare system, the consumer – or patient in this case – would have the ability to select the best possible product or service, at a price they are willing to pay, from the provider that they choose. This competition leads to higher quality and keeps prices lower. 

However, the price of healthcare is hidden from the direct consumer, the patient. And in the cases where there is information available, it can be highly complex and difficult to understand. 

Take the case of choosing a health insurance plan. Understanding what the out-of-pocket costs will be in a given year is a function of multiple factors including:

  1. Monthly premium
  2. Annual Deductible
  3. Cost shares, such as co-pays or coinsurance
  4. Prescription coverage
  5. Prescription deductible (unless it is included in a total medical deductible)
  6. Availability of a Health Savings Account
  7. Coverage limits or restrictions

Depending on your age, family composition, or health condition this adds up to enormous complexity and can feel a bit like making gamble given the uncertainty of what anyone could face for healthcare needs in the future. 

When seeking care or treatment for those needs, the current system is not designed to provide the price of that treatment with the recipient as part of the decision-making process. Patients find out after they receive the care or treatment and that can sometimes be a shocking surprise. 

In any other major purchase in our life (appliances, car, schools, etc.), consumers have the ability to assess VALUE, or the benefit we can derive from a product or service in the context of the price we pay. Some consumers will spend hours reading reviews, understanding unique attributes, and comparing pricing of different choices before deciding to spend the amount of money that is synonymous with healthcare costs. 

In a value-based care system, the consumer must have the opportunity to determine what value means to them. Current models being operationalized now through ACOs and alternative payment models are allowing the payers and federal government to define value. This is a great start. We must go further and bring consumers into this equation with better price transparency.

This is an exciting time to be working in healthcare as the industry continues to face disruptions from potential new entrants such as Amazon, integration between payers and providers, and the growing importance of person-centered care as healthcare is pressured to act more like a B2C industry.

Blueprints from these industries can guide the reassembly of the already broken parts of our healthcare system to deliver value to the patient.  Data and technology can be used to anticipate health needs and customize care experiences for the benefit of the patient and provider. 

Interested in learning more about our healthcare practice? Click the button below.

Learn More