Healthcare (re)design

You get up early in the morning and you work all day. That’s the only secret.

- Philip Glass

The healthcare system needs your help. You see, the system as it stands is fundamentally flawed it its design. The system needs reinvention.

From a Jay Parkinson Business Week Post: “Going to the doctor, having routine surgery, buying bulk medications online—all could be radically reinvented with the application of one type of medicine: designed disruptive innovation. Combining the principles of disruptive innovation with design thinking is exactly what health care in America needs. We need to disrupt the current business model of health-care delivery. And we need these disruptions to be designed experiences that are consumer-focused. Imagine: a health-care experience truly on par with a visit to the Apple Genius Bar or buying a book from”

It appears that the predominate disruption that will be seen in healthcare redesign is in the domain of payment. The Health Affairs blog often takes these issues head on, and one post this week does so exceptionally well:

“Costs don’t need to be what they currently are; current costs are a function of how care is currently provided. Much cost reduction can be accomplished by providers without Congress or CMS action. This recommendation is counterintuitive in an industry where fee for service is still the dominant payment mode. Providers are not in control of the timing of what Malcolm Gladwell calls the “tipping point”—when fee-for-service payment will ‘reach the moment of critical mass, the threshold, the boiling point’ and move over to a fee-for-value payment system. This change will include not only payment mechanisms but philosophies and systems of care, which will require of providers new organizational infrastructures, incentives, skillsets, and more.  Hospitals, health systems, and other providers that wait for the last-possible fee-for-service dollar run the risk of being totally unprepared to compete in a radically revised system of care.”

Healthcare is currently built around the wrong things. We know that the system is not built for the patients, but rather the companies who often pay for healthcare services. We know that it is more profitable for providers and hospitals when people are sick versus when they are well. We know that in the fee for service payment paradigm, volume matters much more than value.  At the heart of these problems, there is a design flaw and a redesign opportunity.

The question becomes – who should lead this redesign?

The answer to this question, in my opinion, is the patient. And while there are attempts to bring patients much more into the healthcare arena (PCORI anyone?), patients cannot change provider behavior (or can they?), which is also an important component in redesign. So it appears two things need to happen simultaneously:

1) Patients need to begin to recognize the limitations of the system and demand more. Asking providers to simply behave differently does not acknowledge the design flaws in the larger system that “shape” their behavior into what we all commonly see through healthcare services. However, being aware of the problems and engaging in a productive dialogue with providers and policy makers seems to be a logical first step. But to emphasize, we all need to be aware of what works and what doesn’t work, and outline solutions rather than just restating the problems. I believe that front line providers and patients know better ways to build the healthcare system we all deserve.

2) Providers need to be aware of their “clinical” behavior and become knowledgeable about their “financial footprint”. This one is complicated and challenging – it also assumes that providers want to change the way they deliver services (this is simply not true for all providers – many of the healthcare providers seen online and in social media circles may be more progressive/outspoken in their thinking and relatively enlightened in possible problems and solutions). If providers see the design problems in healthcare, and take steps towards correcting the flaws in the design through their own behavior, different scenarios emerge where conversations can be had on innovation.

From Reuters this morning:

“In an article published last month in the Annals of Internal Medicine, the ACP cited 37 clinical situations where screening did not promote health and might actually hurt patients. They included performing coronary angiography – a procedure that uses a special contrast agent and X-rays to see inside the heart’s arteries – in patients with chronic, stable chest pain that is being controlled by drugs or who lack specific high-risk criteria on exercise testing. ‘It’s medical gluttony,’ said Dr. Otis Brawley, chief medical officer of the American Cancer Society. ‘The ironic thing is that people are talking about rationing. We have got to think about the rational use of medicine in order to avoid rationing medicine,’ he said.”

So we are at a place in our development where we need to rethink healthcare and its (re)design. I question whether or not working harder will change things – we still are in need of disruption, and this may come most dramatically through patient/provider collaboration.

For those interested, the Agency for Healthcare Research and Quality has developed a toolkit for healthcare redesign that is worth checking out.

If Michael Graves, the famous Target designer, can enter into healthcare and offer up redesign issues, why can’t “we”?

Dr. Miller has his doctorate in clinical psychology and is an Assistant Professor in the Department of Family Medicine at the University of Colorado Denver School of Medicine where he is the Director of the Office of Integrated Healthcare Research and Policy. His core task is to integrate mental health across all three of the department’s core mission areas: clinical, education, and research. Opinions expressed here are his own and not those of his employer.

Posted in healthcare, Innovation
  • LIsa Fields

    Thank you for this important article.

    “I think this sentence might truly be the light that brings us the most energy as we continue our work.”

    “..we still are in need of disruption, and this may come most dramatically through patient/provider collaboration.”

    I feel hopeful as we continue, for there have never been more opportunities and channels for patients and providers to work together both through new media channels and face to face meetings.

    • miller7

      Thanks, Lisa! The challenge will be how to create a safe place for these conversations and collaborations to happen. I am optimistic!

  • Mark

    There has been a momentum created last year with rancor caused by the ACA and those that believe HC is privilege not a right and that a free market without regulation will solve any problem. (That’s worked so well.) That momentum along with the growth of HC searching, epatients, SM, etc have begun a re-design of sorts. It has created a greater awareness of our HC footprint and what we as consumers need to do to benefit from the current system.

    What I hope will happen going forward is that we will discover pressure points as a group that will drive change. Similar to the hue and cry about the banks debt card charges in December. A system as large and complex as our HC needs focused niche pressure to drive wholesale change through group awareness. Awareness comes from the masses raising up about a $5 charge not trying to push the Volker rule.

    Change is there it has a foothold but we must not let complexity or size defer our attention and will to succeed.

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  • John Lynch

    I wish i were as optimistic as you, but disruptive change never comes from those who benefit from the status quo. Even the Accountable Care Organizations (ACOs) planned under the ACA are subject to manipulation (over-diagnosis to increase each patient panel’s risk profile and ACO payment levels).

    With twice as many specialists as primary care docs – the opposite of a healthy mix – it’s unrealistic to expect these overpaid specialists to do things contrary to their financial self-interest.

    The fact that the highest paid specialties are also those with the most abuses (unneeded procedures) is no coincidence – and further evidence of our having reached a tipping point in the decline of medical ethics in America.

    The only disruption I find realistic – and it’s a long shot as well – is fundamental re-education of patients to be more skeptical of their treatment recommendations and more aware of the risks of treatment.

    Primary care docs could fill this role, but will be stretched so thin with 30 million+ more patients to serve under health reform that taking on this time-consuming role is highly unlikely.

    So I believe what’s needed is a new patient paradigm of smarter medical consumerism that will need to operate mostly independent of the medical infrastructure. As Dr. Montori of the Mayo Clinic says, “We need a revolution” – and revolutions aren’t generally about collaboration.

  • Eddy

    A business built on treatment thrives on patients needing treatment.

    A business built on good health means while your patient enjoys a healthy life, you get paid. If everybody pays a ‘health’ levy to their primary care practitioner, who sacrifices a proportion of it to those providing more advanced treatment, the whole health care industry is motivated to restore the patient to health while minimising treatment, and minimising cost.

    The problem comes when practitioners cherry pick healthy patients – so you can’t run it as a market. It has to be run as a public service.

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