Picking up a medical journal can be humbling. Easily ¾ of the medications and therapies I read about, including entire classes of drugs, didn’t exist when I was in medical school. At the same time, the basics of what I do as a clinician, and what we do as a hospital, are fundamentally unchanged: patients come to us, we assess and treat them, and we bill for the services which are largely paid by some form of insurance. But now that health care expenditures exceed 17% of GDP, a tipping point seems to have been reached, forcing changes in the basic model of health care. While we are confronted daily with innovations in clinical care, most of the innovations in care delivery haven’t yet reached pediatrics, and certainly not our market. But there are numerous novel approaches to delivering value in healthcare. Here’s a brief view of some of what is happening elsewhere.
1. Retail clinics. CVS recently announced that they would stop selling tobacco products at its 7600 stores around the US. The prime driver is the desire to be seen as a legitimate healthcare provider. CVS, Walgreen’s, Walmart, and others already offer medical services, including both episodic urgent care and chronic disease management. Such arrangements raise legitimate questions about continuity of care, but they have been highly successful. The number of retail clinics climbed 8-fold from 2006 to 2013, with over 1600 such clinics today, and over 6 million visits in 2012. The key drivers are convenience and access, though cost is also a factor. In the US, only 35% of primary care physicians have after-hours care arrangements, compared with 95% in the UK and the Netherlands. Retail clinics are simply filling an unmet demand.
2. Concierge medicine. This term covers a wide range of practices, from One Medical group, encompassing 25 primary care practices in five markets, where patients pay $150-$200 per year for enhanced direct access to and longer appointments with their physician; to the $25,000 a year to be one of only 400 patients to have a physician essentially at your beck and call. Again, the drivers are access and experience. While the rise of these niche services raises questions of equity, in medicine as in so much of the rest of the economy there will undoubtedly be a role for services that cater to those who can afford them.
3. House calls. Remember Marcus Welby, black bag in tow, seeing patients in their homes? Increasingly, physicians or other providers are going back to the future. Not only the old fashioned way, but also using phone or Web contact to bring care not only closer to home, but into the home. Employers are also bringing healthcare into the workplace, with on-site primary care clinics for employees and families. Wisconsin-based Quad Graphics, a large printing company, started this and now operates Quad Medical, which provides these services for other employers. Access and experience, anyone?
4. Price transparency. Many elements of health reform, including high-deductible plans and healthcare exchanges, have the goal of containing costs by promoting price competition. It’s hard to do that, though, if the person doing the buying has no idea what the price is, which has led to numerous efforts are making that information more accessible. CMS, for example, has made publicly available charge data from Medicare providers on 130 common procedures. Some hospitals are starting to do the same, publishing their prices up front.
5. On-line access. My Chart, the patient portal for the Epic EHR, is only the start. Other patient-centered innovations include free-standing patient health records (which are owned by the patient and pull data from all different sources), direct patient access to their records with the ability to edit them, provider-facilitated Web searches for health related information, and shared medical decision-making tools. Interestingly, a JAMA study showed that access to such online tools actually increased patient visits, rather than supplanting them.
I’m not trying to suggest that all, or even any, of these is something we want to embrace. We do, however, need to be aware of what is happening in the market. At the very least, it tells us what our patients and families are seeking. We, then, need to figure out how to meet those needs. To do that, we need to be creative. Selected for success in science and math, many of us in medicine are fairly “left-brained” types; creativity and original thinking often don’t come naturally. We need to be more intentional innovators. To do so, it will be important to think outside the clinic. Leaders in healthcare need to look to other industries to identify trends and come up with new approaches. We also need to tap into talent from outside healthcare. The rest of the economy has been focused on value for a long time. We have a lot to learn.