"If you always do what you've always done, you'll always get what you've always got." - Henry Ford
Tell me this doesn't sound familiar: First, you go to your primary care physician. You mention a healthcare issue, and they refer you to a specialist for assessment. The specialist's office is across town and cannot get you in for three months. You organize your life around that appointment, and best case scenario - the appointment happens. It doesn't get rescheduled because the provider is out on leave, or the equipment you need is not available. You make it through the appointment, then at some point you get your results and feedback through the care portal. You don't know what to make of these results at first, and either you wait for a provider to call you about this (which may or may not happen), or you pepper your care team with secure messages until someone tells you what things mean.
In March 2024, I attended a virtual conference held by the New England Journal of Medicine (NEJM) entitled: "New Models, Measures & Money: Care Delivery Innovation." I also had the chance to read "The People's Hospital: Hope and Peril in American Medicine," by Dr. Ricardo Nuila, which was published last March. Both address aspects of healthcare that need to change. Below are some of my take-aways.
During the NEJM conference, one of the speakers acknowledged that the field of healthcare is in a "dilemma period." From this speaker's perspective, we are currently caught between an era of sustaining innovation in healthcare, and a new dawn of disruptive innovation in healthcare.
When systems are generally working, we tend to get sustaining innovations: ways of doing the same thing for the same people, only better. Disruptive innovation, on the other hand, occurs when we invent something completely new, or reinvent a technology or business model by drastically altering or improving a product or service.
In business, disruptive innovation means that change is happening in ways that the market did not expect. For example, a business might disrupt markets by discovering new categories of customers, or lowering costs while enhancing quality in the existing market. They do this partly by harnessing new technologies, but also by developing new business models and exploiting old technologies in new ways. An example of how this is happening in healthcare would be Amazon using AI to lower costs and improve prescription access (while also reportedly cutting down on prescription errors) in the United States.
For better or worse, healthcare is a business. The consequences of this are discussed in depth in “The People’s Hospital,” by Ricardo Nuila. Dr. Nuila is a practicing physician and associate professor at Baylor College of Medicine. His book focuses on Ben Taub, the hospital that succeeded Jefferson Davis as Houston’s publicly funded medical facility. Dr. Nuila candidly discusses the manner in which "Medicine, Inc." contributes to the deplorable inequality that creates the need for Ben Taub to exist, as the largest safety-net hospital in what has become one of America’s largest and most diverse cities, in the state with the nation’s biggest population of uninsured.
During a dilemma period, we see disruption start. What this looks like: we begin asking questions. Who is healthcare helping? Who is it leaving behind? What are ways we can structure healthcare to be more supportive to our patients? Dr. Nuila certainly calls for a re-examination of how healthcare is funded. He notes the effects of rationing, which occurs when healthcare systems do not have the resources in place to effectively meet patient needs. Rationing is an idea we traditionally associate with war - e.g. when the government dictates what kinds of foods we can eat, because there is not enough to go around. This happens in healthcare, too, and we feel its effects when we have to wait for an appointment because a system does not have enough providers to meet the volume of patients they serve, or wait for an assessment because there are only so many MRI machines at a facility. Dr. Nuila notes that rationing in healthcare is inevitable, but there may be ways to mindfully choose when and where it happens.
Meanwhile, the speakers at the NEJM explored whether healthcare systems are measuring the "right things," that would promote both quality care and the experience of being known and understood by our healthcare providers. They also talked about new ways to structure healthcare teams, in order to break down silos and streamline communication in medicine.
When it comes to disruptive action that is already occurring, one new model appears to be taking hold: integrated care. Over the past century, we have learned so much about the body and tending to it that it is impossible for any one provider to hold it all in their head. As such, specialty care has emerged. In older healthcare delivery models, which were organized around the expertise of individual healthcare providers rather than a central patient need, a specialist would not be on site with other healthcare providers e.g. a primary care physician. Sometimes different providers barely talk with one another, leaving the patient to travel between locations, bearing the burden of translating what one provider has recommended to the rest of their care team. This old model inevitably led to chaotic care and confusion, as patients and families were tasked with navigating multiple different recommendations, some of which were in conflict with one another. Siloed care produced scenario after scenario in which there was "inefficiency, highly uneven coordination, erratic quality, and anxious patients and families (Porter & Lee, 2021)."
"Healthcare does not have to be chaotic. Patients and families should not have to worry about coordinating their own care. Clinicians should not have to wonder who will provide the other services that their patients need." (Porter & Lee, 2021)
Of course, this still happens; we are not out of the woods yet. However, in order to counteract this, Drs. Michael Porter & Thomas Lee put forth the concept of the Integrated Practice Unit (IPU). IPUs are organized around the needs of patients, rather than around specialties or a particular intervention. IPUs are multidisciplinary teams that are, ideally, co-located. Within these teams, a patient is supported over the full course of caring for a particular issue. For example, an IPU organized to help those struggling with a chief complaint of "back pain" would have a team of clinicians in one spot who could help with assessing and treating that issue. The primary care physician, physiatrist, spinal surgeon, radiologist, and neurologist would all be in one building, talking to one another and creating a coordinated set of recommendations for a patient to follow. Best practices for addressing medical stress and trauma would also suggest having a mental health provider co-located and collaborating on site, with specialty experience addressing and treating pain using modalities such as Cognitive Behavioral Therapy for Chronic Pain.
So! Where does all of this leave us? Well, we do not have everything figured out, that's for sure. We may still need to travel across town to see a specialist, and bug our care teams for explanations of what our lab results mean, for now. However, conversations about change are happening, which is hopeful, and it is very possible to get involved and get your voice heard. One way to do that would be to attend the next virtual NEJM event entitled "Patient-Centered Innovation," which occurs on June 27, 2024. Interested? You can register to attend here.
You do not have to be a physician to attend this event. We need diverse voices at the table to imagine a better future for healthcare, for everyone. So - come, ask questions, and get informed! You never know what insights your presence will spark.
Action step: Take a moment to journal and reflect. What would positive, disruptive innovation in healthcare look like, to you? How do you think we could make it happen? Who can ally with you to get your ideas heard?
National Public Health Week is April 1 - 7. Celebrate by attending the NEJM Catalyst conference, offering your care team gratitude & encouragement, and perhaps by making a donation to a healthcare organization or cause that you value.
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