Flipping the Care Delivery Paradigm on Its Head to Improve Outcomes
Six out of ten people in the U.S. suffer a chronic condition (diabetes, hypertension, etc.); life expectancy is at a 20-year low, and healthcare cost per capita at $13,000 annually in the U.S. is the most expensive in the world, growing at 2x nominal inflation.
This state of our nation's health requires real solutions that can be put in to place by clinicians and health consumers without the government being involved. To do so, health care providers might consider embracing a suite of consumer technologies (ambient, wearables, medical IoT) that can rapidly extend the capacity of health systems and hospitals beyond their four walls.
This shift in care delivery to a “need-based” model can leverage a variety of consumer health status data (temperature, weight, blood glucose levels, blood pressure, etc.) to engage and guide care teams to proactively intervene rather than bank on consumers to decide when it is appropriate to see a physician. Need-based care (see Exhibit 1) can improve care utilization, reduce the cost of care by better managing the need for acute care, enhance engagement with health consumers, and potentially create space to serve underserved communities.
Providers must embrace consumer technologies to adopt need-based interventions to improve outcomes across the quadruple aim of care
The battle to improve the quadruple aim of care—reducing the cost of care, enhancing the experience of care, improving health outcomes, and addressing health equities—has been losing so far. However, there is a chance of reversing the failures by redesigning the care delivery paradigm from demand-based to need-based.
The current care delivery paradigm can be identified as demand-based, where a consumer, based on how they feel, seeks medical help. This is a function of the severity of the problem, self-diagnosis, and basic triage to determine the needed care type. Consequently, the consumer may likely seek help from the wrong type of clinician (orthopedic versus chiropractic) or facility (emergency versus urgent care or primary care). This further results in a level of experimentation by the clinician to diagnose and treat, mostly driven by the symptom being exhibited instead of the cause. This approach to care is expensive, does not improve overall health outcomes, and can often reflect a poor experience and engagement for the consumer.
Contrast that with a need-based paradigm leveraging technologies available in the market, as shown in Exhibit 1. The idea is to leverage a suite of technologies to predict, identify, and communicate specific data to clinicians to decide how and when to intervene. Imagine that a patient recently discharged after surgery can be monitored through a combination of medication adherence and nutrition, captured digitally with wearables that track vitals and calibrating with their social determinants of health, to help care teams follow their recovery or predict the need for intervention rather than wait for the patient to decide to visit the emergency room.
The need-based care delivery approach would start with creating a personal health benchmark, the state of normality. Next providers could identify intervention thresholds based on science, social determinants, individual tolerance, and other attributes deemed appropriate. Monitoring could be measured against these thresholds. A trigger for a care team intervention could be designed to happen only if patterns show either continued deviation from set thresholds, sudden spikes, or other personalized patterns. This path could help to ensure that clinicians are engaged only when needed, and when they are engaged, they have all the relevant data to intervene appropriately without needing to experiment too much.
Extending hospital-level interventions to everyday living without high costs
High costs for inpatient care are often significantly driven by the infrastructure (buildings and equipment), treatments (clinical specializations, procedures), and the level of monitoring required by various clinicians. The need-based intervention paradigm can replicate the monitoring part at a fraction of the cost with significant potential to improve health outcomes (early intervention), reduce the cost of care (avoiding emergencies), and enhance the experience (lack of friction) with the potential to engage the patient by establishing better trust and care.
Let us explore the possible costs for a sample of Wi-Fi or Bluetooth-enabled consumer health tools such as a continuous glucose monitor or CGM ($35), electrocardiogram or ECG ($79), home sensor for temperature, humidity, motion ($100-$200), inhaler ($150). While the total cost of a combination of these devices could vary depending on the type of condition being managed, they are relatively inexpensive and even more so in preventing or managing disease versus providing inpatient care.
Compare that with the average daily price for acute care, which is between $3000 and $3500, depending on the location. The average length of stay (ALOS) in an acute care facility is 4.5 days. An average acute care visit costs between $13,500 and $16,000. Reducing the length of stay or avoiding acute care by being able to manage a disease condition or deliver high-efficacy post-acute care proactively can translate into real savings, better health outcomes, and arguably better experience.
While many of the above consumer digital health tools are not Food and Drug Agency (FDA)- approved medical devices, they provide directional information that can help clinicians to understand the need for intervention. An iWatch’s ECG is not an FDA-approved medical device or app, but if it shows atrial fibrillation on multiple occasions, it certainly can provide reason to consider a cardiac intervention.
The idea in leveraging these technologies is not to replicate the level of sophistication in an intensive care unit (ICU) or in a standard acute care bed in a hospital but rather to create an environment to capture relevant real-time health data to decide with high confidence the level, type, and timing of intervention. A decision that a care team is allowed to make tends to have a high quality of health outcomes compared to individuals making a choice based on their feelings.
Possibilities across the quadruple aim of care are real and meaningful
In the 21st century, where sophisticated technologies such as the internet of things (IoT), artificial intelligence (AI), and medical devices that can be worn or swallowed have become ubiquitous, there must be an effort to leverage these technologies to drive a new meaningful care delivery paradigm.
While activity, nutrition, DNA, and social determinants of health (SDoH) impact our health, we have an opportunity to manage that health proactively with the technologies listed above. Using technology to understand how each patient’s body works, what triggers ill health, what improves health, and when to seek help are all important to ensure a high quality of life.
A higher quality of life then helps keep the cost of care low by letting data decide when medical help is needed over feelings. This process can improve health outcomes by letting data inform one's health in real-time, and likely enhance the care experience. A very large consequence of this approach is that it frees clinicians to expand their panel of health consumers. There is a possibility that this time can be used to serve communities that have never been served or are underserved appropriately.
Thinking ahead as we arrive at a perfect storm over the next decade where the U.S. will have more older adults than younger people (unprecedented in U.S. history), a clinician shortage of over a hundred thousand people, worsening health with the prevalence of chronic conditions, and the unknown (yet very likely severe) impacts of climate change, current demand management technique will likely not cut it. We have no choice but to adopt a more efficient and effective care delivery paradigm, which will likely be a data-driven, need-based paradigm leveraging the evolving canon of sophisticated technologies.
The Bottom Line: Technology can rescue us from us and improve outcomes across all attributes of the quadruple aim of care.
Market efficiencies are driven by the synchronicity of the supply chain, where demand meets supply at the right time. To make this true in healthcare, we must find a way to optimize the supply (clinicians), which is in short supply and predicted to shrink further with the constant increase in demand. The need-based intervention paradigm is our best practical chance to improve the efficiency of the healthcare market and, hence, improve the outcomes across the quadruple aim of care.
Rohan Kulkarni is executive research leader, Healthcare & Life Sciences at HFS Research, a Cambridge, U.K.-based global research and analysis firm specialized in the disruptive power of emerging technologies. He draws on two decades in healthcare, including as head of healthcare strategy at multiple Fortune 500 companies and product management executive and CIO at two health plans. He can be reached at [email protected].
