4. Decentralizing approaches to problem solving

If healthcare were to follow the trends observed in the most innovative industries, we would expect it to become more decentralized, both in the way it pursues new therapies and in the way it delivers patient care.

A. Pushing care delivery out to the patient:

The delivery of care must be pushed out from traditional “experts” at centralized facilities to wider networks of providers and patients. Read more

B. Decentralizing the innovation process:

As with care delivery, the process of innovation itself should be pushed out toward patients. Read more

C. Leveraging decentralization while controlling fragmentation:

Leveraging the benefits of decentralization—without incurring the costs of fragmentation—will require broad and effective information sharing. Read more

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A. Pushing care delivery out to the patient

The delivery of care must be pushed out from traditional “experts” at centralized facilities to wider networks of providers and patients.

A recurring view expressed during the conference was that healthcare delivery is becoming increasingly decentralized. More concretely, if progress in healthcare is to mirror the giant leaps we have experienced in other industries, we should expect to see technology and talent spread away from concentrated centers and toward a much broader, front-line network of patients and providers. To this point, more than 86 percent of the survey respondents believed that the use of non-physician personnel would help control the cost of care. That statistic is consistent with a number of trends discussed at the conference.

Clayton M. Christensen, the Kim B. Clark Professor of Business Administration at Harvard Business School, suggested an analogy to the information technology (IT) industry. In the digital world, the market has moved from a highly centralized platform based on mainframe computers, where problems were brought to the technology experts, to one that evolved through minicomputers to micro-computers where the technology— and its embedded expertise—was brought to the problems.

Similarly, Christensen proposed, hospitals have served as centralized repositories of specialized expertise. “Do we think that healthcare will become affordable by expecting the hospitals to be cheap?” he asked. “It just won’t happen.” He described the alternative as a decentralized model of care in which technology and expertise are pushed outward toward a broader network of caregivers and patients. “We need to bring technology to personal physicians so that they can begin doing some of the things that today they have to refer to the specialists. The dynamics of decentralization will allow lower-cost caregivers to offer more sophisticated things. This is what will happen, and it needs to happen.”

“The dynamics of decentralization will allow lower-cost caregivers to offer more sophisticated things. This is what will happen, and it needs to happen.”

– Clayton M. Christensen

Kim B. Clark Professor of Business Administration, Harvard Business School

The shift toward a broader healthcare team utilizing providers such as nurse practitioners and physician assistants can be found in new models of care delivery, such as that at MinuteClinic, a retail healthcare provider with more than 640 clinics in 25 states located within CVS pharmacies. Andrew J. Sussman, MD, President, MinuteClinic and Senior Vice President/Associate CMO, CVS Caremark, described an impressive program in which 2,000 nurse practitioners and physician assistants serve patients seven days a week in walk-in clinics with an average wait time of just 20 minutes.

“Now most of our care is for acute services: sore throat, bronchitis, ear infection,” said Sussman. “But increasingly we’re seeing patients with non-acute issues, such as monitoring of chronic diseases like diabetes, high cholesterol, and hypertension.” Patients receive printouts of their medical records, which also are faxed or electronically distributed to their primary care physicians—if they have one. “More than 50 percent,” Sussman said, “are effectively medically homeless. We give them lists of physicians in their areas who are taking new patients.”

MinuteClinic’s progress, Sussman suggested, was not just demonstrated by its 40 percent annual revenue growth rate, but also by its performance with respect to care quality and cost. “Patients at MinuteClinic did as well or better than those treated in traditional primary care settings,” said Sussman. Yet, cost was 40 to 80 percent lower than in other settings.

Sussman attributed the clinic’s success to the application of evidence-based guidelines, consistent throughout the country, and to the effective use of non-physician providers. Regarding the former, he noted, “It is absolutely essential that we practice on evidence-based guidelines where they exist for routine conditions. We can no longer afford a heterogeneity of practices when we all agree about what best practice represents.” On the latter issue, Sussman pressed for “the best and most meaningful use of nurse practitioners, physician assistants, pharmacists, and other healthcare providers and allowing them to practice at the top of their license.”

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B. Decentralizing the innovation process

As with care delivery, the process of innovation itself should be pushed out toward patients.

Many conference participants suggested the decentralization of care delivery will and must occur in tandem with a decentralization of the innovative process more broadly. Like centralized providers, the traditional avenues of innovation may be too narrow, unnecessarily restricting the universe of possibilities. By opening doors for untapped talent, we might discover innovations that would otherwise be overlooked by the usual professionals.

Alpheus Bingham, Co-founder of InnoCentive—an online platform for connecting those with innovation problems with potential solvers—said that finding real innovation means tapping the expertise of “non-experts.” He cited the conference itself as an example: “There were 509 invitees, and I’m going to just guess that the total problem-solving power of the ones who weren’t invited to this conference is greater than the total solving power of those who were.” Bingham cited a collaboration among InnoCentive, Harvard University, and the Helmsley Foundation, which investigated potential hypotheses in diabetes treatment that “were not being adequately resourced.” When they looked beyond major university science initiatives to reach patients, doctors, and other caregivers, they found fruitful areas of diabetes research focused on prevention, care, and support of the patient.

Bingham suggested that “our identities as experts” have become an obstacle to broader innovation. “Maybe the reason that people with your skills and backgrounds solve the interesting problems of the world is only because you’re first in line. It wasn’t because the questions got asked of everybody at once.”

“Maybe the reason that people with your skills and backgrounds solve the interesting problems of the world is only becauseyou’re first in line. It wasn’t because thequestions got asked of everybody at once.”

– Alpheus Bingham

Co-founder, InnoCentive

As with care delivery, the decentralization of the innovation process is increasingly relying on patients themselves. When organized into collaborative groups, patients can be agents for accelerating the search for cures. Kathryn Giusti, Founder and CEO, Multiple Myeloma Research Foundation (MMRF), articulated a model rooted in her own personal experience. At age 37, she was diagnosed with multiple myeloma, “a 100 percent fatal blood cancer,” with a life expectancy of three years from diagnosis. Recognizing that hers was a “hugely neglected cancer,” she founded the MMRF. By combining fundraising with an open tissue bank and a unique depository of sequential patient data, the foundation was able to attract more scientists and stimulate new research.

“In the years since I was diagnosed, we have more than doubled the lifespan of our patients from three years to eight,” Giusti said. The crucial element, she suggested, was creating a patient community that developed “our own data systems and got everybody working together… the whole point of this is to make sure that we start to identify new targets and new biomarkers, with all the data being in the public domain for thousands of people to look at, instead of just having one or two or three academic centers. It’s much more about crowdsourcing and information gathering.”

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C. Leveraging decentralization while controlling fragmentation

Leveraging the benefits of decentralization—without incurring the costs of fragmentation—will require broad and effective information sharing.

Many participants raised concerns that decentralization would result in a scattering of the very data necessary to effectively coordinate care. If patients can receive care from a greater number of providers in a wider variety of settings, how will the subsequent clinical data be gathered and integrated?

To prevent fragmentation, successful implementation of new initiatives will require more sophisticated means of gathering and distributing information, regardless of where care is delivered. Panelists and participants agreed that for decentralized approaches to succeed, all parties— from patients and providers to payors and suppliers— would need access to data that measure the quality as well as the cost of care.

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