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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