Shifting Sickcare Providers to Health Improvement

It seems clear, to me at least, that large numbers of providers, perhaps eventually a majority of them, will be shifting from traditional “sickcare” to managing the health of populations, for their own as well as the world’s good. Some will shift entirely to a proactive health focus, but most will probably retain a mixed health and sickness focus. This shift will be slow in coming, especially where medical care is decentralized as much as in the US, though may occur swiftly where there are national systems that can help manage the process. The reasons for this shift are the same almost everywhere – the cost of preventable illness and injury have become or are becoming unsustainable.

In the US, there may well be the most varied approach to shifting the health care “paradigm”. We have so many different approaches to medical and health care already, and all will be competing to be among the survivors. These include:
• Traditional modest-sized practices
• Large group practices
• “Concierge” practices
• Retail clinics
• Worksite clinics
• Group practice insurers
• Integrated health systems
• Complementary and alternative medicine providers


The broadest shift that will have to be part of structural change will be focusing the attention of physicians on the costs of care, rather than solely on the effectiveness thereof. While physicians have traditionally been insulated from cost issues, even trained to consciously avoid considering costs when choosing treatments, there will be a major shift toward comparative cost effectiveness as a key if not chief consideration. This is especially true for health management, in contrast to sickcare, since there is little justification for a “damn the torpedoes” attitude in selecting solutions.

Already, medical schools are introducing courses or at least discussions of the costs of care into medical education, and residencies are required by accreditation standards to do the same. [S. Okie “Teaching Doctors the Price of Care” KaiserHealthNews.org May 4, 2010] While emphasis in such education and training is on the costs of sickcare at the moment, health management will clearly emphasize selection of the most cost-effective solutions out of necessity, at least in the long run as payers learn how best to select and pay providers.

The growth of concierge practices has already been promoted by the potential for health management to be a separate basis for charging patients annual fees. And fees have tended to focus on affordable to middle class levels, in contrast to the only the wealthy need apply approach of the earliest examples fifteen years ago. {L. Stein “Concierge Doctors Say an Annual Fee Can Mean Better Care” St. Petersburg (FL) Times May 4, 2010 (www.tampabay.com)] Where early examples focused on luxury levels of access/availability and amenities, most of the current practices focus on better health management, and have the data to prove it. (www.mdvip.com)

The idea of patient-paid health management is only half the story, of course. Physicians and hospital-physician integrated systems are developing and testing medical homes. While most seem to be starting out focusing mainly on reducing patient re-admissions and managing chronic illness, they will surely end up as “comprehensive health management homes”, though with another name, since already the “medical home” sounds too much like a nursing home to consumers.

Physicians are sure to recognize, eventually at least, that the best approach to both managing chronic illness patients and healthy or at-risk patients is to lead broad-based team approaches and larger organizations. Physicians, themselves, are not only untrained in, but too expensive for all but a leadership role and motivator in proactive health management. [D. Brown “New Health Care Law Might Make Your Doctor More Informed, Efficient, Responsive” Washington Post.com May 4, 2010] As payers insist on the most cost-effective, proven ROI approaches thereto, practices will have to be in a position to deliver them.

Retail clinics are likely to enjoy at least an early lead in PHI, since there are so many of them already conveniently located, reasonably priced, and staffed by nurse practitioners or physician assistants who can do the job so much more inexpensively than physicians. Already, many of the existing examples are adding disease management and wellness services to routine sickness care, in order to both increase and smooth out demand for their services. Where they are located near small to medium sized employers, they may be enlisted by organizations in workforce health improvement efforts, as well.

Worksite medical clinics are already growing, among large employers at least, as part of their continuing, indeed growing efforts to improve employee health and productivity. As employers stretch their goals and evaluations to include performance and value measures, and gain a more complete picture of their ROI from such investments, these clinics figure to grow even more. Despite the economic recession and reform legislation, most employers plan greater emphasis on workforce health and performance. [“The Road Ahead: Under Construction with Increasing Tolls 2010 HewittAssociates.com May 2010]

Pre-paid group practice insurers, such as Kaiser Permanente and Group Health organizations, have been investing in proactive health for some time, though not as long as the original “Health Maintenance Organization” model anticipated. As long-term bearers of risk for healthcare costs, as well as providers, they recognized the value of prevention, wellness, disease management, etc. earlier than other insurers, and have made effective use of their expertise in attracting payer clients. Even insurers have taken on the challenge, recognizing the interests and intentions of their employer clients.

A significant element of the development of health management will be discovering and developing an appropriate role for “complementary and alternative medicine”. Consumers already have a far stronger attachment to CAM approaches to health as well as sickness than science supports, but providers will certainly include proven approaches where they fit demand for cost-effective results. Already, large numbers of physicians and hospitals have created “integrated medicine” programs that include CAM solutions in which they have confidence, and evidence relative to what truly works most cost-effectively is growing, as it is in traditional medicine.

It is far too early to predict, at this stage, which provider organizations and approaches to health management will survive longest and dominate the future. Payers are generally still unsophisticated with respect to what the full value of outcomes they can achieve, and to evaluating what they are already getting. As they increase their own skills and understanding, they will stimulate far more informed competition which will weed out less cost-effective providers in the market.

With respect to health management, we are much like the early 20th century when automobiles, bicycles, airplanes, railroads, and other means of getting us from place to place all competed for the same market, and hundreds of different options were often available within each category. We will eventually reach a far more concentrated group of providers and set of options, though it will take some time. But having in mind “The Gretsky Principle” of going where the puck is going to be instead of where it is now should help providers and customers alike make the process of creating a truly cost-effective solution easier and earlier.