Health-care changes signal much-needed paradigm shift

November 30, 2011

Vineeta Vijayaraghavan is a Senior Research Fellow at Innosight Institute, a think tank focused on disruptive innovation. Clayton Christensen is the Kim B. Clark Professor of Business Administration at the Harvard Business School, co-founder of Innosight Institute and co-author of “The Innovator’s Prescription: A Disruptive Solution for Health Care.”

The U.S. Supreme Court announced on Nov. 14 it will hear a case that challenges certain aspects of the Patient Protection and Affordable Care Act (PPACA). Regardless of the law’s pros and cons, some of the government’s most significant, positive changes to health care exist outside of it.

These changes are enabling more disruptive innovations – the types of innovations that could radically improve cost, quality and access in health care. They also demonstrate how the U.S. is starting to make changes that will improve our national health care, regardless of the fate of health-care legislation.

Let’s start with Medicare, which has never before recognized online clinical care. This includes a failure to recognize e-mailing and online clinical conversations with brick and mortar providers. That changed in October when the Centers for Medicare & Medicaid Services (CMS) authorized a Minnesota Medicare plan to cover care provided by the online convenience care clinic virtuwell.com.

Virtuwell connects patients with nurse practitioners for online diagnosis, treatment and prescriptions, treating about 40 simple conditions around the clock. Online care may be new, but virtuwell is grounded in rigorous safety protocols and the decades-long clinical experience of its creator, Minnesota-based HealthPartners. HealthPartners is a leading integrated health care system, which means that the role of both payer and provider are combined.

These factors may have increased CMS’ comfort-level, and rightly so, making it likely that other online venues will become reimbursable over time, so long as they meet similar thresholds for safe, satisfying and high-quality care. The move towards online care will empower patients, leverage a greater array of providers, and yield enormous improvements in cost and access.

Next come hospital regulations. In October, the Department of Health and Human Services (HHS) announced a set of proposed changes to hospital regulations. These changes make it easier to use advance practice nurses and physician assistants in lieu of physicians. They also removed onerous safety and fire-code restrictions on dialysis centers and outpatient surgery centers that had required costly equipment or structural changes. They also revised earlier hospital restrictions that often limited patients’ ability to take medications by themselves.

These changes are significant, since they demonstrate a shift from expensive hospital- and specialist-centered care models to a future where team-based care, more outpatient care and more patient self-care are supported. This can result in care at the same or better levels of quality that is less expensive over time.

In the past, ambulatory care centers were often impeded by having to meet regulations originally written for hospitals that stipulated how many sinks had to be in a room or how far apart pieces of equipment needed to placed. These outdated regulations added unnecessary expenses, hampering the cost-effectiveness of investing in innovations. Investments should be made in similar sites to advance disruptive innovations, as they help lower the aggregate cost of health care.

Last, but not least, are the changes made to prostate cancer guidelines. The U.S. Preventive Services Taskforce (USPSTF) recently changed its guidelines on prostate cancer, following changes to mammograms and cervical cancer screenings also announced in the last five years. For the first time, across multiple conditions, based on studies of hundreds of thousands of patients, the USPSTF recommends that fewer screenings might actually be better from both quality and cost perspectives.

This is nearly as big of a third rail in health care as end-of-life care. After the change in mammogram guidelines, select congressmen promised they wouldn’t let insurance companies take mammograms away from women.

For once, the issue is not about the purported tightfistedness of insurers. The USPSTF changes were made along the line of thinking that if we value science and evidence-based care, then we need to move away from excess medicine. Excess radiation and invasive tests are not only physically painful, they cost patients time and money. That may finally be sinking into the government’s conscience. There was far less of an outcry over the change in prostate guidelines, perhaps because many men are already living with the mixed results and difficult choices that too much screening had caused.

If we are to have both more affordable and higher quality health care in the coming decades, moving away from the “more is always better”-philosophy for medical care is a fundamental shift our health care system desperately needs.

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