Over the last 2 days, I have been diligently reading Clayton's book Innovator's Prescription. The keyword here is "diligent", ie read relatively intensely and with a highlighter in hand to highlight key points and a pen nearby, to scribble notes along the margin of the book. It does help too that my copy of the book was personally autographed by Prof Christensen himself when he was recently in Singapore.
Buy why? One major reason, although I personally love reading, is that my Chairman has started a series called "Talk the Walk, Walk the Talk". This is a regular session where we will discuss possible disruptions to public healthcare using ideas from the Innovator's Prescription book. The first session has been scheduled on 1 July! Hence, got to push on the reading...
Tonight, I finished Chapter 5 - the chapter on "Disruptive solution for the care of chronic illnesses". Here, Singapore has started some work to push the boundaries by incentivising people to start treatment early by allowing the use of medisave in the outpatient setting and tracking the improvement of health outcomes over time. But more remains.
Why a special chapter on disrupting care for chronic illnesses? It is widely known for example that 5 chronic illnesses - diabetes, congestive heart failure, coronary artery disease, asthma abd depression account for majority of the healthcare cost. In fact, the large share of expenditure by patients in the last 18 months of their life is largely due to the impact of treating the manifestation of symptoms from chronic illnesses.
What have I learnt from the discussions in this chapter?
1. The current business models used to care for patients with chronic illnesses are primarily set up to deal with acute diseases, ie they make money when people are sick and not when they are well.
2. There are 2 types of chronic illnesses, (a) intuitive chronic illnesses, ie those where diagnosis and treatment lacks clarity eg. lupus, chronic fatique, etc and (b) rule-based chronic illnesses, ie those where precision medicine is/ almost available and treatment are rule based eg. diabetes, chronic hepatitis, blood cancers.
3. Intuitive chronic illness require coherent solution shop approach, ie organised teams of specialists coming together to arrive at a correctly defined diagnosis and treatment protocol. Mayo clinic is well known in this regard and practices what is popularly known as Team Medicine.
4. Rule-based chronic illnesses is easy to manage but require long term compliance by patients to therapy and behavior modifications. The keywords here are "compliance" and "behavior changes"
5. Clayton invests a significant proportion of the chapter to identify categorization of types of chronic illnesses, the likelihood for compliance by patients and the various business models that may incentivise both the provider and the patient's behavior. There are essentially 4 types of chronic illnesses:
i. High immediate consequences + low behavior dependent eg. Epilepsy
ii. High immediate consequences + High behavior dependent eg. Chronic back pain
iii. Low immediate consequences + low behavior dependent eg. hyperlipidemia
iv. Low immediate consequences + high behavior dependent eg. Type II diabetes
6. Group (i) is already quite effectively managed by current business model. As consequences are immediate and low behavior change is required, patient will comply to treatment and doctors simply must schedule follow-up and they get paid.
Group (ii) and (iv) where it is high behavior dependent, the ideal approach is through facilitated networks eg. alcoholic anonymous where patients share information and teach each other how to overcome alcoholism.
Group (iii) and (iv) needs to be overseen by providers that profit from keeping their patients well rather than from their sickness. The entities that can profit are those who are integrated providers who are also insurers, or those who provide health care to a group of patients at a fixed fee. Employers like GE, HP have started have been using "disease management networks" to contract care for employees with certain costly chronic illnesses, and have proven to be successful in containing cost while improving outcome.
7. Patients are generally more interested in their financial health than their physical health. One approach to incentivise patients' compliance to therapy is to tie compliance to financial wellbeing.
Some ideas are already in action in Singapore. The national "Delivering on Target (DOT)" programme first started by SingHealth has proven early success but more needs to be done from the reimbursement angle.
It is also interesting to note what Cleveland clinic has reportedly started to do. They have moved away from the traditional departmental approach of medicine, surgery, paediatrics etc into "institutes" which comprise an integration of various specialists working together in "coherent solution shops".
I started this blog talking about incentives. It is therefore fitting to end to note that even in healthcare, the correct incentives built into business models can drive both provider and patients' behavior in a manner that will provide better outcomes and make healthcare more affordable!
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